Philippines - Second Population Project

Document of The World Bank FOR OFFICIAL USE ONLY FILE COPY Report No. 2453-PH PHILIPPINES STAFF APPRAISAL OF A SECOND POPULATION PROJECT May 23, 1979 Population Projects Department This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  CURRENCY EQUIVALENTS US$1.00 1 P 7.40 P 1.00 - US$0.135 P 1 million = US$135,135 GOVERNMENT OF THE PHILIPPINES FISCAL YEAR January 1 to December 31 ABBREVIATIONS AV Audiovisual BHS Barangay Health Station BHW Barangay Health Worker BSPO Barangay Supply Point Officer FMS Financial and Management Service FTOW Full Time Outreach Worker IEC Information, Education and Communication IUD Intra-uterine Device MHC Main Health Center MIS Management Information System MOH Ministry of Health MLGCD Ministry of Local Governments and Community Development NEDA National Economic Development Authority OHEPT Office of Health Education and Personnel Training NFPO National Family Planning Office PCF Population Center Foundation PHC Primary Health Care POPCOM Commission on Population RHCDS Restructured Health Care Delivery System RHU Rural Health Unit (now MHCs) TIDA Total Integrated Development Approach UNFPA United Nations Fund for Population Activities USAID United States Agency for International Development WHO World Health Organization f  FOR OFFICIAL USE ONLY DEFINITIONS Crude Birth Rate: Number of live births per year per 1,000 population. Crude Death Rate: Number of deaths per year per 1,000 population. Rate of Natural Difference between crude birth and crude death rates; Increase: usually expressed as a percentage. Rate of Population Rate of natural increase adjusted for (net) migration, Growth: and expressed as a percentage of the total population in a given year. Age-Specific Number of live births to women in a given age group Fertility Rates: per 1,000 women in the same age group, in a given year. It is usually calculated for 5-year age groups. Total Fertility The average number of children that would be born Rate: per women if she were to live to the end of her childbearing years, and bear children according to a given set of age-specific fertility rates. The Total Fertility Rate often serves as an estimate of the average number of children per family. Gross Reproduction This is the same as the Total Fertility Rate, but Rate: refers to the number of daughters a women would have under prevailing fertility patterns. Net Reproduction The number of daughters a woman would have under Rate: prevailing fertility and mortality patterns, who would survive to the mean age of childberaring. Infant Mortality Annual number of deaths of infants under 1 year Rate: per 1,000 live births during the same year. Maternal Mortality Number of maternal deaths per 1,000 births attri- Rate: butable to pregnancy, childbirth, or puerperal complications (i.e., within six weeks following childbirth). Life Expectancy: Average number of years expected to be lived by children born in the same year if mortality rates for each age/sex group remain the same in the future. Dependency Ratio: Number of people 14 years and under plus people 65 years and over, divided by the population aged 15 to 64 years. This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  PHILIPPINES: BASIC DATA 1975 census 1978 estimate Area (km ) 300,000 300,000 Population (millions) 42.3 45.5 Density (per km ) 141 150 Crude birth rate (per 1000) 37.0 35.0 Crude death rate (per 1000) 10.4 10.0 Rate of natural increase 2.7 2.5 Age structure 0-14 43.9% 15-64 53.9% Average age (years) 22.4 Dependency ratio 88.5 Life expectancy at birth (years) 60.8 Infant mortality rate (per 1000 livebirths) 81.0 (1970) General marital fertility rate (per 1000) 316 Total fertility rate 5.4 Women of reproductive age (millions) 9.8 Married women of reproductive age (millions) 5.6 Family planning acceptors (1972-1977) (millions) 4.0 Eligible women currently contracepting 27% (survey) Urban population 31.6% School enrollment: elementary (millions) 8.3 secondary (millions) 2.2 tertiary (millions) .7 Literacy rate (aged 10+) 87.9% Labor force (aged 10+) (millions) 29.6 Unemployment rate 5.6% (1977) Population: per physician 2,620 per nurse 2,950 per midwife 3,622 Gross National Product at current price Total (million) $23,524 Per capita $508 Annual growth rate 7.5 This report is based on the findings of the appraisal mission which visited the Philippines on October 9-November 5, 1978. The mission consisted of the following IDA staff: Mrs. M. N. Maraviglia, Messrs. H. W. Franckson, D. Radel, M. Singh and R. Barger and Ms. A. Hammond. Other mission members were Mrs. T. DeRosa (Consultant-Training), Dr. V. Jagdish (Consultant-Public Health) and Dr. A. Angara (WHO Consultant). This report was prepared by Mrs. Maraviglia with contributions from other mission members.  PHILIPPINES STAFF APPRAISAL REPORT OF A SECOND POPULATION PROJECT Table of Contents Page No. I. POPULATION GROWTH, HEALTH AND SOCIOECONOMIC DEVELOPMENT ....... 1 A. Introduction ............................................. 1 B. Recent Demographic Trends ................................ 1 II. POPULATION AND HEALTH POLICIES AND ORGANIZATION .............. 4 A. Population Program ....................................... 4 --Historical Overview of the Population Program .... ...... 4 --National Goals and Strategies .......................... 5 -POPCOM's Structure and Coordinating Role .... ........... 6 --Role of Other Agencies in the Program .................. 7 --Project Outreach Under POPCOM's Coordination .... ....... 8 -Performance and Constraints of the Population Program .. 9 --Training ............................................... 10 --Information, Education and Communication .... ........... 11 --Management Information System .......................... 12 --Population Research .................................... 13 B. Health Services .......................................... 13 --Health Status .......................................... 13 --National Goals and Strategies in the Health Sector ..... 14 --Organization and Manpower of the MOH Health Services ... 16 --Performance and Constraints of the Health Services ..... 17 --Training ............ ................................... 17 --Health Education/IEC ................................... 18 --Management Information Systems ......................... 18 C. First Bank Population Project ............................ 19 D. External Assistance to Population and Health Programs in the Philippines ..................................... 21 III. THE PROJECT .................................................. 21 A. Project Concept .......................................... 21 B. Project Objectives ....................................... 22 C. Summary Project Description .............. ................ 23 D. Detailed Project Description .............. ............... 25 --Part A: Commission on Population ........ .. ............ 25 --Expansion of POPCOM's Infrastructure ........ ......... 25 --Training in Population and Family Planning ........... 26 --Demand Creating Activities-IEC ......... .. ............ 26 --Research on Population and Family Planning ..... ...... 29 --Management Information System .......... .. ............ 30 --Innovative Activities-Population ........ .. ........... 30 --Part B: Ministry of Health ........... .. ............... 30  Page No. --Expansion of Health, Family Planning and Nutrition Services .............. .. ................. 31 --Training of Health Personnel .......... .. .............. 33 --TEC for Health/Family Planning/Nutrition ...... ........ 34 --Management Information System ............. 0 ........... 35 --Innovative Activities in Health Care and Family Planning .......................................... 36 IV. PROJECT COST, FINANCING AND DISBURSEMENT ...................... 37 A. Cost ...................................................... 37 B. Proposed Financing ........................................ 41 C. Disbursements and Accounts ................................ 41 V. PROJECT IMPLEMENTATION AND RISKS ............ .. ................ 42 A. Project Management ....................................... 43 B. Implementation of the Physical Facilities ...... .. ......... 45 C . Procurement ....................... ........................ 46 D. Flow of Funds ...................... ....................... 47 E. Risks ..................................................... 48 VI. PROJECT JUSTIFICATION ......................................... 49 VII. RECOMMENDATIONS ................................ ............... 50 ANNEXES 1. Organization Charts for POPCOM and MOH .................... 52 2. List of Project Training Activities ..... .................. 55 3. Description of IEC Component .............................. 63 4. List of Research Component Activities-POPCOM .... .......... 74 5. Primary Health Care Component ............................. 75 6. Estimated Project Cost by Expenditures and Functional Categories ................................... 78 7. Proposed Financing Plan ................................... 81 8. Disbursement Schedule ..................................... 82 9. Administration of the Project ............................. 83 10. Summary Project Implementation Schedule ................... 88 11. Procedures for Disbursements Against Certificates of Expenditures ...................................... o ........ 99 12. Tables ..................................................... 102 13. Selected Documents and Data Available in the Project File . 110 14. Maps of the Philippines ................................... 112  I. POPULATION GROWTH, HEALTH AND SOCIOECONOMIC DEVELOPMENT A. Introduction 1.01 Rap-d population growth remains one of the most serious problems facing the Philippines over the next two decades. This high level of popu- lation growth affects all aspects of the economy of the Philippines, seriously undermining the country's efforts to provide adequate levels of education, housing, employment, food, and health care to its people. Although in recent years there has been some decline in the average annual rate of population growth, from 3% in the 1950s to 1960s, to 2.7% by 1975 and probably 2.5% by 1978, the potential for sustained high population growth rates remains great because fertility levels are still high, the population is young and mortality levels (particularly for those below age five) are expected to be reduced further. 1.02 The decline in the crude birth rate during the 1970s was due mainly to later age of marriage, an increase in non-marriage, and some fertility decline in urban areas. In rural areas people still marry young and few practice contraception. On the national average, total marital fertility has remained almost unchanged between 1958 and the early 1970's (around 9.6 children per married woman of reproductive age). 1.03 The crude death rate--the other factor determining population growth--is still relatively high in the Philippines at 10.4 per 1000 in 1975. High infant mortality contributes significantly to the high crude death rate, since one-fourth of all deaths are those of children under one year. Those children who survive their first year face a series of health threats, par- ticularly from communicable diseases such as tuberculosis, gastroenteritis and respiratory infections. Malnutrition has reached an alarmingly high level, as about 78% of all the children surveyed in 1977 were shown to be malnourished. 1.04 High fertility contributes to existing health problems as a con- sequence of large family size, insufficient spacing of pregnancies, low standards of living, low nutrient intake, low productivity, and a continuously increasing burden on the health services. It is therefore essential that the Government's efforts to improve the health situation and to decrease morbidity and mortality include increased actions to reduce fertility through public education and the provision of family planning services. This concerted effort to lower mortality, improve the health status of the population, and reduce fertility is necessary to achieve the reduced rates of population growth required for an improved quality of life and a better environment for socioeconomic development. B. Recent Demographic Trends 1.05 Seven censuses conducted between 1903 and 1975 show that the popula- tion of the Philippines has increased more than fivefold--from 7.6 million in 1903, to 42.3 million in 1975 (trends in age distributions are presented in  - 2 - Annex 12, T.1). Population growth rose to 3% per year during the 1960's, from the almost constant 2% annual growth rate which prevailed since the early 1900's. The rate declined slightly to 2.7% per year in 1975. The following table shows population and demographic rate trends during 1948-1975. Average Annual Estimated Crude Estimated Crude Census Census Population Growth Rates Death Rates Per Birth Rates Per Years (millions) (%) 1000 Population 1000 Population 1948 19.2 1.9 21.8 /1 46.8-51.0 /2 1960 27.1 3.1 13.7 42.7-50.0 1970 36.7 3.0 12.6 39.3-42.7 1975 42.3 2.7 10.4 37.0 /1 Estimated for the period 1946-50. /2 Estimated for the period 1948-60. Source: National Census and Statistics Office, Census of the Philippines, 1903-1975. 1.06 Crude death rates declined steadily between 1948 and 1960. However, since the late 1960s mortality reduction has been less pronounced. The earlier mortality decline was mainly due to massive vector control programs and socioeconomic improvements rather than widespread availability of modern medical technology. The rough estimates of infant mortality available suggest a decline over the period 1950 to 1965. However, analyses made between 1968 and 1973 show no evidence of continued decline in the more recent period. This explains in part the slower decrease in total mortality in recent years, since one fourth of all deaths are those of children under one year of age. Further declines in total mortality and more so in infant mortality will depend largely on improved, expanded and accessible health care services emphasizing prevention, health education, lower fertility levels and better nutrition. 1.07 Crude birth rates remained fairly constant until very recently, hovering around the high level of 45 to 50 per 1,000 population through the 1950s and 1960s. In 1975 the crude birth rate was estimated at 37 per 1000, down from the 39 to 43 per 1000 estimated in 1970. Total marital fertility was still very high and unchanged between 1958 and the early 1970s (around 9.6 children per married woman of reproductive age). The decline in the crude birth rate during this period was due to a consistent trend toward later marriage, an increase in non-marriage and some fertility decline in urban areas, where family planning services have been available since the late 1960s. 1/ However, both age at marriage and contraceptive practice decrease rapidly in relation to distance from urban areas. 1/ As no recent data are available on these factors, an analysis of their relative effect upon the decline in the crude birth rate between 1972 and 1978 is not now possible.  1.08 Recognizing population growth and attendant socioeconomic pressures as serious constraints in reaching medium and long-term development goals, in 1970 the Government adopted a national population policy which had as its objective the reduction of the rate of growth of population to 1.6X and a total population size of no more than 70 million by the year 2000. This long-term goal, which was reaffirmed in the Five-Year Philippine Development Plan 1978-82, 1/ implies the achievement of a net reproduction rate of one by 2000. The table below presents population projections made by the Government, which would be necessary to reach the mentioned targets (projected age dis- tributions are presented in Annex 12, T-2). These goals, while ambitious, are achievable if program efforts already begun can be improved and sustained. Population Average Annual Crude Birth Crude Death Projections /1 Population Rate Per 1000 Rate Per 1000 Year (in millions) Growth Rate (%) Population Population 1978 45.5 2.5 35 10 1979 46.7 2.5 35 10 1980 47.9 2.4 34 10 1981 49.0 2.4 33 9 1982 50.2 2.3 32 9 1987 56.0 2.1 29 8 2000 70.0 1.6 22 6 2070 /2 94.0 0 /3 /3 /1 The Government target of population growth is the low projection prepared by the National Census and Statistics Office, which assumes an NRR=l by year 2000. Under the medium projection, population would reach 83.4 million by 2000 and, under the high projection, 97.3 million. /2 Stationary population (zero growth) would be achieved by 2070. /3 No crude birth and death rates were calculated for 2070. 1/ This Plan is complemented by a Ten-Year Plan and the Philippine Long-Term Development Plan to year 2000.  - 4 - II. POPULATION AND HEALTH POLICIES AND ORGANIZATION A. Population Program Historical Overview of the Population Program 2.01 During the 1960s, family planning services were provided mostly by private physicians, missionaries, and private clinics. In 1967 the President of the Philippines, together with 17 other heads of state, signed the UN Declaration of Population which recognized population growth as a major consideration in long-range socioeconomic planning. In 1968, a small unit for maternal and child health and family planning was created in the Department of Health (recently re-named Ministry of Health-MOH). 2.02 In 1969 the Government created the Commission on Population (POPCOM) as a planning, coordinating and policy-making body. It consisted of 22 members from the public and private sectors, with the University of the Philippines' Population Institute as its secretariat. In 1970, acting upon POPCOM's recommendations, the Government launched a national population program which POPCOM was to coordinate and evaluate. 2.03 In 1972, POPCOM's functions were extended to include promoting family planning education, coordinating relations with international organizations concerned with population and ensuring that adequate family planning services were made available to the public. At the same time, MOH was instructed to provide family planning services through its health care delivery system. The Ministry of Health in time became the principal source of family planning services (by 1977 MOH was providing services to 64% of all family planning acceptors in the country). 2.04 Since 1975, following a decision that family planning services shiould increasingly be delivered by multi-purpose (non-health) field workers, instead of mainly through clinics, POPCOM has organized three projects designed primarily to provide family planning information, education, and services, in rural areas where clinic services were limited or not available. The first of these projects, the Total Integrated Development Approach (TIDA), begun in 1975 with United States Agency for International Development (USAID) financial assistance, was soon found to be too broad in its develop- ment objectives and generally ineffective in motivating couples to practice family planning. In 1976 POPCOM initiated Project Outreach (see para. 2.23), also with USAID assistance, using TIDA's organizational structure and manpower. 2.05 The third project, Project Compassion, is implemented by the Popula- tion Center Foundation (PCF)--a private organization which receives Government funds. Project Compassion is similar to Project Outreach, but operates in six provinces only. When, in 1977, Project Outreach was extended to the whole country, problems of overlap arose, and POPCOM decided to designate PCF as the "implementing agency" for Project Outreach in the six provinces where it operates.  -5- 2.06 At the same time as Project Outreach was being established, MOH continued the expansion of its basic health services, which included family planning. In 1974, MOH introduced a program for retraining health personnel, called the Restructured Health Care Delivery System (RHCDS), as part of the first Bank-ass4sted population project (para 2.58). MOH has also established mobile clinical services for family planning, particularly for sterilization services, and extended the roles of nurses and midwives to include pill dispensing and intrauterine device (IUD) insertion. 1/ 2.07 In response to a downward trend in family planning acceptors and in order to resolve the organizational, managerial and technical shortcomings of the population program, in January 1977 the President of the Philippines commissioned a comprehensive review of the program to a seven-member Special Committee headed by the Commissioner on Government Reorganization. In May 1978, the Government called a meeting of Government officials, population experts, and external donors, to discuss the committee's draft report. The final report, submitted to the President in November 1978, contains a sound evaluation of policies and program activities and valuable recommendations on POPCOM's organization and specific program strategy questions which have mostly been accepted by the Government and are reflected in the program that the proposed project would support. The President has instructed POPCOM and the participating agencies to prepare a plan to implement the recommendations. During negotiations the Government gave assurances that this population plan, already partially completed, will be made available to the Association for its review and comment by December 31, 1979 and, by March 31, 1980, the Government will consult with the Association on a timetable for implementation of such plan. 2.08 At the Consultative Group Meeting on Philippines held in Paris in December 1978 the population situation in that country was discussed as a special subject; at the meeting, the Government reported on the recommenda- tions of the Special Committee and several donors, including the United Nations Fund for Population Activities (UNFPA), USAID, and the Association, presented their viewpoints concerning the strengths and weaknesses of the Philippine population program and indicated the areas and levels of future assistance. National Goals and Strategies 2.09 The Five-Year Philippine Development Plan 1978-82 aims at reducing the annual population growth rate from an estimated 2.5% in 1978 to 2.3% in 1982 and to 2.1% in 1987. The long-term goal is the attainment of a net reproduction rate of one by 2000. The national population program is expected to contribute significantly to the achievement of this goal. POPCOM has esti- mated that, in order to reach these targets, it is necessary to: increase the proportion of protected couples from 27% in 1978, to 40% in 1982 and 50% in 1987; (b) increase contraceptive effectiveness from 86% in 1978 and to 90% in 1982, by emphasizing more effective and lasting methods; and (c) improve 1/ This was authorized in 1972 through Presidential Decree No. 79, but not put into practice until 1974.  - 6 - follow-up services. Improvements in socioeconomic conditions, particularly in health and nutrition, also are expected to help reduce fertility and mortality and, probably with a time lag, to reduce population growth rates considerably. POPCOM's Structure and Coordinating Role 2.10 In addition to its original coordinating and policy-making functions, POPCOM now has several implementing functions, including the distribution of contraceptives, the general supervision of Project Outreach, which is imple- mented in the field by local governments, and the conduct of information, education and communication (IEC) activities through its central, regional and local staff. 2.11 POPCOM has two main components (see Organizational Charts in Annex 1, C-1 and 2): the POPCOM Board and the Secretariat. The POPCOM Board consists of ten members as follows: the Minister of Economic Planning (currently its Chairman), the Ministers of Health, Education, Social Services, Local Govern- ments, and Labor; the Dean of the University of the Philippines' Population Institute; the Executive Director of the Population Center Foundation; and two other representatives of the private sector. This composition is appropriate to POPCOM's coordinating role, since the presence of the heads of agencies represented in the Board ensures coordination. 2.12 Following a recommendation of the Special Committee, the POPCOM Board has recently introduced a needed change in the structure of technical committees that assist the review and approval of project proposals for the population program. For several years POPCOM had four such committees for service delivery, IEC, training, and research; this compartmentalization in project review hindered coordination. The creation of one supervisory com- mittee, which recommends appropriate actions on project proposals to the Board, should improve coherence among program activities. Committee members are selected from the Board, the Secretariat and other agencies as required. Part of the membership is fixed and part changes according to the specialties required for reviewing specific projects. 2.13 The POPCOM Secretariat has a central office in Manila with a staff of about 200 persons, and 13 regional offices, each with a staff of about 30. The Secretariat is headed by an Executive Director, assisted by a Deputy Director, and five associate directors. The headquarters staff has recently been reorganized into seven divisions (see Annex 1, C-1). This represents a substantial improvement over the past situation in which POPCOM staff was regrouped from time to time to meet the needs of special projects (mostly externally financed) into temporary units with functions that duplicated those of the regular divisions and overlapped with one another. 2.14 Since its inception, POPCOM has had difficulties in gaining accept- ance from the agencies it is supposed to coordinate. This is due in part to managerial and technical weaknesses, aggravated in recent years by a high turnover of professional staff; but it is also the result of a lack of clear policy guidelines, overall plans and strategies, and weak support from higher Government levels. A first important step to improve the situation is the completion of the national population plan (para 2.07) that would guide the  - 7 - full implementation of the recommendations of the Special Committee. Also, there is a need to continue improving the staffing situation in POPCOM's Secretariat through staff development and careful recruiting of any vacancies which may occur from time to time. Some key management and technical posi- tions are now filled with qualified staff; several other professional posts are currently occupied in an acting capacity by junior staff. During negotia- tions, the Government gave assurances that it will cause POPCOM to take all necessary measures for improving its administrative operations, including the following measures: (a) to prepare by October 31, 1979 an organization and staffing plan for POPCOM; and (b) to employ, by October 31, 1979 and there- after, suitable qualified professionals as associate directors, and as Manage- ment Information Systems (MIS) and Research Chiefs. 2.15 In each of the 13 POPCOM regional population offices the 30 member staff is divided into six units: finance, training, IEC, research, logistics and field support team (for Project Outreach). Although some of the regional offices are faced with staff capability constraints, in general their organi- zational and technical situation is better than that at headquarters. There is, however, a need for more adequate guidance from the central office and for a staff development program aimed at improving staff quality. Regional offices also need better equipment and transport to operate effectively in the field. Planning and programming capabilities need to be encouraged at the regional level, as local needs are not always recognized when the planning is done at the center. 2.16 Population staff at the provincial level consists of one provincial population officer per province, who is on the staff of the provincial Gover- nor, and receives technical supervision and logistics support from POPCOM's regional offices. Until the end of 1984 the salaries of these officers, as well as those of the municipal level population staff called full-time out- reach workers (FTOW) are to be paid by POPCOM's central office using Project Outreach funds provided by USAID. Role of Other Agencies in the Program 2.17 There are about 40 agencies participating in the population pro- gram; some of the major public and private agencies engaged in population activities are described briefly in the following paragraphs. 2.18 The home economics extension program of the Ministry of Agriculture, Bureau of Agricultural Extension, provides rural families with seriously malnourished children with integrated family and community living activities, which include nutrition and family planning education. Since 1972, the Population Education Program of the Ministry of Education and Culture has been promoting population awareness through the formal school system. The program, which is supported by UNFPA, prepares curricula and materials for elementary and secondary schools and colleges. Since 1972, the Ministry of Local Govern- ment and Community Development (MLGCD) has included family planning IEC in its community development, local government, and cooperative programs. The Ministry of Social Services and Development provides information and counsel- ling on family planning as part of its basic programs and services. The  - 8 - Ministry also oversees the Population Awareness and Sex Education Program, the aim of which is to prepare over one million out-of-school youth aged 13-24 years for responsible parenthood. 2419 The family planning project of the Institute of Maternal and Child Health, organized in mid-1967, covers training and service delivery. By 1977, this private organization which has been a pioneer in the field of family planrning, had trained about 13,340 doctors, nurses, midwives and other health and family planning workers from Government and private agencies. This agency also operates about 353 family planning clinics in well-populated areas and helps to coordinate the services of sterilization teams. 2.20 The Population Center Foundation, a primarily grant-giving agency established in 1974 to encourage the participation of private groups in the population program, finances projects which test innovative service delivery systems. PCF also holds workshops and seminars on research utilization and prepares IEC materials, training modules, quarterly and bi-monthly magazines and state--of-the-art papers. Much of PCF's funding comes from POPCOM. The Family Planning Organization of the Philippines is a private International Planned Parenthood Federation-affiliate established in 1969. Through its 53 chapters, it provides TEC, training, clinical services, and research and evaluation, 2.21 The University of the Philippines Population Institute offers grad- uate courses in demography, sponsors conferences and seminars on demographic data analysis, publishes research papers, and conducts in-service training in population studies for personnel in Government, colleges, and universities. Project Outreach Under POPCOM's Coordination 2.22 This USAID-financed project, begun in 1976, was operating throughout the country by October 1978 and employing about 3,000 Full-Time Outreach Workers in municipalities. The FTOWs were trained as information officers/ service providers and community organizers. Each FTOW is responsible for recruiting, supervising and supplying contraceptives and IEC materials to five to seven volunteer Barangay Supply Point Officers (BSPOs). By October 1978 about 21,000 Barangay Supply Points had been set up. The BSPOs prescribe and resupply acceptors with pills, dispense condoms, and refer clients to health clinics for family planning methods which require medical attention. It was estimated that, by the end of 1977, contraceptive use prevalence in selected surveyed areas where BSPOs were operating was close to 33%, compared with 27% for the whole country. 2.23 Although Project Outreach was initially conceived to serve areas where clinic services were limited or unavailable, in practice BSPOs have been set up without reference to this criterion. Health workers consequently consider that the BSPOs' are duplicating their own functions and resent having to treat complications arising from contraceptives dispensed by BSPOs. POPCOM and MOH are completing an agreement to establish an appropriate division of labor that would make clinic and BSPOs' services truly complementary. After agreements are reached, both POPCOM and MOH will issue precise instructions to their respective field staffs.  - 9 - 2.24 Project Outreach now has a network which should be extended to all areas outside the reach of clinics, maximized, given sufficient time to establish itself and be properly evaluated. During negotiations, assurances were given by the Government that it will cause POPCOM and MOH to reach a final agreement, not later than December 31, 1979, on complementarity between population fl- Id workers and the clinic services-under the population program. Performance and Constraints of the Population Program 2.25 At the end of December 1977, there were almost 3,000 public and private family planning clinics in the country, 672 sterilization centers and 21,500 Barangay Service Supply Points (Details in Annex 12, T-3). The per- formance of the family planning program is presented in the following table. Indicators 1972 1973 1974 1973 1976 1977 1978 1979 1980 1981 1982 1. Eligible PuplattIe OtLared vcn age 15-49) 4377,9 4512.3 4650.9 5117.4 5274.5 5436.5 5603.5 5775.6 5953.0 6136.8 6326.2 2. Pily Planing Acceptore (NMJ) (in thousaud) Target 505.6 665.3 781.1 781.0 720.0 720.0 463.2 477.5 492.1 509.8 525.2 Actual 526.1 691.3 762.2 716.6 715.1 550.8 - 3. Prevalence Rate (in per cent) Target - - - - 25 27 32 35 38 40 Actual - - - - - 27 - - - - 4. Current Users (in thousand) Target - - - - - 1512.9 1848.2 2083.6 233.20 2530.1 Actual - - - - - 376.8 - - - - S. F1ly Planning Acceptors as a Percntage of the Eligible Population Target 11.5 14.7 16.8 15.3 13.7 13.2 8.27 8.26 8.21 8.31 8.30 ctual 12.0 15.3 16.4 14.0 13.6 10.1 - - - - - 6. Pmily Planning Clinics (cumulative) Target 1270 1670 2312 2595 2595 2595 3553 3553 3553 3553 3553 Actual 1490 2042 2192 2719 2794 2956 - - - - 7. Numb er of PTWs Target - - - - 2629 2941 2997 3102 3102 3102 Actual - - - - 2565 - S. Nuber of uSPs Tsrget - - - - - 10148 33083 54365 54365 54365 54365 Actual 15597 - - urcet Final Report of the Special Cosneittee to Review the Philippine Population Program, lmxila, June 1978.  - 10 - 2.26 The national contraceptive prevalence rate increased from an estimated 15% in 1973 to 27% in 1978. Compared with most countries with fertility reduction programs, this improvement over a five-year period is considerable. The family planning services provided by the national program have contributed to the decline in the birth rate in the 1970s as a result of the cumulative increase in the number of contraceptive users. However, othler countries in East Asia (some with older programs) have prevalence rates from 35% to 75%. The number of new acceptors assumed an upward trend up to l974, and then became stationary and declined in 1977. This reflects a decline in average clinic performance because couples eager to practice have already been recruited and clinics, mostly located in urban areas, cannot meet the needs of clientele outside a three to five kilometer radius. This is a pattern experienced by many national programs. However, the declining trend in new acceptors is of particular concern because the attainment of the Government's goals of fertility reduction depend largely on maintaining a steady stream of new acceptors for several years. This can be remedied only by intensive and effective motivational programs and increased service coverage. 2.27 Data on contraceptive method mix (Annex 12, T-4) show that new acceptors increasingly favored condoms while the proportion accepting pills and TUDs declined between 1971 and 1976, the shift being most marked between 1971 and 1974. A contributing factor was the expansion of the program to rural areas where there are few trained health workers to provide the more complex (but more effective) methods such as IUDs and pills. Other factors were side effects, misinformation, and, in the case of the pill, poor follow up of dropouts and the lack of alternative brands for acceptors who experi- enced side effects (only NORINYL is available now through the national pro- gram, although recently UNFPA has agreed to provide other types of oral contraceptives). Since 1975, however, the average number of months of effec- tive protection has been increasing as a result of higher acceptance of sterilization, from 17,000 in 1975 to 42,000 in 1976 and 69,000 in 1977. Female sterilizations constitute almost 90% of all cases. By 1977, 1,200 physicians had been trained in sterilization procedures, and were working in 672 sterilization centers and 15 mobile teams (203 centers were MOH hos- pitals). Rhythm (natural family planning) has been used in the Philippines since the program began; it is the only contraceptive method approved by the Catholic Church. Training 2.28 One of the main weaknesses of the family program is the inadequate number of workers trained in family planning skills, program management, and IEC. During 1972-74, population and family planning were introduced into the priorities of other programs outside the health field and social workers, municipal development officers, and volunteer workers were supposed to be trained for motivational work. However, in 1974-75 and 1975-76, almost 75% of some 113,000 workers trained in population and family planning were teachers. In CY1977, 80% of 34,200 workers trained were FTOWs and BSPOs of Project Outreach. In the last five years, family planning training of exten- sion and volunter workers and medical and paramedical personnel fell short of program needs. Between 1974 and 1977 only 20% of all medical and paramedical manpower in the country (both public and private) had received any training in  - 11 - contraceptive methods and procedures. The training of health and other workers in effective communication with the public has been inadequate. 2.29 In 1978, to prepare for the IDA population project, the training unit of POPCOM developed a national training plan, designed to remedy these deficiencies. This effort was undertaken in collaboration with other agencies among which the most prominent was MOH. 2.30 Family planning training needs improvement in terms of quality as well as quantity particularly as regards: (a) the teaching capabilities of all personnel engaged in training; (b) coordination among training agencies; (c) the relevance and practical content of curricula; (d) training in the art of communicating with the public; (e) the use of an appropriate vocabulary for training, which can be easily understood by workers and the general public; and (f) creating opportunities for in-service training as part and parcel of supervision, to minimize the need for formal training courses. Information, Education and Communication 2.31 IEC activities in support of the population program were started on a small scale in the 1960s by non-governmental organizations, and mainly took the form of face-to-face communication. In the early 1970s various Government agencies initiated IEC activities involving field motivators, production of mass media materials, and formal and non-formal education. However, training and supporting materials for these workers lagged behind and their IEC activities were not properly coordinated; consequently, the effects were limited. 2.32 In 1970, the Government's National Media Production Center estab- lished a Population Information Education Office which designed and produced over the years a number of flipcharts, leaflets, posters, calendars, slide sets, films, and radio programs. With the gradual decentralization of the IEC program, the Center's regional offices have taken over the production of IEC materials for use in rural areas, while the central office now concentrates on urban areas, especially Metro Manila. Since 1971 the chief source of research in support of the IEC program has been the University of the Philippines Institute of Mass Communication, which made a major inventory of regional TEC needs in 1975 that contributed substantially to POPCOM's IEC strategy in subsequent years. The Institute has also developed and tested a number of prototype materials. UNFPA has provided support for these research and development activities. 2.33 The shortcomings of the IEC program are reflected in what is known as the "KAP gap", i.e., the gap between knowledge and awareness on the one hand and practice on the other. The 1973 National Demographic Survey indicated that while 62% of married couples of reproductive age approved of family planning and 51% knew how to use a method, only 17% were actually practicing family planning. The relatively high figures for knowledge and awareness are a tribute to the program's past IEC efforts. Now the challenge is to translate awareness into more solid knowledge, and knowledge into more effective action.  - 12 - 2.34 Four major analyses 1/ show that the following constraints affect the IEC population field: (a) certain audiences are not being adequately reached by the program, especially husbands and low income groups, but also women who have recently had a baby, actual and potential dropouts and couples about to be married; (b) materials do not always convey straightforward information on contraceptive methods and their effectiveness under realistic conditions; (c) translations are often not appropriate for low education, rural audiences; (d) there are insufficient quantities of materials often because no funds are available to move tested prototypes into mass produc- tion; (e) materials fail to reach the lowest level (e.g., rural clinics); (f) central and regional IEC technical staff are insufficient in numbers and some need professional upgrading; (g) audiovisual (AV) equipment is in short supply and inadequately maintained due to lack of funds; (h) there is a lack of data on field worker performance and program impact, and many studies that are available have not been used in planning IEC activities; and (i) better coordination of IEC activities is needed. A master IEC plan prepared by POPCOM in connection with the proposed second project, is designed to remedy these shortcomings. Management Information System 2.35 Since 1974, POPCOM has developed and implemented a computer-based clinic information system which provides data on family planning acceptors and a manual monitoring system for Project Outreach--Field Operations Monitor- ing System--which handles financial, inventory and personnel data as well as operational data. POPCOM still needs reliable service statistics and regular data on contraceptive and equipment inventories, personnel, and financial matters to exercise its coordinating and operating functions effectively. Insufficient, incomplete and irregular information has delayed the identifi- cation of problem areas in the program and allowed unfavorable conditions to remain unattended for long periods. The development of information systems for the population program which are relevant and responsive to the needs of managers and supervisors is a priority. In order to establish an adequate system, the present MIS unit at POPCOM would need to be strengthened with technical staff. Compatibility and linkages among the health, population and nutrition information systems under MOH, POPCOM and the National Nutrition Council respectively appear desirable at the field level; it is also possible that the three systems may benefit from utilizing common computer hardware for data processing. Two feasibility studies are being financed under the first Bank population project: one study will assess the possibility of linking the three systems at various levels and a second study will determine the computer hardware requirements of the three systems. 1/ 1973 National Demographic Survey; 1974 National Acceptor Survey; 1975 survey of TEC needs at the regional level conducted by the University of the Philippines Institute of Mass Communication, and 1978 assess- ment by the Special Committee to Review the Philippines Population Program.  - 13 - Population Research 2.36 A great quantity of population-related research has been done in the Philippines, much of it on trends in fertility and mortality, patterns of formation _nd age of marriage, migration and urbanization. In recent years some research has been done on socioeconomic and demographic interrelation- ships, primarily correlations of socioeconomic and geographical factors and fertility; few have addressed fertility determinants. There have been also numerous studies of family planning program effectiveness. Although some of these studies have been useful to policy-makers and program planners, the majority have not been utilized. Additional research identified by the Special Committee as needed covers such subjects as: demographic levels, patterns and trends; the socioeconomic determinants of fertility; the impact of policies on demographic behavior; and improving the effectiveness of the national population program. 2.37 There are about 26 institutions in the Philippines engaged in population research; nearly all are Manila-based. Of these, the primary contributors are the National Census and Statistics Office, University of the Philippines Population Institute, PCF and Xavier University. The census office has dealt primarily with census taking (1970, 1975) and analysis, prepared pop- ulation projections, carried out a survey of households (including KAP-1972) and participated in the World Fertility Survey. The state-supported Popula- tion Institute conducted research and analysis on demographic levels and trends and on socioeconomic variables. PCF, although not undertaking research itself, has helped to fund basic biomedical research, a study of the socio- economic correlates of fertility, and some pilot projects testing alternative delivery systems, and has done much to disseminate research results. 2.38 Although the quality of population-related research in the Philip- pines is quite good, there are four major shortcomings in the research done to date. First, it has not been fully utilized partly due to failure to dis- seminate it and partly because policy-makers and program planners have not taken an active part in study, identification, and design of the research. A second shortcoming has been a lack of order of priority among studies. A third shortcoming is the lack of coordination as no one organization is fully aware of all population-related ongoing research. A fourth constraint is that most research is done by Manila-based institutions. The proposed project's population research component has been designed to address these shortcomings and to complement the efforts of other external donors in this area. B. Health Services Health Status 2.39 The average life expectancy at birth in the Philippines increased from 55.6 years in 1968, to 61 years in 1975. This compares favorably with  - 14 - countries at a similar level of development. 1/ Certain communicable diseases such as tuberculosis, gastroenteritis, and respiratory infections are still prominent among the leading causes of morbidity and mortality, although there have been increases in cases and deaths from chronic diseases as a result of increased life expectancy. The morbidity pattern in the country continues to reflect relatively unfavorable environmental and nutritional conditions. Infant mortality was 74 per 1,000 in 1976, but in rural areas it is still over 100 per 1,000. The leading causes of infant deaths are communicable diseases; the underlying factors are poverty, high fertility, insufficient information and education about basic health concepts and good health practices, mal- nutrition, and poor environmental sanitation. Environment-related diseases such as malaria continue to affect a great number of people, mostly in the Cagayan Valley, South Western Mindanao, Palawan and Isabela. Schistosomiasis is prevalent in the Mindanao and Eastern Visayas, with programs to combat these diseases especially intensive in these regions. National Goals and Strategies in the Health Sector 2.40 The Health, Population, and Nutrition chapter of the Five-Year Philippine Development Plan 1978-82 includes among the main goals of the health and nutrition sectors the following: (a) to extend life expectancy (in years) from 61 in 1975, to 63 in 1983 and 66 in 1987; (b) to reduce infant mortality from 74 per 1,000 live births in 1976, to 60 per 1,000 in 1983 and 56 in 1987; (c) to reduce the prevalence of second degree malnutrition among children under six years of age from 25% to 16% in 1982 and 11% in 1987; and (d) to reduce morbidity from priority communicable diseases 2/ by 20% by 1983 and by 45% by 1987 from present levels. 2.41 The Plan proposes to attain these goals by increasing the range of services offered, by reaching more people--especially in city slums and depressed areas--and by encouraging people to make better use of the services provided. The private sector and voluntary agencies will be encouraged to increase their health activities among low-income groups. Funds received from external sources will be utilized to complement national resources. 2.42 The National Health Plan recognizes that large families, frequent pregnancies, and low standards of living and nutrition that accompany rapid population growth aggravate existing health problems and impose an increasing burden on the health services. Another urgent health-related problem identi- fied in the National Health Plan is malnutrition. In 1977, a nationwide weight survey found that 78% of the more than four million pre-school children examined were malnourished. Of those, 6% were severely malnourished (third degree), 25% moderately malnourished (second degree), and 47% slightly 1/ For example, in 1975 in Thailand the average life expectancy at birth was 59 years and in Indonesia, 49 years. 2/ Gastroenteritis, tuberculosis, malaria, and schistosomiasis.  - 15 - moderately malnourished (second degree), and 47% slightly malnourished (first degree). Only 22% were of normal weight. Malnutrition is due not only to inadequate food, but also to dietary habits and cultural practices. This points to the need for intensifying nutrition education which has up to now received very limited resources among the Ministry of Health programs, although official policy is now changing in this respect. 2.43 The above stated strategies and policies of the Government in the fields of population, health, and nutrition are sound. The Government has a clear commitment to reduce fertility and proposes an integrated framework which would take into account the interactions between the fertility behavior of couples and health, nutrition, and education. The program will, however, impose a severe burden on the staff and organization of both MOH and POPCOM, and the proposed second project is designed to increase the capacity of these agencies to carry it out. 2.44 Although the public health services sector (national, provincial, and municipal) are responsible for providing health care for about 67% of the population, 1/ they currently reach only one-half of that number. In 1978, health ranked fourth in total new appropriation of Government funds with 4% of the total national budget. Of this amount, 82% went to the Ministry of Health. The private health sector spends as much on personal medical care as the Government spends on public health services. It is not realistic to expect any substantial increase in the share of resources devoted to health in the near future. It is therefore important to find the most economic way of extending health services to the people now not served. 2.45 Under the Restructured Health Care Delivery System started as part of the first project, MOH redistributed functions among health team members to achieve a better utilization of doctors and nurses, who now can delegate some functions to auxiliary personnel. In spite of the progress made so far (about 45% of the MOH health staff has already been retrained) much more remains to be done to extend health and family planning services to the one-third of the total population (mostly rural) who now lack them. A study in five provinces of the country has shown that, even when fully implemented, the RHCDS could not meet more than 47% of community health needs, since only those persons living within a radius of three kilometers of health centers can easily avail themselves of their services. The Government has decided to test further innovations in low cost health care based on encouragement of self- care, community sharing of costs, preventive actions, and the use of community health workers trained in appropriate technologies (the Primary Health Care-- PHC--approach is discussed in paras 3.30-3.34). 1/ It is estimated that one-third of the population, mostly in urban areas, has access to private medical care. Most of the remaining two-thirds dependent on public health care live in rural areas and urban slums; these two-thirds of the population should receive health care from the Rural Health UJnits and Barangay Health Stations, but actual coverage is about half of the target or approximately one-third of the population.  - 16 - Organization and Manpower of the MOH Health Services 2.46 The MOH health and family planning delivery system comprises four levels: central, regional, provincial and local. The organization of the Ministry of Health is shown in Annex 1, C-3. There are 12 regional health offices, each of which maintains a training center and a laboratory. There are 76 provincial health offices. 2.47 At the local or field level, the health and family planning ser- vices of MOH are administered by: (a) 60 city health offices in chartered cities which, although directly under the jurisdiction of the regional health offices, are fully funded by the city governments; (b) 1,700 main health centers (MHC) located in urban areas called municipalities, each of which provides services to about 20,000 to 50,000 people within a three to five kilometer radius; 1/ (c) 236 community hospitals and health centers with almost 10,000 beds, situated in municipalities lacking easy access to city hospitals (in most cases these hospitals serve as main health centers for those municipalities); and (d) about 100 hospitals with a total of about 20,000 beds (70% in Metro-Manila). Some MHCs are supported by three to six satellite Barangay Health Stations (BHSs) (there are only about 3,000 BHSs in the country). MHCs are basically staffed by one doctor, one nurse, two to three midwives and one sanitary inspector, although more staff are assigned to MHCs serving large populations. The complex of one MHC, several satellite BHSs and, occasionally, another health center, is now called a Rural Health Unit (RHU). (See Annex 12, T-5 for details on health facilities.) 2.48 The key health personnel are physicians, nurses, midwives and sanitary inspectors. In 1977 there were altogether 48,500 health workers in the country. Of those, 13,100 were doctors , 8,200 nurses, 7,000 midwives and 2,700 sanitary inspectors (details are shown in T-6 in Annex 12). About 30% of the doctors and the same proportion of nurses are in the public health services. Although the medical, nursing, and midwifery schools in the country turn out as many professionals as the country needs, they are unevenly distri- buted because they prefer to live in the urban areas which offer the best career and earning prospects. The Government is aware of this problem and is committed to taking remedial action. However, realistically this situation will take a long time to change significantly. This makes the potential for using paraprofessional workers more important. An interministerial committee is preparing guidelines on the use of para-professional health workers by Government and private agencies, including whether and how these cadres should be paid. 1/ In cases where there is more than one health center in a municipality, one is designated as Main Health Center and takes leadership in health matters in that municipality.  - 17 - Performance and Constraints of Health Services 2.49 The present health and family planning delivery system in the Philippines suffers from: (a) over-centralized planning and management; (b) existence of a large number of offices/bureaus/units at the central level with no clear definition of functions and often with overlapping re- sponsibilities; (c) weak coordination and communication among the various offices at the central level; (d) scarcity of adequately trained managerial staff at all levels which results in lack of planning and proper prioritiz- ing of programs and a lack of technical, administrative and logistic support for peripheral units; (e) consequent deficiencies in the peripheral units reflected in inefficient utilization of resources, inadequately trained and supervised staff, failure of logistics and supply systems, poor utilization of the health facilities by communities and inadequate outreach of the health personnel into the community; and (f) weak coordination of MOH's programs with those of other relevant ministries. 2.50 Recognizing these problems, the Ministry of Health decided that a functional analysis of the health delivery system be carried out before making any changes. The object of this study is to identify the various causes of dysfunctions within the health services and to suggest remedies. This study will be carried out during 1979 as part of the activities under an amendment to the first Bank population project. During negotiations, assurances were obtained from the Government that it will make the study results available to the Association by December 31, 1979 and that by April 30, 1980 it will consult with the Association on a timetable for implementa- tion of the recommendations arising from this study. Training 2.51 Although it has been recognized since the mid-1950s that in-service training was necessary to increase the efficiency and quality of the health service staff, inadequate funds have been devoted to this kind of training. During preparation of the first Bank project, training was identified as particularly in need of support. With a view to implementing the training component of the project more effectively, the Government decided to create a new training unit alongside the existing Office of Health Education and Personnel Training (OHEPT) in MOH. Although this approach proved successful from the point of view of preparing curricula, organizing training and meeting targets, several problems developed including: (a) organizational dysfunctions-- two units in a Ministry undertaking the same functions; (b) unsatisfactory cur- ricula in several areas--e.g., family planning and IEC--because of insufficient consultation with pertinent central offices of MOH; and (c) lack of institu- tionalization of training programs in MOH. 2.52 While processing the second population project, an analysis of training activities in MOH undertaken by the Government reached the follow- ing conclusions: (a) there is a need to strengthen OHEPT's technical and managerial capabilities in order to enable it to design, organize, administer and evaluate MOH training programs; (b) the temporary training unit estab- lished for the first project should be merged with OHEPT, thus strengthening  - 18 - that office with the experienced personnel; (c) NFPO's training division, which has hitherto been responsible for family planning training within MOH, should retain responsibility for family planning training, but should work in close coordination with OHEPT; (d) MOH trainers at all levels need upgrading in training and supervisory skills, and as a first step a core of "master trainers" should be developed to institutionalize among all MOH trainers the capability to design, administer, implement, evaluate and re-cycle training programs; (e) the proportion of practice to theory in training programs for health personnel should be increased and be made more relevant to desirable behavioral modifications iii job performance; and (f) concerning family pla.n- ning training, it is desirable to share training resources (consultants, re- source personnel, trainers and training materials) among all participating agencies in order to ensure a common national approach. Health Education/IEC 2.53 Although there has been a health education unit in MOH since 1920, it has never been allocated enough funds to enable it to have much impact. In addition to the staff of this unit, there are a few health educators working on special projects in other branches of MOH headquarters. Gradually a corps of health educators has also been developed in the field with two in most regional health offices, one or two in about half of the provincial health offices, and several in city health offices. Most of the printed materials produced in MOH during the past several years have been reproduced in small quantities only, essentially for pretesting. In recent years, external support for health education has largely been limited to WHO assist- ance in staff development. During project preparation, IEC was identified as one of the weakest aspects of the RHCDS. The health education/IEC system has suffered from the absence of an overall plan. In consequence, the IEC work being carried out as part of various vertical programs (e.g., nutrition, immunization, family planning, environmental sanitation) is largely uncoordi- nated. Another weakness is the lack of training and supervision of the rural health staff responsible for face-to-face communication with the public and community leaders. Health education in the field also suffers from a dearth of IEC materials and AV equipment. During project preparation, MOH developed an overall IEC plan for health services which addresses the major weaknesses and serves as the basis for the MOH/IEC component of the second project. Management Information Systems 2.54 The MIS UJnit initiated through the first population project has been incorporated into the MOH structure. That Unit, with the assistance of consultants, has developed and is implementing systems to monitor finance, inventory and personnel and is currently preparing systems to monitor the operation of hospitals and rural health units. The process of systems devel- opment has been slow, but the problems have not been unusual for this complex field which requires specialized expertise. The rural health unit sub-system, for instance, is still not producing usable data at the national level, but it is being tested in a few provinces. Results from those tests will be used in the further development of that system and its national implementation is  - 19 - planned to be effected by end-1979. The MIS will require financial and technical assistance over the next five years to enable it to acquire and place in operation computer and peripheral hardware needed to make the system fully operational; regular evaluation of its effectiveness will also be essential. C. First Bank Population Project 2.55 In 1974 the Bank made a US$25 million loan for a first population project designed to: (a) strengthen POPCOM's capacity to coordinate the population program establishing a training division and an IEC division, and 12 regional offices; and (b) improve service delivery by helping MOH introduce a "Restructured Health Care Delivery System" and further expand the delivery of services in rural areas. The POPCOM component of the project was undertaken with parallel financing from USAID and UNFPA; the Government has already absorbed the consequent increase in recurrent costs. The loan agreement was amended in December 1978 to enable additional activities and equipment to be financed from unneeded contingency funds. The total cost of the amended project is US$40 million. The loan of US$25 million, is allocated as follows: US$9.5 million for construction; US$6.5 million for equipment and furniture; US$3.9 million for technical assistance and training; US$0.8 million for IEC; US$1.0 million for incremental recurrent costs; and US$3.3 for contingencies. The first project consists of financing: (a) for service expansion: in MOH, new buildings for 207 RHUs and 12 regional training centers, the hiring of 5,000 mid- wives to serve in rural barangays and the procurement of 400 vehicles; and in POPCOM, procurement of radio equipment and 161 vehicles; (b) for training, establishment of a training division in POPCOM and courses in teaching methodology, management, planning, primary health care, and family planning skills under POPCOM and participating agencies, including MOH; (c) for IEC, a mass media campaign and production of IEC materials in support of the population program and additional technical staff for POPCOM's IEC Division; (d) establishment of an MIS in MOH and feasibility studies for an inter-linked health, population and nutrition MIS and for assessment of computer hardware needs; (e) preparation of a second project and several studies, including one of a condom marketing scheme and a functional analysis of the Ministry of Health; and (f) technical assistance for several of the above components.  - 20 - 2.56 The first project was designed in 1973-74, when the population pro- gram was just starting. The Government had identified the MOH network as a main conduit for family planning services and adopted a policy of integration of health and family planning services. Other donors, and most prominently USAID, were providing the bulk of the external assistance for the software aspects of the program, i.e., contraceptives, salaries, research, evaluation, etc. The Bank assessment during project identification concluded that while the inputs that were being provided through such assistance were essential to establish the program, on a long-term perspective: (a) the MOH health services would need considerable strengthening to stand successfully the additional burden of a new and difficult program such as family planning; and (b) the population program should be multisectoral, utilizing many other agencies besides the health services, and therefore a strong umbrella agency-- POPCOM--was needed to coordinate activities. The project was formulated on the basis of these premises; the components were chosen to begin assisting the institutional development of the two main agencies responsible for the program-- MOH and POPCOM. 2.57 The first project will be completed by December 31, 1979. At that time the main health centers built will be operating in over 200 towns scattered in 56 of the 76 provinces of the Philippines (see map); they will serve as referral points for rural midwives who work in rural barangays surrounding the centers, in addition to providing services to persons living nearby. The 5,000 midwives hired through the project are trained and posted in rural barangays, their salaries already picked up in the Government's regular budget. Nine of the scheduled 12 regional training centers, are now operating; they house trainees and teaching staff for in-service health and family planning courses. 2.58 The impact of this project on health improvement and fertility reduction activities will be measured on a continued basis through the MIS established by the project. The first such data are expected by mid-1981 (see para. 3.28). Although there are still organizational and technical shortcomings in the two agencies that the project was designed to assist, the environment for improving their programs has definitely been enhanced as a result of the first project. The benefits derived so far are: (a) a strong and constructive dialog has been established, not only between the Bank and the two implementing agencies, but also between the POPCOM and MOH, and among international and bilateral agencies assisting the population pro- gram; and (b) the problems faced in implementing the project, i.e., weaknesses of the "project unit" approach, and deficiencies in family planning training, have contributed to a better designed second project that is fine tuned to improve the agencies organizationally and technically, while reemphasizing the need to address the long-term requirements of the health and population programs. The project inputs of physical infrastructure in MOH and training and additional personnel in both POPCOM and MOH are all necessary resources in the continued, long-term process of institution building and program improvement.  - 21 - D. External Assistance to Population and Health Programs in the Philippines 2.59 Until 1973, more than 60% of the population program was financed by external assistance. In CY1977, the share of foreign assistance had declined to about 45%. This proportion is expected to level off at about 20% in 1982. Past contributi,)ns and projected amounts of population assistance to the Philippines are presented in Annex 12, T-7. The main external donor has been USAID and the next largest contributors have been the Bank and UNFPA. Other donors had obligated a total of US$8 million through the end of 1977. The Government contributed US$44 million for the period 1969-1977. 2.60 Throughout the preparation of the proposed project, USAID, UNFPA, and the Association--the main external contributors-- have been in close coordination to ensure that there will be no overlapping of assistance. 2.61 The largest external financial assistance received for the health program in the Philippines in recent years has been through the first Bank assisted population project (para. 2.55). Also two other Bank projects--one rural and one urban development project--have health components consisting of providing buildings for MHCs and BHSs. The next largest contributor has been USAID, in the past mainly for the nutrition program and, more recently, for health services. In 1978, USAID approved a US$5.4 million loan for a five- year health project for Panay Island (Project PUSH) aimed at improving the health status of the population living in 600 depressed barangays (336,000 beneficiaries). WHO and UNICEF render a wide range of technical assistance in the health field. The latter also provides financial support for training, equipment and vehicles mainly devoted to improving maternal and child health care; recently it approved financing for a four-year vaccination program. III. THE PROJECT A. Project Concept 3.01 This project was designed to assist the Philippines in its efforts to reduce fertility levels over the next five years and, at the same time, to decrease infant mortality and malnutrition among children and improve the health status of semi-urban and rural populations. The project design is based on the premise that fertility reduction on the one hand and improved child survival and better family health on the other, are interconnected and mutually influencing events. Awareness by parents that they can raise healthy children is thought to be an important factor in stimulating family planning practice. Improvements in the provision of health services and health education may therefore be significant in making the practice of family planning widely acceptable. A second connection which is basic to the design of this project is that the health services are a major structure for delivering family planning services and that in order to improve these services it is necessary to address the major problems and constraints of the parent health system. A third consideration in project formulation is that,  - 22 - apart from the direct effects of improved health and family planning services on fertility reduction, there is a need for support and institutional develop- ment of the coordinating structure of the national population program at central, regional and local levels in order that it may exert effective policy- making, planning, coordination, and evaluation of all population-related activities. A fourth aspect taken into account is that in order to increase effectively the health and family planning service outreach it is not enough to expand the formal infrastructure of facilities and personnel, but it is essential to obtain the widespread participation of an informed and knowledge- able community. PersonLnel training and IEC activities are, thus, essential components of this project. 3.02 The arrangements for project implementation take into account the experience, including both strengths and weaknesses, of the health and family planning programs, and especially, of the first project during the past 5 years. The project will assist the two main organizations involved in the population program--POPCOMl, the "umbrella", coordinating body, and MOH, the main family planning service provider. It will consist of two parts: (a) Part A, under POPCOM, will finance a central and field staff development program emphasizing training and recruitment, IEC activities, population research and an appropriate regional infrastructure; and (b) Part B, under MOH, will strengthen and expand the restructured health care delivery system, initiate primary health care schemes in the 12 health regions, and improve administration, supervision, training and IEC. B. Project Objectives 3.03 The objective of the project is to assist the Government to reach the target of providing 40% of couples in reproductive ages with family plan- ning services by 1982 and 50% by 1987, and the health and nutrition targets stated in para. 2.40, by increasing the proportion of the population reached by MOH's services from the present 33% to at least 50%. The project is expected to: (a) increase the number of couples practicing family planning as a result of considerably intensified IEC efforts, improved clinic services by well trained and supervised staff, the opening of new health facilities and the introduction of primary health care (PILC) schemes; (b) reduce infant mor- tality through better health care services to mothers and children, better birth spacing, and the inculcation of better health practices by an intensive IEC program; (c) reduce second degree malnutrition of pre-school chidren by means of improved counseling to mothers, early detection and follow-ups, intensified nutrition education, and a faster response to nutrition problems in areas identified by the nutrition surveillance system which forms part of the MIS component; and (d) reduce morbidity and mortality from priority communicable diseases as a result of preventive IEC campaigns and prompter treatment of cases by better trained staff well supplied with appropriate medicines.  - 23 - C. Summary Project Description 3.04 In summary, the project will consist of: Part A. POPCOM (a) Constructing, furnishing and equipping seven regional office buildings, and thirteen contraceptive warehouses and vehicle maintenance workshops as part of POPCOM's regional offices; (b) Equipment for training and IEC, including training models, kits for family planning, audio-visual production and utilization equipment for central, regional and provincial offices, and materials for finished products; (c) 85 vehicles and 21 boats for POPCOM's coordinating, supply, and IEC activities; (d) Other development costs including: (i) advisory services for population activities (person- months): 18 months in financial and auditing matters; 6 months in maintenance, evaluation and continuous development of MIS; 12 months in re- search design and evaluation; 50 months in IEC; and 9 months in training; (ii) fellowships for population activities: 15 6-week in computer technology, information systems develop- ment, and data management; 4 6-month in research design and management; 3 1-month study tours, 9 6-month foreign, and 4 12-month local in TEC; and 15 4-month in specialty training; (iii) design and development of prototype population IEC materials (e.g. master tapes for radio programs), production of IEC materials; and research studies and evaluation; (iv) architect and construction management consultant fees. (e) Incremental operating costs, including salaries for project administration; incremental salaries for training, !EC, MIS and research activities; vehicle and equipment operation and mainte- nance; distribution of IEC materials; and travel and per diem for training, IEC, MIS, research activities and rentals for training activities; (f) Innovative activities in the population program, i.e. activities which are identified at a later stage of the project as important complement to POPCOM program.  - 24 - Part B. MOH (a) Constructing, furnishing and equipping: (i) 75 health centers; (ii) 915 barangay health stations; and (iii) MOH space remodeling for IEC; (b) IEC and MIS equipment, including computer hardware, TEC production and utilization equipment for central, regional, provincial and local levels, materials for finished products and seed funds for PHC schemes; and (c) 12 4-wheel audiovisual vans, 3 utility vehicles for MOH's central IEC office, 12 vehicles for MOH's regional training activities and 10 boats for service expansion; (d) Other development costs including: (i) fellowships for health/family planning/nutrition activities: 25 6-week in computer technology, in- formation systems development, and data management; 15 4-month for specialty trainers; and 4 12-month in IEC; (ii) design and development of health/family planning/ nutrition prototypes for IEC materials, production of IEC materials, and evaluation activities; (iii) advisory services for health/family planning/nutrition activities: 18 months in financial and auditing matters; 6 months in MIS evaluation, maintenance, and upgrading; 27 months (foreign) and 120 months (local) in training; 13 months (foreign) and 17 months (local) in IEC; 70 months to design and implement an improved logistics system; 6 months in PHC design and imple- mentation; (iv) architect and construction management consultant fees; (e) Incremental operating costs, including salaries for project administration; incremental salaries for the construction unit, training, IEC and MIS activities; vehicle and equipment operation and maintenance; distribution of IEC materials; travel and per diem for training, IEC, MIS, and research activities; and rentals for training activities; and (f) Innovative activities in the health services, i.e. activities which are identified at a later stage of the project as impor- tant complement to MOH components.  - 25 - D. Detailed Project Description Part A: Commission on Population Expansion of POPCOM's Infrastructure 3.05 After the organizational and managerial problems affecting POPCOM's Secretariat at the central level are satisfactorily resolved (para. 2.14) it will need assistance at the regional level in the form of buildings, equipment, and vehicles to undertake its coordinating role and to operate the IEC and training programs. 3.06 Regional Offices. The project will help finance infrastructure for POPCOM's regional offices. Buildings for six of the 13 POPCOM Regional Offices were financed in 1974-75 through a USAID grant. The remaining seven offices are poorly housed in rented quarters, which do not provide a proper environment for conducting coordinating activities such as meetings and seminars and for storing IEC, training equipment and contraceptives, keeping and repairing vehicles and enabling in-house production of printed materials, audio tapes, and photo processing. The project will finance new buildings, equipment and furniture for POPCOM Regional Offices in the following regions: Central Luzon (Region III), Metro Manila (Region IV), Eastern Visayas (Region VIII), Western Mindanao (Region IX), Southern Mindanao (Region XI), and Eastern Mindanao (Region XII) and Southern Tagalog (Region XIII). Each building will provide office space for 30-35 staff, a conference and lecture r6om, a library, a production room and a photo laboratory; it will also include a storage area or small warehouse for contraceptives and for training and IEC materials and equipment, and a garage for keeping and repairing vehi- cles. Warehouses and garages will also be built adjacent to the existing six POPCOM Regional Offices in: La Union (Region I), Tuguegarao (Region II), Albay (Region V), Iloilo (Region VI), Cebu (Region VII), and Misamis Oriental (Region X). The POPCOM will train 26 drivers as automobile mechanics to repair and maintain the vehicle fleet in good condition. 3.07 Vehicles and Radio Communication. POPCOM has a fleet of 339 vehicles of which about 200 (59%) are in poor state of repair. Under the amended first population project, 161 utility vehicles will be added in CY1979 for deliver- ing contraceptives and other materials, for field visits, and for training purposes, both in relation with Project Outreach and other POPCOM coordinating activities. This second project will finance the procurement of another 85 vehicles, as follows: 14 audiovisual vans for film showings, photo exhibits and mobile displays; 26 two-wheel drive, 13 four-wheel drive vehicles and 4 heavy duty vehicles for monitoring and coordinating field activities and transporting staff and materials; 26 two-wheel drive vehicles for transporting contraceptive supplies, IEC materials, and equipment from regional offices to the field; and 2 dual-drive trucks to haul commodities to and from piers for shipment to regional warehouses or for direct transportation to regional warehouses. The project will also finance 21 boats for the transport of staff and supplies, to be used to reach otherwise inaccessible coastal and island towns. Single-side band radio equipment will also be financed to extend the network already available to POPCOM, which was partly financed through the first Bank project.  - 26 - Training in Population and Family Planning 3.08 Training is essential to the success of the population program. There is need for a concerted effort over the next five years to train trainers, program staff and field workers, in order to remove the constraints listed in para. 2.28. The national population training plan covers training activities carried out by some 20 agencies with POPCOM's coordination. Developing the plan involved the following steps: (a) the national program's available manpower were analyzed by category and functions; (b) administrative/ managerial constraints requiring decisions and solutions other than training were identified, described, and presented to the agencies' managements for proper resolution; and (c) all remaining constraints which were amenable to improvement through training were spelled out and specific training activi- ties were designed to address those problems or deficiencies. 3.09 The objectives of the POPCOM training component of this project are to enhance the capacity of trainers at various levels in designing, conducting, evaluating and re-cycling population/family planning training programs; and to enable effective large-scale training of managerial and service delivery staff. In order to achieve these objectives, in implementing this training component POPCOM and the participating agencies will give priority to the training of trainers (using as a basis the "master trainers" organized under the first project); also, training resources (consultants, trainers and training materials) will be shared by the agencies. The POPCOM Training Division will coordinate the implementation of the POPCOM population training component of the project with the help of a coordinating team at the working level in which all the participating agencies will be represented. The POPCOM training component is distinct from the MOII family planning training component; the latter will be directed by NFPO in coopera- tion with OHEPT. 3.10 The POPCOM training component will finance technical assistance, teaching equipment and materials, and the incremental recurrent costs for the following training activities (for a list of courses, see Annex 2): teaching methodology for "master" trainers and trainers of trainers; management; information/motivation on the population program; record-keeping, logistics, administrative and financial management, disbursements and accounting; plan- ning and staff development; skills training in IEC; and family planning skills (including pill dispensing, IUD insertion and sterilization techniques). This training component will be complementary with assistance that POPCOM will receive from UNFPA and USAID for other training activities. Demand Creating Activities - IEC 3.11 IEC Objectives. The purpose of the POPCOM IEC component, is to increase the acceptance and practice of family planning by encouraging: (a) non-users and dropouts to use effective family planning methods; (b) current users to switch from less effective methods to more effective methods;  - 27 - (c) husbands to support their wives' family planning practice or to practice a male method themselves; (d) youth to delay marriage, to enter marriage with the intention of delaying the first birth, and to integrate family planning into their marital life; (e) political, religious, and other leaders; officials; professional groups; and other influential persons, to suipport family planning practice and the overall aims of the population program; and (f) communities to accept family planning as a normal aspect of everyday family life. 3.12 Major Strategies. The design of the expanded IEC program is based on the analysis of the life cycle of the typical Filipino: the institutions through which he or she passes and the times when key decisions are made in relation to family life. Thus the program stresses (in developmental order): population education for children and youth in school (to be supported by UNFPA), family life education for out-of-school youth, premarital informa- tion for couples who are about to be married, family planning information for married couples and postpartum mothers, and follow-up services for actual or potential dropouts. In addition, a number of activities will be supported that would reach those who in turn influence these ultimate users: various leadership and professional audiences and those who control resources needed by the program as a whole (e.g., mass media executives, heads of extension services, and municipal health officers). 3.13 Instead of, as in the past, acting as a passive conduit for funds and as monitoring agency, POPCOM will in the future act as leader of the par- ticipating agencies in IEC and other areas. While POPCOM will provide proj- ect resources to enable specific participating agencies to continue and expand their contributions to the national population program, there will be improved mechanisms for planning and coordination. Mass media materials will be designed to support the efforts of field workers, and field workers will be encouraged to refer clients to the mass media to reinforce or validate their own messages. The design, development and, where appropriate, the production of materials will increasingly be decentralized to take account of substantial regional differences in knowledge, attitudes and practices. Some programming will be carried out separately by each region, and in other cases, neighboring regions with the same dialect or similar cultural groups will combine forces for joint implementation. Although it has been assumed for planning purposes that resources should be provided on the same scale for each region, POPCOM proposes to allocate such resources taking into account the number of married couples of reproductive age, the overall IEC capacity of the regional staff (both in POPCOM and in participating agencies), the number of mass media outlets and any prioritization for regional support that may result from changes in program strategies.  - 28 - 3.14 Main Channels. The IEC program will utilize the rich variety and extensive availability of media and "human channels" (e.g., field-workers). The program is based on specific research findings and the now conventional wisdom that the field-worker is the crucial link between the program and the people, having far more impact than the mass media, which can only provide information and reinforce inter-personal communication. The project will facilitate the IEC activities of special purpose population workers, other extension workers, and groups of volunteers in two main ways: through train- ing in IEC skills and provision of training materials (films and manuals); and through provision of audio-visual aids and various printed handouts. 3.15 The media mix is based on the overall communication situation in the Philippines, which is described in more detail in Annex 3. The project will provide assistance in the design, development, mass replication and dissemina- tion of radio programs and spot announcements, newspaper articles and adver- tisements, cinema spots and films, comic books and a variety of traditional or folk media. A detailed list of materials to be produced is given in Annex 3. Since the distribution of support materials has repeatedly been identified as the weak link in the TEC program, during negotiations the Government gave assurances that it will cause POPCOM to undertake a review of the IEC distri- bution system and that the recommendations arising from such review will be conveyed to the Association by October 31, 1980. 3.16 Supporting Structure for IEC. In order to carry out the greatly expanded population IEC program, the staff and equipment of POPCOM and the participating agencies must be strengthened. One junior and four senior staff members will be added to the IEC Division of POPCOM. Senior staff will be added to the central planning, training and research divisions. The IEC units of each POPCOM regional office will be strengthened by the addition of two senior professionals and a second mobile information, education, and motivation team. New and existing POPCOM staff (including, of course, IEC staff) will benefit from the training program (para. 3.10) and selected staff will receive fellowships enabling them to participate in a one-year course in population communication, to study effective IEC activities in other coun- tries, and to obtain specialized technical training overseas. A total of 4.2 person-years of consultant services in IEC related matters will provide POPCOM with technical guidance on a range of topics, including equipment maintenance and evaluation. Each regional office will be provided with a four-wheel drive van. Each of 76 provinces will be supplied with basic AV equipment (slide and film projectors, cassette tape recorders, screens and other miscellaneous items). During negotiations, assurances were obtained from the Government that POPCOM, in consultation with the participating agencies, will develop not later than December 31, 1980, a system acceptable to the Association for the management and maintenance of these equipment pools. Such a system should include a policy on priority uses of the equip- ment; a mechanism for monitoring its use and whereabouts; and a scheme for supplying replacement parts and carrying out general maintenance and repair of equipment.  - 29 - 3.17 IEC Research and Evaluation. The project will finance several research projects of special relevance to the IEC program. Consultants will evaluate the effectiveness of such items as the population education program for out-of-school youth, the premarital information program, and materials for fieldwork. POPrOM will collect baseline data for measuring the impact of the population IEC )rogram. Funds for this and subsequent measurements are included under the research component of the project. Research on Population and Family Planning 3.18 As discussed (para. 2.36), although a massive amount of population- related research has been carried out over the past decade, it has not been linked with policy and program needs, nor has there been appreciable feedback into operations. The proposed research component will complement the assis- tance provided for population research by other external donors--especially UNFPA and USAID--and will help POPCOM to select and design research activities more responsive to policy and program needs, and to disseminate the results quickly and in a usable form. 3.19 To encourage closer linkage between research and policy and opera- tions, POPCOM will conduct semi-annual two-day workshops of about 25 research workers and administrators, and initiate a regular publications program. In addition, the research and evaluation coordinators in POPCOM's regional offices, whose services have not been properly utilized in the past, will help identify operationally useful research studies. 3.20 Proposals for twelve specific studies urgently needed were developed by POPCOM and will be financed by the project (they are listed in Annex 4). They address current policy and program needs, and the users of the results have been identified. It is expected that the need for additional studies will emerge during the project period. A small amount of funds for these additional studies and for any other study identified by the regional research and evaluation coordinators may be made available from the innovative activi- ties component of this project if they meet the requisite criteria (see para. 3.23). POPCOM will encourage institutions outside Metro Manila to build up research capability. 3.21 The proposed research component will be administered by POPCOM's Research UJnit in the Planning Division. During negotiations the Government gave assurances that it will employ, by October 31, 1979, and thereafter maintain a suitably qualified professional as Chief of the Research Unit. Two research staff from each of POPCOM's functional units (IEC, Training and Clinical Services) would be reassigned to the Division to assist with the increased workload. Tn addition, two senior researchers and an editor (for publications) will be contracted. Local consultants will be engaged to advise on the technical design of studies and to evaluate research proposals. One- day workshops of about 25 representatives of concerned agencies will be held quarterly to monitor ongoing and plan future research. The regional research and evaluation coordinators will also meet semi-annually.  - 30 - Management Information System 3.22 POPCOM needs to strengthen its MIS Division (para 2.35) by training existing staff in technical aspects of data processing to form a group of 10 data processing professionals, 6 population data specialists and 4 computer operators. The necessary staff training is included in the POPCOM training component. The project will also finance 22.5 person months of overseas fellowships in: computer technology (use of terminals, communication input- output, and storage devices); information system development (including training in structured design and programming, software engineering, manage- ment of systems development, and use of equipment and software such as report writers, programming language processors, and program library systems); and data administration/data base management (including techniques for controlling data and use of packages such as data dictionaries, data base management systems, and query processors). Another important project contribution to the POPCOM/MIS will be six person-months of consultant services to help determine the information needs of management at all levels, the frequency and timing of reports, and the deficiencies of the present system. During negotiations, the Government gave assurances that it will employ, by October 31, 1979 and thereafter maintain a suitable qualified manager (or chief) for the MIS Unit. The inputs of this component will be complemented by essential advisory ser- vices in management information systems to be provided with USAID financing. Innovative Activities - Population 3.23 Experience with the first Philippines population project and with projects in other countries have shown the advisability of providing funds for support of innovative activities that may develop in the course of project implementation. In this project, funds amounting to US$900,000 have been allocated for innovative population activities that may be identified during implementation of Part A of this project. Some of these innovative activities could be an outgrowth of a project component (e.g. local IEC programs or additional research studies), or they may be entirely new activi- ties. The utilization of these funds by the Government will be subject to the same degree of care and scrutiny on the Association's part as it has been the case for other project components. To obtain the Association's approval, proposals must meet the following criteria: (a) relevance to program objec- tives; (b) appropriateness of financing from the credit; (c) feasibility of administration and evaluation; and (d) demonstrated replicability with regular program means. Approval of these proposals will be a condition of disburse- ment against this category (para. 7.03). Part B: Ministry of Health Expansion of Health, Family Planning and Nutrition Services 3.24 The Government's long-term health, population, and nutrition goals will be difficult to attain unless health service coverage is expanded in the next decade to the one-third of the country's population currently without adequate health care. The network of hospitals, main health centers, and barangay health stations (described in para. 2.47) is the backbone of ser- vice delivery. The physical infrastructure, equipment, and staffing, especially at the periphery (BHSs), require expansion. As already noted  - 31 - (para. 2.45), even if the RHCDS were operating at maximum efficiency, it could only meet the needs of persons living within a radius of three kilometers of the clinics. In this light, the Government's thrust to provide services to peripheral villages would need a complementary move originating from the com- munity. The key to this approach is to elicit community acceptance and partici- pation through non-professional health workers who can bridge effectively the wide cultural gap between the people and the modern health care approach. 3.25 The health services expansion component of the project will consist of: (a) expansion of physical infrastructure; (b) strengthening of logistics; and (c) development of primary health care schemes using barangay health workers. This service expansion will be complemented by qualitative improve- ments in manpower and supervision (through the training component), in demand creation among the community (through the IEC component), and in management and evaluation (through the MIS component). 3.26 Expansion of Physical Infrastructure. This project would finance construction of 75 health centers and 915 BHSs in 19 provinces where health facilities fall far short (40 to 60%) of the prescribed norm of one MHC per 20,000 people and one BHS per 5,000 population. Although there are deficien- cies in other provinces as well, this component will be confined to the provinces most in need. New health centers 1/ will only be built in places where services are now not available (no replacements of existing buildings-- either owned by the Government or rented--will be included in this project). This will ensure a net increase in service coverage. BHSs will be built only in barangays where midwives (mainly hired, trained and posted as part of the first Bank population project) are operating without adequate facilities or equipment, or where no services at all are available. During negotiations, assurances were given by the Government that it will employ in time staff for each of the 75 health centers and the 915 BHSs to be built through the project. 3.27 BHSs, which are simple structures, will be built by the local com- munity (this approach is being tested during 1979 in 25 barangays with funds from the first population project). The implementation of this BHS component is described in para 5.15. It is expected that community participation in building BHSs, in addition to cutting construction costs, will also increase community concern for cooperating with the midwife in maintaining the BPS, volunteering to help her in various health tasks, and making use of the services offered there by the resident midwife and visiting health personnel. 3.28 Through its MIS, the MOH will give priority to obtaining data on the utilization of facilities--distinguishing between existing and first and second project facilities--which should enable the MOH to detect any cases of low utilization; annual data will be processed regularly on a nationwide basis, starting with data for CY1980. These data, together with training in mapping to be given to municipal health officers under the training component, should facilitate in the future the effective planning of physical infrastructure for the health and family planning delivery system. 1/ Each project health center will be under the jurisdiction of a MHC and will share responsibility for providing services and supervising sur- rounding BHSs (the RHU structure is explained in para 2.47). In second map, references to MHC should read "health centers".  - 32 - 3.29 Strengthening of MOR Logistics Network. Partly because of financial problems, the MOH has had considerable difficulty in keeping health facilities adequately supplied with medicines and equipment. The first Bank project provided equipment (worth about US$3 million) for MHCs and BHSs serving as practice areas for in-service training programs. The project will include a study of the MOH logistics system which will recommend: (a) the quantities of medicines and other supplies required; (b) the required organization of the logistics system, including revised staffing patterns at the center and throughout the network; (c) the additional equipment (for maintenance and warehouse handling) transport and physical infrastructure required, providing equipment lists, specifications for procurement and schedules of accommodation for any physical infrastructure recommended; and (d) specific terms of refer- ence for the technical assistance that will be needed to make the system oper- ational. The credit will also finance 26 person months of technical assis- tance in the following areas: operational aspects of logistics (including flows and channels, transport means, normal times and risks); equipment main- tenance (to recommend organization of maintenance, a simple equipment inven- tory system with continuous updating and cost control to identify repair/ replacement trade-offs, and training required); and communication systems (to produce a feasibility study on the communications system for MOH, with indication of present communication needs and usage and cost trade-offs between use of public communications systems versus investment in a separate MOH system). 3.30 Primary Health Care Schemes. The primary health care component has been planned utilizing various experiences within the Philippines. Recognizing that community participation in health activities has been a crucial element of most low cost health care programs that have been effective and efficient, this program will be developed around the community with technical support from the formal health system and it will be based on the use of local work- ers. Barangay Health Workers (BHW) will be non-professional workers from the barangay they are to serve. They will be suported by the barangay and account- able to it. Training and technical support will come from the rural health unit (as defined in para. 2.47). In existing programs of this type, tradi- tional healers, hilots, or other health related workers such as the barangay nutrition scholars, often have been chosen by the community to become BHWs; this may be the case also in this component. 3.31 In the 12 provinces where this component will be implemented, it should provide opportunities to test the effectiveness of different forms of coordination and rationalization of the activities of several categories of health-related barangay workers currently existing in different parts of the Philippines (e.g. FTOWs, barangay nutrition scholars, private group health workers). NEDA has organized an advisory technical committee formed by representatives of several ministries (e.g. MOH, MLGCD, Ministry of Human Settlements, etc.) to address this issue; the Committee will present recom- mendations to NEDA's Social Development Council as a basis for a national policy on primary health care. During negotiations, assurances were received from the Government that it will develop and furnish the Association by April 30, 1981, a policy on primary health care which would set guidelines on the use of barangay health workers including whether and how these cadres should be paid.  - 33 - 3.32 The functions of BHWs will be determined by the needs and priorities of each barangay. Each province will adapt the primary health care scheme to its own needs. (Annex 5 presents the concept of primary health care.) The program will be implemented by barangay development councils that in many cases will ne d to be revitalized. Since the rural health unit is also crucial for the success of the scheme, municipal health officers will be given appropriate training during 1979 under the first project. UNICEF has agreed to provide technical expertise and other necessary assistance to facilitate the social preparation of communities. This will include a series of activi- ties involving MLGCD, non-government groups, and the MOH. These activities will be carried out as part of the regular program between the Government and UNICEF and are not included in the project cost. The role of the central, regional and provincial health levels will be one of general support through the regular channels of administration. This component will be evaluated through periodic survreys and regular reporting. 3.33 PHC schemes will be introduced in 12 provinces (one province per region) in order to test the approach and provide a basis for developing a national primary health care strategy. It is estimated that the total population of the 12 provinces to be covered is 4.4 million, and that only 75% of the barangays in those provinces are within the catchment areas of existing health services and personnel (although not necessarily receiving any ser- vices). The total number of people to be covered by the scheme is estimated to be 3.3 million in 4,050 barangays. 3.34 The primary health care program should be supported by the community. The project will accordingly provide each barangay with seed funds to start income generating projects, and the profits will then be used to support the local costs of the primary health care program, especially salaries of the workers. The project will also provide seed funds to start cooperative vil- lage level pharmacies (boticas), an approach that has already been tested successfully in the Philippines. Training of Health Personnel 3.35 As already mentioned (para. 2.51), MON in-service training needs to be stepped up considerably in the next five years. This project will finance a training of trainers program (initiated under the first project) for central ("master") trainers as well as for trainers at regional, provincial and municipal levels, and a series of training programs for service managers, and service providers in planning, management, IEC, and service skills. Training resources for family planning (consultants, resource personnel, trainers and training materials) will be shared among all participating agencies, and in particular between POPCOM and MOH. 3.36 The project will finance the following types of training for MOH personnel (a detailed list is presented in Annex 2): (a) courses and work- shops for trainers in planning, administration, evaluation/supervision, oper- ational training methodology, management of training and promotion of team  - 34 - work; (b) the training of selected municipal and barangay health staff who in turn will teach lower-level health workers; (c) the training of directors of regional training centers and of regional health planners in operational planning, management and supervision of health services; (d) the training of health staff in MIS implementation and utilization; and (e) the training and refresher courses for appropriate service providers in IEC 1/ and such skills as pill prescription, IUD insertion and sterilization. The IEC part of the training component will enable to continue testing a scheme, initiated under the first project, consisting of ways of utilizing informal leaders at the neighborhood or Purok level as family planning multipliers. If proved suc- cessful, the expansion of this approach may be proposed by MOH through the category of "innovative activities". 3.37 The health training component will be implemented by OHEPT; while the NFPO will be responsible for the family planning training sub-component in close coordination with OHEPT. The project will finance the additional personnel, travel, per diem, equipment and consultants needed to enable OHEPT and NFPO to administer a considerably expanded training program. Two component coordinators will be designated for this project: one in OHEPT and another in NFPO. Training materials and audiovisual equipment are being provided under the IEC component. IEC for Health/Family Planning/Nutrition 3.38 IEC Objectives. The health IEC program addresses the following problem areas: poor nutrition, especially of mothers and children, and the decline in breastfeeding; low family planning acceptance and continuation; inadequate levels of immunization; high maternal and infant mortality; lack of safe drinking water and poor sanitary waste disposal; and high prevalence of certain communicable diseases. 2/ 3.39 The MOH IEC program is based on the assumption that IEC is a funda- mental part of the job of every frontline health worker. The health system presents certain opportune settings for IEC that must be utilized to their fullest: maternity wards, prenatal and postnatal clinics, nutriwards, mothers' classes, mothercraft centers, and home visiting. Besides these settings within MOH's field of operations, the IEC program will take advantage of other oppor- tunities in the community and through the schools to reach parents, youth, and various leadership groups. In this effort MOH will cooperate with a number of other agencies--governmental and non-governmental, including in particular POPCOM. 1/ Additional MOH staff will be trained in IEC as part of an Expanded Program for Immunization being supported by a UNICEF grant. 2/ These priorities and other elements of the IEC plan were developed by the planning team that consisted of health education staff and representatives of five key MOH bureaus/offices; its work was based on a careful analysis of the health plan and other relevant data.  - 35 - 3.40 Specific Component Objectives. The thrust of the IEC component is to strengthen the critical face-to-face communication carried out by MOH field staff and volunteers by increasing the capacity of the MOH to design, produce and distribute IEC materials; to supervise field staff in IEC; and to evaluate IEC activities. The training component will provide training in more advanced IEC skills for field staff. 3.41 Materials Development/Design/Production. The project will provide equipment and personnel to set up a print production section in MOH's IEC unit. During negotiations, assurances were obtained from the Government that by December 31, 1979, it will employ a suitably qualified chief of this unit. In-house production will be complemented with contracted production of IEC materials. Remodeling of MOH space for a print shop is included in the project. 3.42 IEC Supporting Structure. To support the IEC efforts of field staff and the design and production of IEC materials, the project will provide (for detailed listing, see Annex 3): (a) sixteen professional and technical staff in the central unit to operate the print production section, manage the mass media program, design and develop basic printed materials, and conduct pretest- ing; (b) an Assistant Regional Health Education Advisor helped by an AV Technician-cum-Driver, in each of the 12 regions (outside Metro Manila); and (c) one Provincial Health Educator in each of forty provinces that have no IEC specialists. During negotiations, the Government gave assurances that appropriate IEC staff will be employed by December 31, 1980. 3.34 The training component will provide IEC training for all new Provin- cial Health Educators and for all old and new IEC specialists in appropriate IEC skills. In addition, the project includes financing of fellowships, and travel and per diem for supervision of IEC activities. A total of 2.5 years of consultant time will be provided to assist in the establishment of the production unit, for a mass media support program, for the evaluation of key activities, and for other critical operational activities. (It is expected that WHO will provide other IEC consultants and fellowships). The project will provide three vehicles for the central health education/IEC unit, one AV van for each of the 12 Regional Health Offices, a pool of basic AV equipment for each of the 76 Provincial Health Offices, and AV kits for the health centers. 3.44 Health Education/IEC Research and Evaluation: With the help of consultants, MOH will evaluate key aspects of the IEC program. A consultant will help the MOH to draw up an IEC research and evaluation program. With project funds, MOH will conduct periodic evaluations of the impact of the IEC program. Appropriate baseline data will be collected early in the project period; subsequent final data will be collected and analyzed in time to guide the periodic planning of activities. Management Information System 3.45 The MOH/MIS component of this project has as main objectives: (a) making fully operational the MOH/MIS established through the first project; (b) assisting the National Nutrition Council to develop and computerize the nutrition surveillance system; and (c) helping to set up an integrated MIS by inter-linking the MOH, POPCOM and the National Nutrition Council MIS systems.  - 36 - 3.46 This component will be implemented by the MOH/MIS unit and the National Nutrition Council, concerning health and nutrition MIS respectively. The project provides funds for data processing equipment and computer hardware, computer time until hardware is acquired, additional technical staff, 6 per- son-months of technical assistance to undertake periodic evaluations of the system's effectiveness and 11 person-months of overseas fellowships for advanced study in data management and processing. The project also includes funds for training locally MOH staff (under training component) so that they can cooperate effectively in data gathering, transmission of reports, and utiliz2t-inn of data oUtput. 3.47 The project will also finance the development of the MIS of the National Nutrition Council to enable the operation of its nutrition sur- veillance system. This system has been designed to provide a number of early warning signals or indicators of malnutrition. At the municipal level, the system collects the following information: percent of newborn with low birth weight; number of children per 1,000 who had diarrhea during the last month, number of children per 1,000 with night blindness; number of children per 1,000 who died from all causes in the last month; percent of second and third degree malnourished pre-school children; and percent of second and third degree malnourished pupils. The system is only operating in areas where nutrition scholars are working. 3.48 In order to expand this system over the whole country, it is neces- sary to link it for data collection purposes, with the health and population MISs. A feasibility study of an integrated system is beinig financed under the first population project. The present project will provide financing for the development of the integrated system, on the basis of this study. Another study is being conducted with funds from the first project to assess the hardware needs of the three MIS systems at MOH, POPCOM and the National Nutrition Council. Innovative Activities in Health Care and Family Planning 3.49 For health and family planning, US$1,100,000 will be allocated to Part B of the project to finance high priority innovative activities which may arise during the course of project implementation. Examples of areas that may need support with these funds are special management studies , special surveys complementing the management information system, studies on PHC, or further expansion of project components such as the Purok leader approach. Government proposals for utilization of these funds will be subject to the same care and scrutiny by the Association, as devoted to the appraisal of the other project components. To obtain the Association's approval, such proposals will have to meet the criteria listed in para. 3.23. Approval of these proposals will be a condition of disbursement against this category (para. 7.03).  - 37 - IV. PROJECT COST, FINANCING AND DISBURSEMENT A. Cost 4.01 The total estimated project cost is US$72 million equivalent, of which US$24.2 million, or 34%, is foreign exchange. The foreign exchange component has been calculated assuming 30% for construction, 30% for furni- ture, 100% for equipment, 87% for special equipment, 60% for vehicles, 55% for advisory services, studies and fellowships, and 50% for TEC contracts and innovative activities. Project cost estimates by expenditure categories are summarized in the following table:  - 38 - % of ('000 P) ('000 US$) % of Base Category Local Foreign Total Local Foreign Total F.E. Cost Capital Cost 1. Construction 82,900 35,500 118,400 11,200 4,800 16,000 30.0 27.0 2. Furniture 5,000 2,100 7,100 600 300 900 33.0 1.5 3. Equipment - 12,300 12,300 - 1,700 1,700 100.0 2.9 4. Special equipment 4,500 22,900 27,400 600 3,100 3,700 84.0 6.3 5. Vehicles 3,200 4,700 7,900 400 700 1,100 64.0 1.9 6. Materials for finished products 4,400 3,000 7,400 600 400 1,000 40.0 1.7 7. Seed funds 18,200 - 18,200 2,500 - 2,500 - 4.2 8. Advisory services, studies & fellowships 9,300 11,300 20,600 1,300 1,500 2,800 54.0 4.7 9. Professional fees, construction 7,900 - 7,900 1,100 - 1,100 - 1.9 10. Contracts IEC prototypes & production 45,900 45,900 91,800 6,200 6,200 12,400 50.0 20.9 Subtotal Capital Cost 181,300 137,700 319,000 24,500 18,700 43,200 43.3 73.0 Incremental Operating Cost 11. Project administration 5,200 - 5,200 700 - 700 - 1.2 12. Incremental salaries 18,500 - 18,500 2,500 - 2,500 - 4.2 13. Vehicle & equipment maintenance 8,900 2,100 11,000 1,200 300 1,500 20.0 2.5 14. Distribution (IEC materials) 1,000 - 1,000 100 - 100 - 0.2 15. Travel & per diem 67,200 - 67,200 9,100 - 9,100 - 15.4 16. Rentals 1,000 - 1,000 100 - 100 - 0.2 Subtotal, Incremental Operating Cost 101,800 2,100 103,900 13,700 300 14,000 2.1 23.6 17. Innovative activities 7,300 7,400 14,700 1,000 1,000 2,000 50.0 3.4 Subtotal Base Cost 290,400 147,200 437,600 39,200 20,000 59,200 33.8 100.0 Contingencies Physical 8,800 3,800 12,600 1,200 500 1,700 29.4 2.9 Price 54,800 27,400 82,200 7,400 3,700 11,100 33.3 18.8 Subtotal Contingencies 63,600 31,200 94,800 8,600 4,200 12,800 32.8 21.6 TOTAL PROJECT COST 354,000 178,400 532,400 47,800 24,200 72,000 33.6 121.6  - 39 - 4.02 The costs of construction, furniture and equipment have been esti- mated using October 1978 prices and are based on MOH experience with similar construction under the first Bank project. Cost estimates for special equip- ment, vehicles, materials and IEC production are based on recent price quota- tions. About 4% of the project's total cost are salaries and honoraria for incremental staff; these have been costed according to standard Government schedules. Other capital costs have been estimated as follows: (a) for consultants/local advisory services, US$1,000 per month; foreign advisory services, US$5,000 per month; (b) for fellowships for study abroad, US$1,500 per person-month, and for fellowships for study in the Philippines, US$250 per person-month. These figures include all expenses. 4.03 The contingency allowance of US$12.8 million includes: (a) physical contingencies for unforeseen factors, estimated at 10% of base civil works costs and professional fees; and (b) price contingencies averaging 19% of the base cost plus physical contingencies. Price contingencies were calculated on the basis of the project expenditure schedule and on the assumptions that: (a) local wages for civil works will increase by 10% yearly and prices of local construction materials by 6%, resulting in an average construction cost increase of 7% per year up to 1984; (b) all other salaries, maintenance costs, and the cost of IEC materials will increase by 6% per year; and (c) prices of all imported goods will increase by 6% annually during the project period. 4.04 Cost estimates by functional categories are summarized in the following table (detailed costs in Annex 6):  - 40 - % of ('000 US$) ('000 US$) % of Base Category Local Foreign Total Local Foreign Total F.E. Cost Base Cost 1. Service Infrastructure 116,900 50,200 167,100 15,800 6,900 22,700 30.4 38.3 expansion 2. Training 75,700 7,500 83,200 10,200 1,000 11,200 8.9 19.0 3. IEC 60,100 62,900 123,000 8,100 8,500 16,600 51.2 28.0 4. MIS 4,500 13,800 18,300 600 1,900 2,500 76.0 4.2 5. Research 25,900 5,400 31,300 3,500 700 4,200 16.7 7.1 6. Innovative Activities 7,300 7,400 14,700 1,000 1,000 2,000 50.0 3.4 Subtotal, base cost 290,400 147,200 437,600 39,200 20,000 59,200 33.8 100.0 Cant ingencies Physical 8,800 3,800 12,600 1,200 500 1,700 30.0 2.9 Price 54,800 27,400 82,200 7,400 3,700 11,100 33.3 18.8 Subtotal, contingencies 63,600 31,200 94,800 8,600 4,200 12,800 32.8 21.6 TOTAL PROJECT COST 354,000 178,400 532,400 47,800 24,200 72,000 33.6 121.6 4.05 Government current expenditures for health, population and nutrition in FY78 amounted to about P 1,096 million or 3.2% of the total national budget in FY79. The project would add about P 7 million at 1978 prices to MOH's annual current expenditures (or 6.5% of total MOH current expenditures) and P 15 million to POPCOM's annual current expenditures (or 8% of total POPCOM current expenditures) in 1985 after completion of the project. The increase seems reasonable in view of the priority assigned by the Government to these programs and the considerable expansion of services included under the project. The Government has agreed to assume financing of all ongoing activities initiated under the project when it is completed. 4.06 The operating costs originating in the project, including price contingencies, are as follows: ('000 P) 1980 1981 1982 1983 1984 Total 25,227.1 28,704.5 28,600.2 31,130.2 30,285.1 Reimbursed by IDA 10,169.1 10,438.6 10,210.3 11,162.4 10,244.2 Not reimbursed by IDA 15,058.0 18,265.9 18,389.9 19,967.8 20,040.9  - 41 - B. Proposed Financing 4.07 The proposed five-year project would be financed by an Association credit of US$A0 million equivalent, which excludestaxes, and a contribution from the Gov:-nment of the Philippines of US$32 million equivalent. UNICEF's contribution for social preparation of communities under the primary health care component of the project will be part of the regular agreement between of that agency and the Government; it has not been included in the project cost (financing plan, Annex 7). Total IDA financing would cover the foreign exchange cost of US$24.2 million equivalent and US$15.8 million equivalent of the local cost. 4.08. The credit would be on standard terms. Details of the disbursement plan are given in Annex 8. 4.09 The tight budgetary situation of the Philippines makes it appro- priate that part of the credit should be used to finance local costs in order to enable a considerable expansion of the national health services and of the population program. It is proposed that the Association finance 50% of the per diem allowances and travel costs for training courses, workshops, and supervision, which are incremental operating expenditures. 4.10 The salaries of regular employees of the Government agencies parti- cipating in this project, who are to be hired especially for project activi- ties, or for project administration are part of the project cost and will be financed entirely by the Government. The Government will continue to employ the new staff after the project is completed. C. Disbursements and Accounts 4.11 Disbursements by IDA against project expenditures will be as follows: for civil works, 50%; for furniture, equipment, special equipment and vehicles, 100% of foreign expenditures, 100% of ex-factory cost or 65% of locally pro- cured items; for advisory services, professional fees, studies, fellowships, seed money and materials, 100%; for IEC contracts and travel and per diem, 50%; and for innovative activities, 50%. 4.12 POPCOM and MOH will maintain separate accounts for the incremental operating expenditures (travel and per diem)of their respective parts (A and B) of the project. Reimbursements from the Association for these expenditures will be made against standard documentation. In addition, they should be supported by documentation clearly specifying: the name of the course, work- shop, or type of supervision assignment, date, and the names and agency of those receiving payment. Disbursements for construction carried out by force account will be made against certified statements of expenditures which should include a record of expenditures incurred during the reporting period, explana- tion on the form of implementation of construction, administering party and breakdown of expenditures. The statement should be certified by the Finance Division of the Ministry of Health and the auditor (details in Annex 11). POPCOM and MOH finance units will retain until one year after the Closing  - 42 - Date of the credit, all records pertaining to such expenditures and will allow representatives of the Association to examine such records at any time. During negotiations assurances were obtained from the Government that it will cause POPCOM and MOH to have their accounts and financial statements related to the project for each fiscal year audited by independent auditors acceptable to the Association. Auditing of the accounts of the first project in some cases has been unable to distinguish between expenditures for authorized project purposes and those for other health activities. Similar problems have occurred in POPCOM in connection with other externally financed projects. Therefore, further to the above mentioned assurance, during negotiations, an understanding was reached with the Government to the effect that it would request its Commission an Audit to engage consultants to assist in improving the annual audit of this project, particularly if the Association finds that such improvement is necessary in the future. The Government agreed to furnish the Association a certified copy of the report of such audit not later than six months after the end of each fiscal year. V. PROJECT IMPLEMENTATION AND RISKS A. Project Management 5.01 Realistically, it will be many years before the health and popula- tion programs of the Philippines are fully developed to cover all the popula- tion with consistently high quality services. A significant beginning has been made toward this goal and the proposed project is intended to build upon that base. Because these are major ongoing programs it is not feasible to have all important decisions taken before committing additional funds. The actions which have been agreed by the Government and which are shown as conditions of the credit are timed to take place as soon as preparatory work will permit. 5.02 Part A of the IDA project will be implemented by POPCOM and part B, by MOH. The administration and implementation of each part will be the separate responsibility of the respective agencies (Annex 9 provides functions and responsibilities for all project staff). The project has been designed to complement the programs of each agency, emphasizing the strengthening of the institutions at the same time that incremental activities are undertaken as part of the project. The complexity of the project will necessitate the preparation, each year, of a detailed work plan for each project component. During negotiations, assurances were obtained from the Government that it will cause POPCOM and MOH to provide the Association, for consultation, a copy of the annual work plans for PHC, training, IEC, MIS, research, and construction and procurement (segregating project and non-project activities) not later than September 30 of each of the five project years; the first such submission should be not later than September 30, 1979 (Annex 10 presents project imple- mentation timetables). 5.03 The overall responsibility for planning and coordinating the Philippine population program rests with POPCOM. Several agencies of the Government are responsible for implementing various program components, the most important being MOH for the delivery of family planning services. The  - 43 - responsibility for public health services rests entirely with MOH. Important project activities are aimed at strengthening the capability of POPCOM and MOH to discharge their responsibilities. Part A: POPCOM Project Management 5.04 During negotiations, the Government gave assurances that by December 31, 1979, it will designate appropriate senior staff in consultation with the Association, to implement Part A of the project including a project coordinator and an assistant in the office of the Executive Director and associate direc- tors as component coordinators. Each will be helped by one assistant. Also, an understanding was reached with the Government that the Chiefs of MIS and research will be appointed assistant coordinators for the MIS and research components respectively. 5.05 For handling funds under Part A, POPCOM's organization for finan- cial matters requires realignment. Until recently, POPCOM's financial organi- zation was fragmented as a result of the creation, in the past, of several separate finance units to handle funds from different external sources. During negotiations assurances were obtained from the Government that it will place all financial operations of Part A of the project under the Finance Division of POPCOM and that it will ensure suitable accountability of project funds by designing and adopting, by December 31, 1979 an accounting system acceptable to the Association. Furthermore, an understanding was reached to the effect that the Government will engage consultants in the design of the accounting system. The project also includes financing of 18 person-months of consultants in accounting systems and procedures, for POPCOM's Finance Division. All budgeting, accounting, and disbursement functions in POPCOM, including those related to the project, will be placed under a chief budget officer, a chief accountant, and a treasurer, respectively. To assist in project related work, the Finance Division of POPCOM may be augmented with one budgeting, one accounting and one disbursement officer if required. Financial reports will be prepared quarterly and annually following functional andh expenditure category breakdowns required by the Association. 5.06 The Executive Director of POPCOM will submit quarterly and annual reports to the POPCOM Board and IDA on project progress. Technical coordina- tion of project components within POPCOM will be undertaken by a working committee headed by the Project Coordinator for Part A and consisting of all Part A component coordinators. Other POPCOM central and regional staff will be invited to participate in meetings as required. Part B: MOH Project Management 5.07 The Government gave assurances during negotiations that it will designate appropriate senior staff, in consultation with the Association, to implement Part B of the project, including a project coordinator in the Office of the Minister of Health in accordance with arrangements satisfactory to the  - 44 - Association, and consistent with normal Government practice. The Government also gave assurances that it would designate project component coordinators in the relevant bureaus and offices of MOH. The General Services Division will handle the logistics component and procurement under this project. 5.08 Construction under the project (both for POPCOM and MOH) will be implemented by an MOH Construction Unit which would be placed under the Project Coordinator for Part B. During negotiations, assurances were obtained from the Government that, by December 31, 1979, it will appoint a chief for the construction unit. (see para. 5.13). 5.09 Separate books of accounts for the project will be maintained by MOH's Finance Division of the Financial and Management Service. It would take long to modify the present complex system, with its 20 independent sets of accounts so as to avoid creating a new and separate set of records. During negotiations, assurances were obtained from the Government that for this project, it will make MOH's Financial and Management Service responsible for handling all financial matters related to Part B of the project, and it will cause it to design and adopt an accounting system acceptable to the Associa- tion, by December 31, 1979. As in the case of POPCOM, the Government and the Association reached an understanding to the effect that the former will engage consultants in the design of the accounting system. The project also includes financing of 18 person-months of consultants in accounting systems and procedures, for MOH's Finance Division. To help carry out budgeting, accounting and disbursement functions for the project, one budgeting, one accounting and one disbursing officer may be added if required. The Service will submit quarterly and annual financial reports, following the breakdown by functional categories, sub-classified by expenditure category, as required by the Association. 5.10 The Project Coordinator for Part B will submit quarterly and annual progress reports, based on the component progress reports, to the Minister of Health and to the Association. Technical coordination of project components within MOH will be undertaken by a working committee chaired by the Deputy Minister consisting of the Project Coordinator for Part B and all Part B component coordinators. Other MOH central and regional staff and officers from other agencies will be invited to attend meetings as required. Project Working Committees A and B will hold joint meetings at least semi-annually, under rotating chairmanship to discuss project matters. Individual component coordinators from POPCOM and MOH will meet more often, as required, to dis- cuss specific components. 5.11 Financial support to project management will include salaries for the required additional coordinating staff. These, as well as the salaries of the additional staff to be engaged in various MOH divisions/bureaus/offices for project work have been included in the project cost as incremental operat- ing costs. A total of 31.4 person-years of advisory services have been also included in various components of Parts A and B to assist in project imple- mentation. During negotiations, the Government gave assurances that it will cause POPCOM and MOH to employ consultants whose qualifications, experience and terms and conditions of employment will be satisfactory to the Association.  - 45 - B. Implementation of the Physical Facilities 5.12 A construction unit (mentioned in para 5.08) will serve both MOH's Part B and, in a contractor/client relationship, POPCOM's Part A. The unit will report to both Part A and Part B Project Coordinators, on their respec- tive construction components. It will be headed by the construction unit chief supported by two assistants (one architect and one civil engineer). Other engineers and draftsmen will be employed from time to time according to the changing workload. In particular, one sanitary engineer and one electrical engineer will be engaged temporarily to help prepare bid documents. 5.13 The chief of the construction unit will coordinate and supervise the design, construction and commissioning of buildings. To this end he will: (a) select and appoint the executive architects, engineers and construction management consultants, with qualifications, experience and terms and condi- tions of employment satisfactory to the Association, and brief them as appro- priate; (b) assist in timely selection and acquisition of suitable sites according to agreed criteria; (c) review and revise the executive architect's design and working plans, cost estimates and bid documents and ascertain that the users' requirements will be satisfactorily met; (d) invite and evaluate bids for civil works, award contracts and arrange for community participation in construction; (e) set up a cost control and reporting mechanism, and help the Finance Division operate a system for making payments and for reimburse- ments to barangay councils; (f) coordinate with users' representatives and Parts A and B procurement coordinators procurement of furniture and equipment for the project facilities; (g) assist the executive architects in the pre- paration and production of a manual for the use and maintenance of buildings and equipment; and (h) submit quarterly and annual progress reports, and project completion reports to the respective coordinators for Parts A and B of the project. 5.14 The construction of POPCOM's 13 regional office buildings and/or warehouses and garages will follow the usual procedures. Under the construc- tion unit's guidance the executive architects will design the buildings; contracts will be awarded to contractors after bidding and evaluation. The construction management consultants will supervise the contractor's work, issue payment certificates and accept the completed buildings. 5.15 The largest civil works package consists of 75 health centers in towns of 19 provinces selected for their low level of health infrastructure availability. Although an attempt will be made to attract local contractors by preparing small bid packages, it is likely that many of the facilities located in small and remote towns will not attract acceptable bids. In such cases, construction may be implemented by the MLGCD using force account. Construction of all health centers will be supervised by the construction management consultants. BHSs are very simple structures staffed by one midwife. For their construction, the project will introduce the following alternative procedures:  - 46 - (a) communities wishing to undertake construction by themselves would be provided with prototype designs, materials, tools and a simple construction manual; they would be assisted by barangay development workers to organize themselves; their construction work would be supervised by the municipal sanitary inspector (MOH) jointly with the municipal engineer (MLGCD); they would report using simple performance certificates; BHS construction would have also occasional supervision from the construction management consultants (about three times: once before construction work starts, once during construction (walls/roof) and once towards completion); and the respective barangay development council would receive a monetary payment for labor contributed upon completion of construction, to be used by the council in another developmental project that would benefit the community; (b) in communities where members wish to contribute only partially to the construction of their BHS, the work would be undertaken by the MLGCD using force account and the community would be compensated in proportion to the manpower contributed; the construction management consultants would supervise the work 2-3 times; or (c) in communities which do not wish to take any part in the work, no construction will take place unless there are good reasons for this attitude, in which case BHSs may be built by MLGCD using force account (of course, no payment would be given to the community in this case). 5.16 The evaluation of a pilot component of the first population project-- the building of 25 BHSs with community participation--should provide useful information for implementing this component. 5.17 The action plan for BHS construction includes an information campaign to stimulate community participation and provide details about procedures for applying. The MLGCD, with the assistance of the construction unit in MOH, will carry out these information campaigns in the identified project provinces, by utilizing the regular contacts of barangay development workers with communi-' ties and the monthly "Barangay Letter." These campaigns will explain the advantages of a BHS, how the community can participate in its construction, and the system of payments. 5.18 MOH's construction unit has developed three prototype BHS designs which communities are testing in the pilot scheme. It is also preparing a simple construction manual to guide communities on technical details. C. Procurement 5.19 To the extent practicable, contracts for furniture, equipment, spe- cial equipment, vehicles, materials for in-house TEC production, materials for training and research, and contracts for mass production of IEC materials  - 47 - will be grouped in appropriate packages of not less than US$80,000 equivalent. Such contracts estimated to cost US$80,000 or more will be awarded on the basis of international competitive bidding in accordance with the Bank's Guidelines for Procurement; contracts estimated to cost less than US$80,000 equivalent, but not exceeding US$800,000 equivalent in total, will be procured on the basis of competitive bidding advertised locally and in accordance with Government procedures which were discussed during negotiations and were found acceptable to the Association; such procedures include, inter alia, that bidders shall be prequalified. 5.20 To allow for reasonable flexibility, contracts for smaller items costing not more than US$8,000 but not exceeding US$200,000 equivalent in total and any contract for the supply of tools and materials for constructing BHSs will be procured on the basis of prudent shopping after inviting quota- tions from at least three suppliers. 5.21 A preference margin of 15% of the c.i.f. price of imported goods or the prevailing customs duty, whichever is lower, will be extended to eligible local manufacturers when comparing evaluated bids obtained through international competitive bidding. 5.22 Where reasonable, civil works will be grouped in appropriate bid packages on the basis of geographical locations by region or province as suitable. Of the $16.0 million civil works of the project, $8.5 million are estimated for over 900 BHS in remote areas to be built by the communities themselves. The remaining $7.5 million for some 100 buildings in 90 loca- tions spread over all 13 regions would not attract foreign contractors to participate in bidding. Therefore civil works contracts will be awarded after local bidding in accordance with Government procedures acceptable to the Association (para 5.19). Foreign contractors will not be excluded from bidding and all contractors who participate in bidding will be required to have prequalified. 5.23 In cases where no reasonable bids are obtained, or where communities-- in exceptional cases--are unable to implement part of the construction work of health centers or BHSs, it will be implemented by force account by the Ministry of Local Government and Community Development. Reporting and accounting procedures to handle force account payments are explained in Annex 11. 5.24 Contracts for consultants and advisory services (i.e., for designing and supervising construction and civil works; for carrying out studies, for designing prototypes and producing IEC materials) will be awarded following the guidelines and procedures in the latest edition of "Uses of Consultants by the World Bank and its Borrowers." D. Flow of Funds 5.25 The project will contribute to the objectives of the Five-Year Development Plan, 1978-82 which has Presidential sanction. The Ministry of the Budget has given assurances to Association missions that it will provide yearly budgetary allocations for this project. The project areas--rural health, population, and nutrition--constitute high priority sectors for the  - 48 - Government. Both POPCOM and MOH have already submitted budget requests for the first year of the project--CY1980--in time for consideration by the National Assembly in May 1979. The Ministry of the Budget will approve cash disbursement ceilings in the annual budgets of POPCOM and MOH covering both the national contribution and the counterpart of the IDA Credit; in this manner, delays caused by lack of funds to pay contractors and suppliers, as in the past project, should not occur. 5.26 The Finance Division of POPCOM, suitably reorganized (para. 5.05) will administer Part A fundse MOH's Financial and Mlanagement Service will handle Part B financial matters (para. 5.09). In both cases, the account- ability of project funds will be ensured by suitable accounting systems, being designed with the assistance of consultants and the provision of financial consultants during project implementation. Claims for reimbursement from the Association will be handled separately for Parts A and B by the respective finance offices of POPCOM and MOH. E. Risks 5.27 The risks involved in this project are mainly related to the success or failure of high Government authorities to provide strong support to the organizational changes and managerial and technical upgrading which have been agreed upon by the GOP and the Association as necessary conditions--both in POPCOM and MOH--for successful implementation of the health and population programs. There are, however, favorable signs that such support will be forthcoming. High Government officials have repeatedly stated that primary health care, population and nutrition have high priority for the national development efforts. More specifically, a functional analysis of the Ministry of Health, financed under the first project, which should lead to revision of its present organization, is already underway. The improvements required in POPCOM, consisting of upgrading salary levels and managerial and technical capabilities of the staff have already begun; this improvement process should be followed up carefully to prevent any recurrence of past problems. The streamlining and strengthening of the professional staff should not be diffi- cult, given the availability of qualified professionals in the Philippines and the strong staff development program included in the project. 5.28 Another risk that should not be ignored relates to the community participation approach to be tested in two components of this project--BHS construction and primary health care. Problems and constraints surrounding this approach were recognized and carefully weighed during project conceptuali- zation and design; it was concluded that the potential benefits in terms of increased community outreach and increased possibilities for providing services affordable to the Government made such a risk worthwhile. Several safeguards have been built in the design of these components to minimize the risks; among them there is the involvement of the MLGCD for their direct access to local governments; the participation of UNICEF for their technical support to social  - 49 - preparation activities and their provision of a bridge between the Government and the private sector in these activities; and the provision for continued evaluation. During negotiations, the Government confirmed that a policy on pri-viry health care, presently being developed by an interministerial committee, will be made available to the Association by April 30, 1981. VI. PROJECT JUSTIFICATION 6.01 The attainment of the national targets to increase the proportion of couples practicing contraception from 27% now to 50% in 1987 and the ex- pected consequent decline sought in the annual average rate of growth of the population from 2.5% in 1978 to 2.1% in 1987 and 1.6% in 2000 (para. 2.09) will require a considerably expanded, intenisified and more effective program effort. The health sector goals (paragraph 2.40) of reductions in infant mortality, malnutrition among pre-school children, and morbidity frol priority communicable diseases will be very difficult to achieve unless health services are extended during the next decade to the one-third of the population not now served. The project would contribute significantly to an increase in the scope and depth of the population and the health prograTTs. ITn 1982 the project would provide 20% of the cost of the population program and 23% of that of the health program. 6.02 It is not possible to estimate the numbers of births and deaths that will be averted directly as a result of this project. However, partial contributions would be the provision of both types of services to an addi- tional 3.3 million persons with the primary health care scheme, and another 3 million persons with services from new health facilities. Altogether, these two components would reach about 40% of the population now outside the reach of adequate health services. The project strategy of combining strengthening of the formal health system and supporting a phased introduction of primary health care schemes may have synergistic effects of considerable importance in terms of maximizing the yields of those two efforts. Since primary health care will be introduced in one province only in each of the twelve regions, there will be opportunities for comparing the effects of r combtined" vis-a-vis "formal system-only" inputs to the health services. A novel aspect oF this project is the emphasis placed during its co'icOtrtialization on identifying ways of eliciting the involvement of the community in recognizing, understand- ing, and practicing sound health principles making individuals and communities take major responsibility for their own health. Community participatLoni w[l be emphasized in the following project compoolents: primary health care schemes, construction of barangay health stations, IEC, and training. There is provision in the project Lor evaluating the various approaches to service delivery through the regular MISs, pre-testing of IEC materials, and special st-idies to be undertaken by consultants. 6.03 Besides increasing the coverage of health, family planning and nutrition ser\Ttceo, the project would be a major contributing factor in improving their quality through: more functional organizations; the massive la--;,rvice training programs which would be prteceded by systematic development  - 50 - of trainers; the overhauling and expansion of the logistis :;:tems; the unprecedented nationwide public sensitization and educational campaigns; the support of program relevant researchi; and the further development of data systems for management and evaluation. VII. RECOMMENDATIONS 7.01 During negotiations, assurances were obtained from the G^overnment to the effect that it will: (a) cause POPCOM to complete the population plan and iake if available to the Association for its review and comment by December 31, 1979; by March 31, 1980 the Government will consult with the Association on a timetable for implementation of such plan (para. 2.07); (b) cause POPCOM and MOH to reach an agreement on conliplementarity between population field workers and the clinic services under the population program not later than Decembh-r 31, 1979 (para. 2.24); (c) cause POPCOM and MOH to provide the Association, for review and comment, a copy of the annual plans for PuG., IEG, training, MIS, research, construction and procurement (segregating project and non-project activities) not later than TOe:t 1er ,, of each of the five project years; the first such submission should be not later than September 30, 1979 (para. 5.02); (d) cause POPCOM to take the necessary steps to improve its finan- cial and administrative operations and to easulre an effective coordination of the execution of Part A of the project, in- cluding strengthening of its staff with such additional appointments as will be agreed upon between the Governt'tuiii and the Association, and undertaking such actions as described in paras. 2.14, 3.16, 3.21, 3.22, 5.04, and 5.05; (e) cause POPCOM to undertake a review of the IEC distribution system and convey to the Association, 'by Ocrolhoc 31, 10980, the recommendations arising from such review (para. 3.15); (f) cause MOH to take all necessary measures to ensure an effec- tive coordinatLion in the execution of Part B of the project, including making such additional appointments as agreed upon between the Government and the Association, and undertaking such actions as described in paras. 3.26, 3.41, 3.42, 5.07 and 5.08;  - 51 - (g) cause MOH to provide the Association, by December 31, 1979, the results of the functional analysis study of the health services and to consult with the Association, by April 30, 1980, on a timetable for implementation of the recommendations arising from this study (para. 2.50); (h) cause POPCOM to place all financial operations of Part A of the project, under its Finance Division and to design and adopt by December 31, 1979, an accounting system acceptable to the Association to handle project funds (para. 5.05); (i) cause MOH to place all financial matters related to Part B of the project under its Financial and Management Service and design and, adopt, by December 31, 1979, an accounting system acceptable to the Association to handle project funds (para. 5.09); (j) cause POPCOM and MOH to have the project accounts and finan- cial statements related to the project fiscal year audited by independent auditors acceptable to the Association and furnish the Association a certified copy of the report of such audit not later than six months after the end of each fiscal year (para. 4.12); and (k) develop a policy on primary health care, including the use of barangay health workers, and make such policy available to the Association by April 30, 1981 (para 5.28). 7.02 Also during negotiations the following understandings were reached with the Government to the effect that: (a) the Government plans to engage consultants to assist with the design of accounting systems for POPCOM and MOH, in accordance with terms of reference concurred upon with the Association (paras. 5.05 and 5.09); and (b) the Government would be prepared to ask its Commission on Audit to engage consultants to assist in improving the audit of the project, particularly if the Association finds that such improvement is necessary in the future (para. 4.12). 7.03 For activities to be financed under the innovative activities component of both Parts A and B of the project, no funds will be disbursed unless the Association has approved the activity before its implementation, according to the criteria listed in para. 3.23. 7.04 Subject to the above assurances and understandings, the project is recommended for an IDA credit of US$40 million equivalent on standard terms, to the Government of the Philippines.  PHILIPPINES POPULATION PROJECT II COMMISSION ON POPULATION ORGANIZATIONAL CHART Executive Director Deputy Executive Director | Ad,mkrit,.- | Finan)ce l oitcs 1l ('t,it Information |; ;.: ' | T;ii fl~~~~~~~~~~e FmaieLogistics E..cr-.Tann Division Division Pt i- i, Divsion Division Collection fe 1 Artmvinstinu ersonnel Euin ccutn Fsa Dis- & 1 MIS Pogrmm-nin E l L Ll- J, B.,~~~~Eusement LEu World Bang - 19876  :i..i.i N. ' I; !' ;,It>1. ..1 COMMISSION ON POPULATION REGIONAL OFFICES ORGANIZATIONAL CHART Regional Officer Administrative Project Coordinator Officer Administrative Supply Ao aS icIEC I Eseac IT -a-n i' Assistant Officer Accountant Service Coordinator &Evalua- Coordi.iator Coordinator ion Coordinator Production Store- Accounting Distribution keeper Clerk Specialist World Bank - 19877  1)! . i T.t!>jkI:q1,'1. ORGANIZATIONAL CHART OF THE MINISTRY OF HEALTH Office of the Minister r -------- _ , --__ --- r---_______-- PhitippiiiePlsilippine Tondo ts(iasDngru Medical Care General rhiosounci Dangero Heart Center CnmsinHsia _ _ _ 1 Financial and Office Health Disease Plann i g Administrative Management Education and Intelligence Se vice Service Service Personnel Training Center Dermatology Radiation Schistosormiasis Malaria Naioa National l _ I 1. 1 _ : I _ _ r _ I .1, 1- .]~~~~~~~Pm ~ No n p Cational Caricer Research and Health DrugAdmind Cotitrol and Eradicat ion Nating Nutron Training Project Office Research Service Service Offine Services Rural Health Project ive Special Practice Management eospitals Program Staff Bueuo Buseau ofBueuo | Medical of r BureauoflDental Bureau of Bureau of Research Bureau of S lerices Services Health and Laboratories Quarantine 12 Region. Ifealth Offices World Bank 19875  ANNEX 2 Page 1 PHILIPPINES POPULATION PROJECT II DETAILED LIST OF PROJECT TRAINING ACTIVITIES Total to No. of Ses- Session Person- be Trained sions During Duration weeks of Per Session Project Training Period Per Activity Trainee (1) (2) (3) (l)x(2)x(3) A. POPCOM 1. Master Trainers a. International Fellow- ships 15 1 4 months 240 b. National Refresher Course 20 5 1 week 100 c. Joint POPCOM/MOH Refresher Seminars for Master Trainers 20 5 1 week 100 2. Workshops for POPCOM Execu- tives on Goal Setting/Team Building 47 5 1 week 235 3. Workshop for POPCOM Regional and Divisional Staff on Goal Setting/Team Building 364 5 1 week 1,820 4. Workshop for National Popula- tion Program Coordinating Team on Goal Setting/Team Building 60 5 1 week 300 5. Workshop for National Popula- tion Training Coordinating Team on Staff Development 40 5 1 week 200 6. Workshop for Joint POPCOM/MOH Training Coordinating Team on Staff Development 20 5 1 week 100 7. Workshop for National Popula- tion IEC Coordinating Team 40 5 1 week 200 8. Workshop for National Popula- tion Service Delivery Coordina- ting Team 40 5 1 week 200  - 56 - ANNEX 2 -~~~~~~ ~~Page 2 PHILIPPINES POPULATION PROJECT II DETAILED LIST OF PROJECT TRAINING ACTIVITIES Total to No. of Ses- Session Person- be Trained sions During Duration weeks of Per Session Project Training Period Per Activity Trainee (1) (2) (3) (l)x(2)x(3) 9. Workshop for National Popula- tion Research and Evaluation Coordinating Team 40 5 1 week 200 10. Workshop for Regional Popula- tion Program Coordinating Team 364 5 1 week 1,820 11. Workshop for Regional Popula- tion Training Coordinating Team 160 5 1 week 800 12. Workshop for Regional Popula- tion TEC Coordinating Team 160 5 1 week 800 13. Workshop for Regional Popula- tion Service Delivery Coordina- ting Team 160 5 1 week 800 14. Workshop for Regional Popula- tion Research and Evaluation Coordinating Team 160 5 1 week 800 15. Workshop for Provincial (inclu- ding Metro Manila) Population Program Coordinating Team 3,845 3 3 days 6,921 16. Workshop for Municipal Popula- tion Program Coordinating Team 29,000 3 3 days 52,200 17. Workshop for Media Executives 450 5 3 days 1,350 18. Workshops on Family Planning Integration for Key Media Executives 300 5 1 week 1,500 19. Seminar/Workshop on Maturation/ Information on Voluntary Steri- lization for Medical/Nursing Staff 2,000 1 2 days 800  - 57 ANNEX 2 Page 3 PIIILIPPINES POPULATION PROJECT II DETAILED LIST OF PROJECT TRAINING ACTIVITIES Total to No. of Ses- Session Person- be Trained sions During Duration weeks of Per Session Project Training Period Per Activity Trainee (1) (2) (3) (l)x(2)x(3) 20. Workshop on Records Manage- ment for Selectec, POPCOM and Participating Agencies' Staff 220 3 3 days 396 21. Logistics Management Seminar for Selected POPCOM and Par- ticipating Agencies' Staff 220 3 3 days 396 22. Administrative Management Seminar for Selected POPCOM and Participating Agencies' Staff 220 3 3 days 396 23. Financial Management Seminar for Selected POPCOM and Par- ticipating Agencies' Staff 800 2 4 days 1,280 24. Modern Disbursement Procedures Seminar for Selected POPCOM and Participating Agencies' Staff 440 2 3 days 528 25. Accounting for Non-Accountants Seminar for Selected POPCOM and Participating Agencies' Staff 550 1 1 week 550 26. Vehicle and Equipment Maintenance 880 1 2 weeks 1,760 27. Refresher Course on Vehicle and Equipment Maintenance 880 1 1 week 880 28. Specialized Training on Per- sonnel Planning and Staff Development for POPCOM and Participating Agencies 330 3 2 weeks 1,980  ANNEX 2 -~~~~~ ~~Page 4 PHILIPPINES POPULATION PROJECT II DETAILED LIST OF PROJECT TRAINING ACTIVITIES Total to No. of Ses- Session Person- be Trained sions During Duration weelks of Per Session Project Training Period Per Activity Trainee (1) (2) (3) (l)x(2)x(3) 29. Marital/Pre-Marital Counselling for Selected Field Personnel of Partici- pating Agencies 3,100 1 1 week 3,100 30. Skills Training on Production of IEC Materials, Print 250 2 2 weeks 1,000 31. Skills Training for Production of IEC Materials, Radio 250 2 2 weeks 1,000 32. Workshop-on IEC Research and Evaluation 44 1 2 weeks 88 33. Workshop on Operation and Main- tenance of IEC Equipment 480 2 3 days 576 34. Basic Family Planning Training for Service Providers of Parti- cipating Agencies (with pill dispensing) 500 1 3 weeks 1,500 35. Skills Training in IUD Insertion for Service Providers of Parti- cipating Agencies 200 1 6 weeks 1,200 36. Back-up Support Training to Assist Physicians of Partici- pating Agencies 200 1 1 week 200 37. Minilap Training for Physicians of Participating Agencies 200 1 2 weeks 400 38. Sterilization Assistance Training for Nurses and Midwives of Parti- cipating Agencies 250 1 2 weeks 500 39. Vasectomy Training for Physicians of Participating Agencies 300 1 1 week 300  - 59 ANNEX 2 Page 5 PHILIPPINES POPULATION PROJECT II DETAILED LIST OF PROJECT TRAINING ACTTVITIES Total to No. of Ses- Session Person- be Trained sions During Duration weeks of Per Session Project Training Period Per Activity Trainee (1) (2) (3) (l)x(2)x(3) 40. Cytology Training and Labora- tory Procedures for Lab Tech- nicians of Participating Agencies 400 1 8 weeks 3,200 41. Refresher Courses on Family Planning Concepts and Tech- niques for Physicians, Nurses, and Midwives of Par- ticipating Agencies 3,000 1 2 weeks 6,000 42. Workshop on Field Operations Monitoring System for Regional Population Staff 104 1 4 days 83 43. Workshop on Field Operations Monitoring System for Central, Provincial and District Popu- lation Officers 566 1 4 days 453 44. Workshop on Field Operations Monitoring System for FTOW's (Materials only, Training will be undertaken with USAID Assistance) 3,100 - - - 45. Diploma courses in IEC, Univ 16 1 12 months 768 of the Philippines B. MOH 1. Master Trainers a. International Fellow- ships 15 1 4 months 240 b. National Refresher Course 20 5 1 week 100 c. Joint MOH/POPCOM Refresher Seminars for Master Trainers 20 5 1 week 100  - 60- ANNEX 2 Page 6 PHILIPPINES POPULATION PROJECT II DETAILED LIST OF PROJECT TRAINING ACTIVITIES Total to No. of Ses- Session Person- be Trained sions During Duration weeks of Per Session Project Training Period Per Activity Trainee (1) (2) (3) (l)x(2)x(3) 2. Training of Trainers a. National Level 48 1 6 weeks 288 b. Regional Level 243 1 6 weeks 1,458 c. Provincial Level 550 1 6 weeks 3,300 3. Municipal/Barangay Preceptors/Facilitators 1,533 1 6 weeks 9,198 4. Training of Trainers on Planning, Supervision of Community Health Services and MIS 48 3 3 weeks 432 5. Workshops on PEC a. Regional/Provincial Agency Representatives 300 1 1 week 300 b. Municipal Trainers 2,570 1 2 weeks 5,140 c. Central Agency Represen- tatives 20 1 1 day 0.8 6. Workshops on Health, Nutrition, and Family Planning Program Directions a. Provincial City 138 5 1 week 690 b. Regional Directors 24 5 4 days 96 c. Bureau Directors, Central Level (and MIS) 30 5 2.5 days 75 7. Health Educators, on Develop- ment of IEC Materials a. Basic Training (New Health Educators), and IEC Mate- rials Development 40 1 6 weeks 240  - 61 - ANNEX 2 Page 7 PHILIPPINES POPULATION PROJECT II DETAILED LIST OF PROJECT TRAINING ACTIVITIES Total to No. of Ses- Session Person- be Trained sions During Duration weeks of Per Session Project Training Period Per Activity Trainee (1) (2) (3) (l)x(2)x(3) b. IEC Materials Development (For Existing Health Educators) 120 1 2 weeks 240 8. Training Evaluation Workshop 84 4 1 week 336 9. Workshops Logistics Management a. Central Supply Officers 15 5 1 week 75 b. Regional Supply Officers 24 5 1 week 120 c. Provincial Supply Officers 228 5 1 week 1,140 10. Continuing Education for Rural Sanitary Inspectors (in Family Planning) 1,080 2 3 days 1,296 11. Family Planning Courses for Service Providers a. Skills Training 1,920 1 6 weeks 11,520 b. Basic Course 1,353. 1 4 weeks 5,412 c. Refresher (including purok approach) 10,253 1 2 weeks 20,506 12. Basic Course for Barangay Health Workers 4,050 1 8 weeks 32,400 13. Workshops on Purok Leader Approach a. Health Staff from Various Levels 66 1 2 weeks 132 b. Evaluation 40 1 3 days 24 c. Meetings with Purok Leaders 41,000 1 3 days 24,600 14. MOH Training Coordinating Team, Staff Development 40 5 1 week 200  -62- ANNEX 2 Page 8 PHILIPPINES POPULATION PROJECT II DETAILED LIST OF PROJECT TRAINING ACTIVITIES Total to No. of Ses- Session Person- be Trained sions During Duration weeks of Per Session Project Training Period Per Activity Trainee (1) (2) (3) (l)x(2)x(3) 15. Joint MOH/POPCOM Coordinating Team, staff development 20 5 1 week 100 16. Regional Trainers 84 1 1 week 84 17. Workshop on Operation of MIS a. Regional Health Staff 84 3 3 days 1/ 185 b. Provincial Health Staff 228 3 3 days 2/ 228 c. Rural Health Staff 300 1 5 days 300 d. National Nutrition Council's Barangay Nutrition Scholars 10,910 3/ 1 1 day 2,182 11 Five days the first time, 3 days for refresher courses. / Three days the first time, and one day for refresher courses. 3/ Project includes cost of materials for trainees, travel and per diem for 24 trainers, and per diem for 300 district nutrition program officers.  - 63 - ANNEX 3 Page 1 PHILIPPINES POPULATION PROJECT II DETAILED DESCRIPTION OF IEC COMPONENT A. A Summary of the Communications Environment in the Philippines With Reference to Population and Health IEC. B. Key Weaknesses in Population IEC as Identified in Major Assessment. C. List of IEC Inputs Through Project.  - 64 - ANNEX 3 Page 2 PHILIPPINES POPULATION PROJECT II DETAILED DESCRIPTION OF IEC COMPONENT A. A Summary of the Communications Environment in the PhilipDines with Reference to PoDulation and Health IEC The IEC plans that were developed during project preparation are in part based on assessments of what various audiences need to know or be motivated to do in order to meet the country's population and health goals. Another important consideration in the development of both plans (with spe- cial reference to the IEC materials that are to be produced) is the com- munications environment, i.e., what media exist, how accessible they are, and to what extent people attend to them. In this regard, the following points have been particularly relevant: (a) Language. Although there are a large number of dialects, just five represent the mother tongue of over three-quarters of the population. The national language, Pilipino, which is based on Tagalog, is widely spoken, and to a lesser extent English is also since it is used for instruction in certain subjects in the schools. Pilipino and English are especially widely spoken in urban areas. (b) Literacy. The literacy rate is very high for a developing country--over 85% nationwide--although several regions, part- icularly in the south, have somewhat lower rates (70% or less). (c) Radio. There are about 260 radio stations, including about 15 operated by the Government. Well over half the households in the country own a radio. About three-quarters of a sample of family planning acceptors said they listen daily, with dramatic and musical programs being most popular.l/ (d) Newspapers. Daily newspapers are concentrated in Manila, where they have a circulation of over one million, whereas most of the nearly 50 provincial papers are weeklies with small circulations. About 35% of the family planning acceptors interviewed indicated they read a paper at least once or twice a week. (e) Magazines. Magazines are more widely read than newspapers, especially ones with pictorial stories known locally as "komiks," which are very popular with adults including those with a college education. There are about 20 major magazines and another 50 1/ These and subsequent figures on the media habits of family planning acceptors are taken from Jose R. Lacson, Jr. et al., Family Planning Motivators in the Philippines: A Nationwide Composite Profile, 2 vols., August 1977, Manila: University of the Philippines Institute of Mass Communication and POPCOM.  - 5- ANNEX 3 Page 3 PHILIPPINES POPULATION PROJECT II DETAILED DESCRIPTION OF IEC COMPONENT A. A Summary of the Communications Environment in the Philippines with Reference to Population and Health IEC (cont.) "komiks" magazines. About a million copies of the latter are sold each week. Nearly half of the sample of FP acceptors said they read at least one "komik" magazine a week and about one- third read at least one regular magazine a week. (f) Cinema. A very active movie industry produces about 200 films a year for the 900 cinemas in the country. About 15% of the family planning acceptors attend the cinema at least once a month. (g) Television. Of the 15 television channels, four are in Manila. There are about five million viewers in the country, but they are almost all urban and middle class. Television is a rapidly developing medium, however, and within five years it is expected that inexpensive, locally made receivers will be on the market. About 15% of the family planning acceptors were exposed to tele- vision daily. (h) The unexposed minority. In spite of the high levels of exposure to the mass media, there is a significant minority with little or no exposure. Typically, of course, they are poorer, less well educated, more geographically isolated, and more in need of family planning and health services than the average Filipino. Indicative of the magnitude of this unexposed group are the figures from the study of family planning acceptors (although they obviously under- state the problem): 12% never listen to the radio, 30% never read a newspaper; 30% never read a magazine or "komik," over 25% never attend the cinema, and about 60% never watch television. (This is added reason for stressing in the project the role of interpersonal communication through various fieldworker cadres as they can, with proper stimulus, reach the people who are not touched by the mass media.)  - 66 - ANEFX 3 PHILIPPINES POPULATION PROJECT II Page 4 DETAILED DESCRIPTION OF IEC COMPONENT B. Key Weaknesses in Population IEC as Identified in Major Assessment Analyses of National Acceptor Analyses by the Univ. Assessment by Special Committee to Survey (1974) and National of the Phils. Inst. POPCOM IEC Review the Philippine Area of Weakness Demographic Survey (1973) of Mass Communication Staff (1976) Population Program (1975 & 1976) (1978) A. Key audiences inadequately reached 1. Husbands X X X 2. Postpartum women X 3. Low income groups X X 4. Dropouts or potential dropouts (follow-up) X 5. About-to-be-married couples x B. Content of materials 1. Actual effectiveness of methods not conveyed X X 2. Translations not appropriate for audience X 3. Some materials out of date x 4. Not adequately responding to rumors X C. Number of aterials 1. In general insufficient X X X 2. Tested prototypes not mass reproduced X 3. Provincial media not fed enough materials X 4. Not enough materials on rhythm method or ILUD X D. Distribution Zystem In general inadequate X X E. Personnel 1. Insufficient number X X 2. Lack of IEC skills X X F. Logistics 1. Inadequate transport X 2. Inadequate amount of AV equipment X 3. Insufficient resources to maintain, repair equipment X G. IEC lanning Agreed-upon strategy and plan needed X H. Research, evaluation & monitoring 1. Insufficient data for adequate planning X K 2. Lack of impact data X 3. Ineffective use of existing data K  - 67 - PHILIPPINES POPULATION PROJECT II Page 3 Page 5 DETAILED DESCRIPTION OF IEC COMPONENT B. Key Weaknesses in Population IEC as Identified in Major Assessment (cont.) Analyses of National Acceptor Analyses by the Univ. Assessment by Special Committee to Survey (1974) and National of the Phils. Inst. POPCOM IEC Review the Philippine Area of Weakness Demographic Survey (1973) of Mass Communication Staff (1976) Population Program (1975 & 1976) (1978) 4. Insufficient monitoring of field workers X I. Interagency cooperation Inadequate x  - 68 - AN~NEX 3 Page 6 PHILIPPINES POPULATION PROJECT II DETAILED DESCRIPTION OF IEC COMPONENT C. List of IEC Inputs Through Projectl; Category GOP IDA A. POPCOM 1. Special Equipment AV equipment for regional offices and for Provincial Population Offices (178 cassette tape recorders, 178 slide projectors, 102 film projectors, 89 opaque projectors, 343 screens, 102 public address systems, and 13 generators); production equip- ment for the IEC Division and regional offices (cassette tape duplicator, 2 video tape record- ers with allied equipment, 26 cameras, and dark room facili- ties for 6 locations). 2. Vehicles Thirteen 4-wheel drive vans (outfitted locally) to serve as AV support vans. 3. Advisory Services and Fellowships To assist in preparing various a. Consultants work plans and procedures, to evaluate key elements of the IEC program, etc. (about 50 man-months of local and inter- national consultants) and to train and provide support materials to 4,000 agricultural extension agents. b. Fellowships 22 fellowships for overseas training or study tours and 16 fellowships for local study. 1/ Items that appear in both columns are to be financed both by the GOP and IDA.  - 69 - ANNEX 3 Page 7 PHILIPPINES POPULATION PROJECT II DETAILED DESCRIPTION OF IEC COMPONENT C. List of IEC Inputs Through Project (cont.) Category GOP IDA 4. IEC Contracts a. Design/devel- To prepare following prototypes/master copies: 450 radio spots ment of proto- and jingles; 4,940 segments of radio programs; 16 film spots; types or 20 films; 116 sound-slide sets; 60 press advertisements; 48 master copies feature articles; to integrate population content into 2 of IEC materials feature films, 16 popular songs, 24 comic magazines, and repertoires of 312 folk media groups and 468 rural theater groups; 36 leaflets and brochures; 260 posters; 5 calendars; 13 flipcharts; 70 comic books; and 4 manuals. b. Reproduction/ Mass production of the following materials: 60 bulletins for replication of radio broadcasters (30,000 copies), 16 film spots (8,000 prints), IEC materials 3 entertainment-type films (390 prints), 8 public education films (1,520 prints), 12 training films (2,130 prints), 116 sound-slide sets (1,740 copies), 60 press ads, 50 issues of two newsletters (400,000 copies), 36 leaflets and brochures (7,088,000 copies), 5 calendars (4,000,000 copies), 26 flip- charts (5,265 copies), 70 comic books (34,700,000 copies), signs (59,000), plaques (380), 4 manuals (96,000 copies), 450 tapes of spots and jingles for radio (7,500 copies), 4,940 tapes of one-half hour programs (49,000 copies), and 260 posters (923,000 copies). 5. Salaries of Salary support for additional incremental professional/technical personnel personnel (8 at headquarters and 39 at regional offices) and drivers (13 at regional offices). 6. Maintenance, repairs, replacement parts, and operating costs (vehicles only) for: a. Vehicles For 13 AV vans. b. Equipment For 1,005 pieces of AV equipment, for production equipment, and for repainting 59,000 signs.  -70- ANNEX 3 Page 8 PHILIPPINES POPULATION PROJECT II DETAILED DESCRIPTION OF IEC COMPONENT C. List of IEC Inputs Through Project (cont.) Category GOP IDA 7. Distribution of Funds for distribution of materials IEC Mzterials from headquarters to regional offices. 8. Travel and Per For 18 central office staff and 78 regional office staff to Diem for Staff provide technical assistance/supervision in the field, participate in staff conferences, etc. 9. Raw materials 3,300 audio cassettes, for in-house AV 60 video cassettes, production and 1,040 rolls of film. 10. Project 1 IEC Coordinator Administration 1 IEC Assistant Coordinator  -71 - ANNEX 3 Page 9 PHILIPPINES POPULATION PROJECT II DETAILED DESCRIPTION OF IEC COMPONENT C. List of IEC Inputs Through Project (cont.) Category GOP IDA B. MOH 1. Special AV equipment for Provincial and Equipment Regional Health Offices and for MOH headquarters (181 cassette tape recorders, 178 slide pro- jectors, 102 film projectors, 88 opaque projectors, 267 screens, 102 public address systems, and 13 generators); print production equipment for MOH headquarters (offset press, plate preparation equipment, composition and layout equipment, lettering instrument, paper cutter, special typewriters, electronic stencil scanner, and paper copier); and miscellaneous equipment (8 filing cabinets; 4 fans; air-conditioner; illustrator's table; 10 exhibits, bulletin boards, etc.). 2. Vehicles For headquarters and Regional Health Offices (13 four-wheel drive vans, which are to be outfitted locally, to serve as AV vans; 1 utility van; and 1 sedan). 3. Advisory Services, and Fellowships a. Consultants To assist in preparing various work plans and procedures, to evaluate key elements of the IEC program, etc. (about 30 man-months of local and inter- national consultants), and to evaluate overall effectiveness of the health education/IEC program (baseline survey and two subsequent rounds).  - 72 - ANNEX 3 PHILIPPINES POPULATION PROJECT II Page 10 DETAILED DESCRIPTION OF IEC COMPONENT C. List of IEC Inputs Through Project (cont.) Categ&q GOP IDA b. Fellowships 4 fellowships for overseas training. 4. IEC Contracts a. Design/develop- To prepare following prototypes/master copies: 3,120 segments ment of proto- of radio programs, 10 theme songs, 240 spot announcements, 4 types or training films, and 30 sound-slide sets. master copies of IEC materials b. Reproduction/ Mass production of the following materials: 4 training films replication of (460 copies), 30 sound-slide sets (4,800 copies), 3,120 tapes IEC materials of 1/2-hour radio programs (93,600 copies), 240 tapes of radio spots (2,400), 1 entertainment-type film (100 copies), 3 comic books (8 million copies), 3 booklets (7.6 million copies), 4 posters (340,000 copies), 1 flipchart (15,000 copies), 1 manual (100,000 copies), about 6 stickers and other handouts (300,000 copies), 1 flannel board set (3,000 sets), and 3,000 portable exhibitions-cum-bulletin boards. 5. Salaries for Salaries for additional incremental professional/technical personnel personnel (16 at head- quarters, 12 at Regional Health Offices, and 40 at Provincial Health Offices) and additional support staff (2 clerks and 15 drivers or drivers-cum-AV technicians). 6. Maintenance, repairs, replace- ment parts, and operating costs (vehicles only) for: a. Vehicles For 13 AV vans and 2 other vehicles. b. Special For 931 pieces of AV Equipment equipment and production equipment.  -73- ANNEX 3 Page 11 PHILIPPINES POPULATION PROJECT II DETAILED DESCRIPTION OF IEC COMPONENT C. List of IEC Inputs Through Project (cont.) Category GOP IDA 7. Distribution of Funds for distribution IEC Materials of IEC materials from headquarters to regional offices. 8. Travel and Per For 20 central, 48 regional, and 80 provincial staff to Diem for Staff provide technical assistance/supervision in the field, attend staff conferences, etc. 9. Project 1 IEC Coordinator Administration 1 IEC Assistant Coordinator  ANNEX 4 -74 - _ PHILIPPINES POPULATION PROJECT II LIST OF RESEARCH COMPONENT ACTIVITIES - POPCOM 1. A review of regional population policies, including policies on spatial distribution and immigration, to enable development of a policy to directly affect regional population growth and distribution. 2. Indicators of family planning program performance. 3. Impact of the family planning program on population growth. 4. Influence of religion/moral beliefs on family planning decisions. 5. Male specific IEC strategies study. 6. Study on the causes and extent of pre-marital conception. 7. Studies on cost-effectiveness of various contraceptive methods, 8. Phase III of the condom marketing research program (Phase IT was financed under the amendment to the first Bank loan). 9. A pilot project for integrating family planning into farmers' cooperatives programs. 10. Study on method preferences of varying types of clientele. 11. Pilot program offering benefits for family planning practice to employees of rural-based industries. 12. Development of baseline information and an evaluation of the program's IEC efforts.  - 75 - ANNEX 5 Page 1 PHILIPPINES POPULATION PROJECT II PRIMARY HEALTH CARE COMPONENT 1. In developing countries the insufficiency of basic health services results in considerable suffering and death from preventable diseases. Communicable diseases claim many lives of children and adults in the economically productive age group. In the Philippines, tuberculosis, gastroenteritis, malaria, respiratory infections, viral infections and intestinal parasitic diseases are highly prevalent among low income groups. Some of the important causative factors are malnutrition, poor environment and multiple pregnancies too close to one another resulting in underweight babies. 2. The present development efforts of the Government, as embodied in Presidential Decree No. 1200, are directed toward improving the lives of the rural population. Towards this end, the expansion of the basic health and medical care services in these areas is of crucial importance. As a first step, starting in 1974, the Government adopted and implemented a new approach to health service delivery--the Restructured Health Care Delivery System (RHCDS)1/. The implementation of the RHCDS under the Bank-financed Population Project I is to be completed by the end of 1979. However, an operations research study in five provinces of the country has shown that even with the full implementation of the RHCDS, only 47 percent of the community's health needs could be met. Those persons living outside the reach of the health facilities (more than 3 kms) are not covered even though midwives have been retrained to make more efficient use of their time. 3. It has been pointed out that the competing traditional health services and the existing cultural norms and values of the community contribute substantially to the underutilization of existing health services. In this light, the government's wish to provide services to peripheral villages would need a complementary move originating from the community. The key, therefore, is to achieve, with the assistance of non-professional community workers, known as Barangay Health Workers (BHW), community participation in the solution of individual and collective health problems. 4. The participation of non-professional workers in the delivery of health care, family planning and nutrition services to the community is not a new idea. It has been increasingly adopted by both developed and developing countries as a strategy to improve conditions, especially in areas where the outreach of Government services is inadequate mainly due to lack of resources and/or poor community response. Countries such as the Peoples' Republic of China with their "barefoot doctors", Latin American 1/ RHCDS is an integrated approach to health delivery services focusing on preventive health care, family planning and nutrition, under which functions have been redistributed among the health team members, giving more responsibilities to lower level personnel.  -76 - ANNEX 5 Page 2 PHILIPPINES POPULATION PROJECT II PRIMARY HEALTH CARE COMPONENT (cont.) countries with their "auxiliares de enfermeria", African countries with their "medical assistance" are examples of responses to community needs according to particular situations. A favorable impact on the communities has been achieved through these strategies mainly because the non- professional community worker is able to bridge effectively the wide cultural gap between the people and the modern frontiers of care. This is especially demonstrated when traditional healers and indigenous midwives after appropriate training, are included in the health team. These traditional health workers, sharing values and attitudes of the community at large more strongly than the providers of modern health care, become potent decision leaders and innovators one properly motivated and trained. 5. Equally important to consider, however, is that even ordinary laymen (inhabitants and residents of the village or community other than traditional healers) can be harnessed effectively to become health workers. They provide the necessary link to make modern practices more acceptable to the community, and give the professional health workers a clearer understanding of community needs to solve their own problems more effectively. 6. Applying the concept of primary health care, lf essential health services are made universally accessible to individuals and families in the community by means acceptable to them, with their full participation. There are several primary health care projects in the Philippines con- ducted both by Government and private agencies. These projects were extensively reviewed in a series of seminars conducted during the visit of the IDA Appraisal Mission to the Philippines in October 1978, and also by a WHO conducted field review. Utilizing these experiences, a primary health care component is being proposed as part of the second population project for pilot testing in twelve provinces--one in each of the country's twelve regions. It should be emphasized that the proposed component, while developed from Philippines experiences, is still subject to revision at the municipal level to enable individual municipalities to make adaptations to the program depending upon their local needs and conditions. 7. The BHW will be a non-professional health worker residing in the barangay he/she serves. The BHW will be recruited and selected by the barangay membership, and will be primarily responsible to the people of the barangay through the Barangay Development Council. The BHW will be supported by the barangay through the income of a number of community income generating projects that will be set up under the control of the Barangay Development Council. The BHW's work will complement that of the Government health programs at the primary level, The BHW will be technically supervised by the Government health personnel and his/her work will be linked with that of other health facilities. Thus, while the BHW would be recognized and supported by the Government, he/she would not become a part of the health care delivery system. The BHW would be mainly responsible to the people he/she serves. The barangay 1/ There have been many definitions of primary health care. WHO/UNICEF consider primary health care to be the sum total of all health related activities at the interphase between the community and the health delivery system, provided with active community participation.  - 77 - ANNEX 5 Page 3 PHILIPPINES POPULATION PROJECT II PRIMARY HEALTH CARE COMPONENT (cont.) membership will decide on basic issues and policies, plan activities, and support the implementation of health programs in their own community. The barangay health workers will function as multi-purpose workers engaged in health, family planning and nutrition activities. These workers will coordinate their activities with other workers at the barangay level, through the Barangay Development Council. 8. The program will be implemented in two phases. In the first phase, to begin in 1980, the barangays of 100 municipalities whose medical officers have been trained during 1979 shall be covered. The second phase will cover the remaining barangays in the program. Before the second phase of the program is undertaken, an evaluation of the first phase of the program shall be carried out.  - 78 - ANNEX 6 Page 1 PHILIPPINES POPU1ATION PROJECT I} ESTIMATED PROJECT COST BY EXPENDITURE AND FUNCTIONAL CATEGORIES PART A - POPCOM (in P) Service Infrastructure Research Expansion Training IEC MI4S (population) Innovative Total Base Cost Capital Cost 1. Construction 18,562,700 - - - - - 18,562,700 2. Furniture 933,000 _ _ _ _ _ 933,000 3. Equipment 5,341,000 - - - - 5,341,000 4. Special Equipment 616,000 2,193,000 2,407,200 4,602,600 13,800 - 9,832,600 5. Vehicles 4,148,600 - 395,500 - - - 4,544,100 6. Materials for Finished Products - 1,411,900 1,100,000 103,500 300,000 - 2,915,400 7. Seed Funds - - - - - - 8, Advisory Services 666,000 333,000 1,555,500 210,000 394,800 - 3,159,300 9. Fellowships - 738,800 1,309,800 832,500 266,400 - 3,147,500 10. Contracts (Studies, evaluation) - - - - 7,825,000 - 7,825,000 11. Professional Fees, Con- struction 2,227,700 - - - 2,227,700 12. Contracts for IEC Prototypes - - 14,492,700 - - - 14,492,700 13. Contracts for IEC Pro- duction - - 41 9776 nOn - - - 41.976 000 Subtotal, Capital 32.495,000 4,676,700 63,236,700 5,748,600 8,800,000 - 114,957,000 Incremental Operating Cost 14. Project Administration 500,100 500,100 500,100 500,100 500,100 - 2,500,500 15. Incremental Salaries - 2,378,600 2,835,100 151,200 1,233,600 - 6,598,500 16. Vehicle and Equipment Maintenance 4,183,800 - 2,226,000 223,300 - _ 6,633,100 17. Distribution (IEC Materials) - - 500,000 - - - 500,000 18. Travel and Per Diem - 34,197,700 2,017,000 79,200 550,000 - 36,843,900 19. Rentals (training) - 2795, n - - - - 225,000 Subtotal, Incremental Operating 4,683,900 37.301,400 8,078.200 953.800 2,283,700 - 53,301,000 20. Innovative Activities - - - - - 6,596,400 6,596,400 Subtotal, Base 37,178.900 41.978,100 71,314,900 6,702,400 11,083,700 6,596,400 174,854,400 Contingencies 21. Physical 2,079,200 - - - - - 2,079,200 22. Price 8,716,500 8,040,800 14,122,100 1.283.800 1,621,800 - 33,785,000 Subtotal, Contingencies 10,795,700 8,040,800 14,122.100 1.283,800 1,621,800 - 35,864,200 TOTAL 47,974,600 50.018,900 85.437.000 7,986,200 12,705,500 6,596.400 210,718,600  - 79 - ANNEX 6 Page 2 PHILIPPINES POPULATION PROJECT Ir ESTIMATED PROJECT COST BY EXPENDITURES AND FUNCTIONAL CATEGORIES PART B - MON (in f) Service Infrastructure Research/ Expenditure Category Expansion Training IEC MIS PHC Innovative Total Base Cost Capital Cost i. Construction 99,833,400 -9,3,0 2 Furniture 6,146,500 -99,833,40 3. Equipment 7,003,800 - -6 003,800 4 Speci27 Equipment 217,000 6,373,600 2,078,400 9,237,000 - 170906,000 5S.Vehicles 599,400 1,680,000 1,027,500 - _ 3,306,900 6. Materials for Finished Products - 1,073,200 3,130,000 121,600 200,000 - 3,849,600 7 .Seed Funds, PNC - - - 18,225,000 -5,667,400 8. Advisory Services 1,566,000 1,068,000 821,000 197,300 197,300 4 4,233 800 9. Fellovships 738,800 355,200 832,500 - 710.000 t0. Contracts (Studies, Evaluationu - 210,000 - - 500,000 - 1,926,500 11. Professional Fees, Con- struction 5,667,400 _ - - 4,524,800 12. Contracts, IEC Prototypes . 4,233,800 _ _ 18,225,000 13. Contracts, IEC Production _ 31,055,000 _ _ 31,055 000 Sbbtotal, Capital 121,033.500 11,143,600 42,700,900 10.388;400 19.122,300 -_204 388 700 Incremental ODerating Cos 14. Project Administration 534,900 534,900 534,900 534,900 534,900 - 2.674,500 15, Incremental Salaries 7.573.000 1,067,300 2,948,400 151,100 - - 11.739,800 16. Vehicle and Equipment Maintenance 747,600 1,407,700 2,14.0 000 188,800 - 4,484,100 17. Distribution (IEC Materials) - - 500.000 - _ 500.000 18. Travel and Per Diem - 26,375,300 2,933,500 551,500 549,800 - 30,410 100 19. Rentals (training) , 0- 7 0 _ 799,000 Subtotal, Incremental Operating 8,855.500 30,181,200 9,056,800 1,426.300 1,084,700 - 50,604,500 20. Innovative Activities - 8,076,400 8,076,400 Subtotal Base 129.,89,000 41.324.800 51.757.700 11.814,700 20.207.000 8,076,400 263,069 600 Contingencies 21. Physical 10,550,100 - - - - 10,550,100 22. Price 25.660.000 7,262,300 11,135,500 1.936.600 2 420,800 - 8415,000 Subtotal, Contingencies 36.210,100 7.262.300 11,135.500 1 936600 2,420.800- - . 5 '-3_ TOTAL, MON 166,099 100 48 587.100 62,893,200 13.751,300 22.627.800. 8,076.400 322,034,90Q  - 80 - ANNEX 6 Page 3 PHILIPPINES POPULATION PROJECT II ESTIMATED PROJECT COST BY EXPENDITURE AND FUNCTIONAL CATEGORIES TOTAL PROJECT (IN 1 Service Infrastructure Expenditure Category Expansion Training IEC MIS Research Innovative Total Base Cost Capitol Cost 1. Construction 118,396,100 - 118,396,100 2. F,rniture 7,079,500 - - - 7,079,500 3. Equipment 12,344,800 - - - - - 12.344,800 4. Special EqI,ip-enL 822,000 8,462,700 4,430,600 13,671,000 13,700 - 27,400,000 5. Vehicl-s 14,748,000 1,680,000 1,423,000 - - 7,851,000 6. Materials for Finished Prod-cts - 2,485,100 4,230,000 225,100 500.000 - 7,440,200 7. Seed Fund. _ - - - 18,225,000 - 18,225,000 S. Advisory Services 2,232,000 1,401,000 2,376,500 407,300 592,100 - 7,008,900 9. Fellowships - 1,477,600 1,665,000 1,665,000 266,400 - 5,074,000 10. Co-tr-cts (Studies, Evaluation) - 210,000 - - 8,325,000 - 8.535,000 Lt. Professional Fees, Con- str-rtion 7,895,100 - - - - - 7,895,100 12. Contracts for ITC Prototypes - - 18,726,500 - - _ 18,726,500 13. Contracts for IEC Pro- chuloriop - 73,031,000 - - - 73,031,000 Subtotal, Capital 153,517,500 15,716,400 1058200 15,968,400 27,922,200 - 319,007,100 Lncre-sntaj Operating ('ost 14. Project Administration 1,036,000 1,036,000 1,036,000 1,036,000 1,036,000 - 5,180,000 15. TIcremental Salaries 7,573,000 3,445,900 5,783,500 302,400 1,233,600 - 18,338,400 16. Vehicle and Equipment Maintenance 4,931,400 1,407,700 4,366,000 412,100 - - 11,117,200 17. Distribhtion 'IEC Materials) - - 1,000,000 - - 1,000,000 18. Travel and Per Die-s - 60,573,000 4,950,500 630,700 1,099.800 - 67,254,000 19. Rentals (traflingl - 1.021,000 - - - _ 1,021,000 S,btotal, Incrementra Operating 13,540.400 67,483,600 17,136,000 2,381,200 3,369,400 - 103,910,600 20. Innovative Activities - - - - - 14,672,800 14,672,800 Subtotal, Base 17_057,90_0 83,200,000 123,018,600 18,349,600 31,291,600 14,672,800 437,590,500 Contingencies 21. Physical 12.629,300 - - - - - 12,629,300 22. Price 34 376,500 15,303,100 25,257,600 3,220,400 4,042,600 - 82 200,200 Subtotal, Contingencies 80047,005 15,303.100 25,257,600 3,220,400 4,042,600 - 94,829,500 TOTAL 214,063,700 98,503,100 148,276,200 21,570,000 35,334,200 14,672.800 532 420,000  - 81 - ANNEX 7 PHILIPPINES POPULATION PROJECT II PROPOSED FINANCING PLAN ('000 US$) IDA Base Cost Total Project Cost GOP IDA Financing Ca5ital Cust L- I Foreign Total Local Foreign Total Local Foreign Total Ii I Construction 11,200 4,800 16,000 8,000 - 8,000 3,200 4,800 8,000 50 2 Furniture 600 300 900 - - - 600 300 900 100 3 Equipment - 1,700 1,700 - - _ 1,700 1,700 100 4 Special Equipment 600 3,100 3,700 - _ - 600 3,100 3,700 100 5 Vehicles 400 700 1,100 - - - 400 700 1,100 100 6 Materials for Finished Products 600 400 1,000 - - - 600 400 1,000 100 7 Seed Funds 2,500 - 2,500 - - - 2,500 - 2,500 100 8 Advisory Services, Fellowships, and Contracts (Studies, evaluation) 1,300 1,500 2,800 - - - 1,300 1,500 2,800 100 9 Professional fees, Construction 1,100 - 1,100 - - - 1,100 - 1,100 100 10 Contracts for IEC Prototypes and Production 6,200 6,200 12,400 6,200 - 6,200 - 6,200 6,200 50 Subtotal, Capital 24,500 18,700 43,200 14,200 - 14,200 10,300 18,700 29,000 67 Incremental Operating Cost 11 Project Administration 700 - 700 700 - 700 - - 12 Incremental Salaries 2,500 - 2,500 2,500 _ 2,500 - - - 13 Vehicle and Equipment Maintenance 1,200 300 1,500 1,200 _ 1,200 - 300 300 14 Distribution, IEC Materials 100 - tOO 100 - 100 - - - 15 Travel and Per Diem 9,100 - 9,100 4,800 - 4,800 4,B00 - 4,300 50 16 Rentals (Training) 100 - 100 100 _ 100 - - - Subtotal, Incremental Operating Cost 13,700 300 14,000 9,400 9,400 4,300 300 4,600 17 Innovative Activities 1,000 1,000 2,000 1,000 _ 1,000 - 1,000 1,000 50 Subtotal Base 39,200 20,000 59,200 24,600 - 24,600 14,600 20,000 34,600 58 Contingencies 18 Physical 1,200 500 1,700 800 - 800 400 500 900 50 Price 7,400 3,700 11,100 6,600 - 6,600 800 3,700 4,500 57 Subtotal Contingencies 8,600 4,200 12,800 7,400 - 7,400 1,200 4,200 5,400 56 TOTAL 47,800 24,200 72,000 32,000 - 32,000 15,800 24,200 40,000 56  - 82 - ANNEX 8 PHILIPPINES POPULATION PROJECT II DISBURSEMENT SCHEDULE OF IDA CREDIT (US $'000) IDA Financing Amount Cumulative FY 1981 Sept. 30, 1980 2,200 2,200 Dec. 31, 1980 2,200 4,40C March 31, 1981 2,200 6,600 June 30, 1981 2,400 9,000 FY 1982 Sept. 30, 1981 2,200 11,200 Dec. 31, 1981 2,200 13,400 March 31, 1982 2,200 15,600 June 30, 1982 2,300 17,900 FY 1983 Sept. 30, 1982 2,700 20,600 Dec. 31, 1982 2,700 23,300 March 31, 1983 2,700 26,000 June 30, 1983 2,700 28,700 FY 1984 Sept. 30, 1983 1,500 30,200 Dec. 31, 1983 1,600 31,800 March 31, 1984 1,600 33,400 June 30, 1984 1,600 35,000 FY 1985 Sept. 30, 1984 1,200 36,200 Dec. 31, 1984 1,200 37,400 March 31, 1985 1,300 38,700 June 30, 1985 1,300 40,000  PHILIPPINES POPULATION PROJECT II ORGANIZATIONAL CHART FOR PROJECT ADMINISTRATION tottIOM AQAPO.u .......... .. 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