Philippines - Population Project

Document of The World Bank FOR OFFICIAL USE ONLY Report No. 5544 PROJECT PERFORMANCE AUDIT REPORT PHILIPPINES FIRST POPULATION PROJECT (LOAN 1035-PH) March 19, 1985 Ops-rations Evaluation D-,partn'nt 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. LIST OF ABBREVIATIONS ASEAN - Association of Southeast Asian Nations AOA - Advice of Allotment BHS - Barangay Health Station CDC - Cash Disbursement Ceiling CMC - Construction Management Consultant COA - Commission on Audit DOH - Department of Health EA - Executive Architect FAS - Function Analysis Study FMS - Finance and Management Service FP - Family Planning FPSSP - Family Planning Services' Special Project GOP - Government of the Philippines HOIS - Hospital Operations Information System IBRD - International Bank for Reconstruction and Development IAMCC - Inter-Agency Monitoring and Coordinating Committee IEC - Information, Education and Communication IPPF - International Planned Parenthood Federation MCH - Maternal and 'hild Health iIHC/RIIU - Main Health Center/Rural Health Unit MIS - Management Information System MLGCn - Ministry of Local Government and Community Development 71O - 4unicipal Health Officer MOB - Ministry of the Budget MOH - Ministry of Health NFPO - National Family Planning Office NNC - National Nutrition Council NEDA - National Economic and Development Authority OED - Operations Evaluation Department PCR - Project Completion Report PC U - Project Construction Unit PD - Presidential Decree PHC - Primary Health Care P!iN - Population, Health and Nutrition Department PIC - Project Implementation Officer PMS - Project Management Staff POPCO - Commission on Population POP I - Philippine Population Project I POP fl - Philippine PnpulatLon Project l1 PA.M - Project Performance Audit Memorandum PAR - Project Performance Audit Report RH-CDS - Restructured Health Care Delivery System Ro[S - Rural r)perations Information System RTC - Regional Training Center tNFPA - united Nations and for Population Activities ITSAID) - united States Agency for International Development 'JHl - Wrld 'ieaLth -)rganization FOR OFFICIAL USE ONLY PROJECT PERFORMANCE AUDIT REPORT- PHILIPPINES FIRST POPULATION PROJECT (LOAN 1035-PH) TABLE OF CONTENTS Page No. Preface i....................... Basic Data Sheet ................................................... 11... Highlights .........................................................iii PROJECT PERFORMANCE AUDIT MEMORANDUM I. PROJECT SUMMARY .................................1 II. MAIN ISSUES ........... -........4 A. Donor Coordination .................................... 4 B. Project Management ..................................... .5 C. Bank Supervision ........................................ 7 D. Project Impact ....................................... 8 Annexes: 1. Description of the Project (Schedule 2 of Loan Agreement). 10 2. Summary Description Follow-on Project .... ......... 12 Appendix: Comments by National Economic and Development Agency .... 16 PROJECT COMPLETION REPORT I. Introduction .................... .. ......21 II. Project Identification, Preparation and Appraisal -.... o.22 III. Key Aspects of Implementation Experience ...... 26 IV. Project Implementation and Performance --...... ...... 29 V. Program Performance .................................... 40 VI. Bank Performance ......................................... 41 VII. Conclusions ............ ...................... 43 Annexes: I. Targets versus Accomplishments ........................... 45 II. Loan Allocations .......................................... .55 III. Construction Progress ..................................... 57 IV. Disbursements ............................................. 62 V. Compliance with Loan Conditions ............................. 64 VI. POPCOM Funding ........................................... 65 Map: IBRD 14067 - Location of First Project Facilities 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. PROJECT PERFORMANCE AUDIT REPORT PHILIPPINES FIRST POPULATION PROJECT (LOAN 1035-PH) PREFACE This is a performance audit of the Philippines First Population Project, for which Loan 1035-PH in the amount of US$25.0 million was approved on July 2, 1974. The last disbursement was made in May 1983, a delay of more than three years after the original closing date of December 31, 1979, which was extended three times (June 30, 1980; June 30, 1981 and finally to December 31, 1982). The remaining US$1.65 million undisbursed balance was cancelled in August 1983. The project was followed by the Second Population Project, which was partially financed by Credit 923-PH in the amount of US$40.0 million, signed on June 27, 1979. This audit consists of a memorandum prepared by the Operations Evaluation Department (OED) and a Project Completion Report (PCR). The PCR of the Population, Health and Nutrition Department (PBN) dated February 1984, is based on a completion report prepared in April 1983 by the Government of the Philippines (available in OED). The audit memorandum is based on a review of the Appraisal Report (No. 333-PH) dated May 22, 1974, the President's Report (P-1473-PH) of June 20, 1974, and the Loan Agreement dated July 31, 1974, together with information obtained from a review of project issues as contained in relevant Bank files and interviews with Bank staff who have been associated with the project. An OED mission visited the Philippines in April 1984, and held discussions with Government and project officials and reviewed project investments and programs. A number of project facilities were visited in the field. These interviews and observations also contributed to the conclusions of the audit as contained in the audit memorandum. On the basis of the above procedure, the audit concludes that the PCR generally provides an adequate accounting of the project's background, implementation and impact. The audit memorandum elaborates on some of the PCR conclusions it cannot fully support as well as other issues of signifi- cance to population lending. The draft report was sent to the Borrower for their comments on November 14, 1984 and to the co-financiers on December 5, 1984. Comments received have been appended to the audit memorandum. OED acknowledges the valuable assistance and information provided to the audit mission by NEDA (National Economic and Development Authority), MOR (Ministry of Health), POPCOM (Commission on Population) and the officials and staff of the health and family planning services in Region 3, which con- tributed significantly to the preparation and findings of this report. ADIVIEC FIRIDAMB MASIC DATA SUZ T (LAN 1035-PE) T PDJEC DAM Appraisal Actual or Actual as Z ot Item Etimated Actual Appraisal Estmate Total Project Cost ( MS i mlllion) 50 0 43.0 8Ws Loan Amount (0S$ million) 25.0 23.3 93 oant Board Approval 07102/74 Date Signing 07/31/74/b Date Effectiveness 11/L3/74Tb Date Physical Component Completedc 06/78 03/83 -470/d Proportion tha completed (Z) 80 100 163Td Closing Date 12/31/79 05/31/83/o Institutional Parformane good poor Cumulative Estimated and Actual Disburemants (Iss million) Fr75 FY76 FY77 F78 FY79 FT80 11al F782 FY83 Appraisal estimate (USS million) 1.0L 4.07 13.8 21.81 24.36 25.00 - - - Actual (USS million) 0.02 0.36 2.45 7.33 11.46 13.26 16.1 17.7 23.35 Actual as Z of estimate 2 9 18 34 47 53 64 71 93 Date of financial disbrsement: 05/83 Cancelled: USSI-65 million (CB/18/83) MISSION DATA Date No. of Staff days Specializations Performance Trpea of Mission (mo./Yr.) Persons in Field Reresented /f Rating I Trend /h Problems L1 Identification - - - - - - - Preparation 10/72 3 5 a.e.c - - - Appraisal 03/73 8 30 c.a.e,b,h.f,d.e - - - Supervision 1 11/74 3 11 a.c.e 2 - F,N Supervision II 06/75 3 12 a.c.e 2 1 T,H Supervision III 12/75 1 12 a 2 1 M,T Supervision IV 04/76 1 9 a 2 1 T.M Supervision V 11/76 1 I4 a 2 1 M.P Supervision VI 03/77 1 14 a 2 1 M Supervision VII 08/77 7 13 a,e.e.id,h,f 2 2 NJ Supervislon VIII 12/77 4 6 a.e.c.d 2 2 FN Supervision IX 07/78 2 5 c.e 2 2 r,m Supervision 1 11/78 3 5 a.c.e 1 1 F. Supervision II 03/79 4 15 c.ag.f 2 2 N,P Supervision XIIII 07/79 6 7 c.a.d.e.g,d 2 2 F.K Supervision lIII/ 10/79 4 7 a.e.d.j 2 1 F,M Supervision ]IV/ 04/80 4 7 a.c.e,d 2 2 F,K Supervision LV9/ 12/80 3 6 c.e,d 2 2 F.K Supervision 19I1/ 06/81 2 14 c.e 2 1 F.m Supervision IVIIL1 04/82 3 12 c.e,a 2 2 M.T.F Supervision IVIIIL 10/82 4 11 c.k.e.1 2 1 N,T OTHER PRDJECT DATA Borrower Government of L%e Philippines (COP) Executing Agency Department (later Ministry) of Health (MDR) and the Commission on Population (POPCOM) Piscel Year 01/01 - 12/31 Name of currency (abbreviation) PESOS (P) Currency Exchange Race: Appraisal Year Average ISS 1.00 - P 6.76 lnterventag Years Average US$ 1.00 - P 7.46 Completion Year Average US 1.00 - P 8.54 Follow-on Project: Name Philippines Second Population Project (POP II)/k Credit Number 923-PH Credit Amount (USS million) 40.0 Date Board Approval 06/05/79 /a Underrun of 14Z. Project cost was recalculated in 1978 and 1981. Price contingencies over estimated at appraisal were not needed and thee savings were reprogrammed to cover additional project components /b The loan was transformed from a non pooled loan to a pooled loan July 02. 1981. 7- Several additional construction activities -ere undertaken; completed in March 1983. /d Percentage in third column calculated from Board approval date. 7 Closing Date remained officially established on 12/31/82 according to Statement of Loans. /f a - public health specialist; b - economist; c - population specialist: d - IEC apecialist; e - architect. f - training specialist- g - management specialist; h - demographer; I - nutrition specialist; j - NIS specialist; k - rural development specialist; 1 - operations assistant / I - problem-free or minor problem; 2 - moderate problems; and 3 - major problems. /h 1 - Improving; 2 - stationary; and 3 - deteriorating. 71 F - financial; M - managerial; T - technical; P - polit,al; and 0 - other. / In conjunction with supervision of the second project. Ik See also SAR Second Population Project. Report No. 2455-PH dated May 23, 1979. PROJECT PERFORMANCE AUDIT REPORT PHILIPPINES FIRST POPULATION PROJECT (LOAN 1035-PH) HIGHLIGHTS The main objective of the project was to assist the Government of the Philippines to strengthen its population program and improve its rural health and family planning delivery system. The project included: (a) strengthening the Commission on Population (POPCOM), (b) expanding the rural health delivery system, (c) expanding health training facilities and staff and (d) improving the management information system of the Ministry of Health (MOH). Contingencies were greatly overestimated, and more than a third of the loan had to be kept in the unallocated category. This amount was re- programmed twice during implementation to cover new activities, but, even after a three and a half-year delay of the closing date, US$1.65 million remained undisbursed and had to 'e cancelled. Since the MOH, rather than POPCOM, was the lead agency for the project, and most of the funds were allocated to MOH's "hardware" activities, most of the attention was given to health rather than population objectives, a feature common to most of the Bank's early "population" projects. The Bank's supervisory role, though necessarily low-key, was critical, but was unevenly managed, especially during the early years of project implemen- tation. Overall, the audit's judgement (PPAM, paras. 25-27) about the project varies from that made in the PCR. Other points of interest are: - Many project training facilities and equipment are not utilized as originally intended. Some wastage has occurred (PPAM, paras. 4 and 5; PCR, paras. 4.11, 4.12 and 4.16); - the project's most significant contribution has been the hiring and training of midwives (PPAM, para. 10); - the Bank channelled its assistance through the MOH rather than POPCOM, which had other sources of foreign assistance and because of the largely health based activities of the project (PPAM, para. 15); and - problems resulted from the creation of a powerful, autonomous project unit reporting directly to the Minister of Health (PPAM, paras. 16-21). PROJECT PERFORMANCE AUDIT MEMORANDUM PHILIPPINES FIRST POPULATION PROJECT (LOAN 1035-PH) I. PROJECT SUMMARY 1/ Project Objectives 1. In July 1974, the World Bank approved a loan of US$25.0 million for the first Bank-funded population project in the Philippines. Its main objec- tive was to help the Government of the Philippines (GOP) strengthen its population program and improve its rural health and family planning delivery system. 2. The project had four major components: (a) strengthening the National Commission on Population (POPCOM), by establishing an Information, Education and Communication Division (IEC) and a Training Division (funded by UNFPA and USAID respec- tively); (b) expanding the rural health delivery system of the Department (later Ministry) of Health (MOH) by hiring and training 2400 new midwives, constructing 205 Rural Health Units (RHUs) and 85 staff houses, providing vehicles, equipment, and furniture; (c) constructing, equipping, and furnishing 11 Regional Training Centers for MOH and providing technical assistance for training; and (d) improving the statistical system in MOH by providing needed equip- ment and technical assistance. Project Implementation 3. The project got off to a slow start, but gradually gained consider- able momentum; by December 31, 1979 (the original loan closing date), 48.4% of the loan had been disbursed and 88% of the construction activities and most of the training activities had been completed. However, in December 1978 a reprogramming of the unused (overestimated) contingency funds amount- ing to US$8.9 million was undertaken and several new activities (such as feasibility studies for the second project, construction of 25 village-level Barangay Health Stations (BHSs), training, reproduction of training materials and vehicles) were added. In June 1981 a second reprogramming (construction of a MOH warehouse, vehicles, water supply facilities and techniiLal assis- tance) was done to make use of the remaining funds (see PCR, paras. 3.08-3.12 1/ This Chapter taken from the PCR's Summary and Conclusion as submitted to OED on March 9, 1984. -2- for more details). The loan account was finally closed on May 31, 1983, and an unused amount of US$1.65 million was cancelled (August 18, 1983). A summary of project accomplishments, by component, is given below. 4. Civil Works.2/ Civil works constituted 65% of estimated project cost and 27.6% of the loan (excluding price contingencies). All the planned construction (RTCs, RHUs, BHSs, warehouse, MOR building renovation) has been completed, though 1-2 years behind schedule. Construction surfaces and costs have been slightly higher than appraisal estimates. While no comprehensive assessment of utilization of project services and facilities has yet been undertaken, available evidence indicates that about 50% of the RTC spa,,e has been converted into offices for Regional Health Staff, and that some of the RHUs are underutilized (partly due to initial water supply problems and partly due to their large size). BHS construction has been undertaken using local contractors rather than community participation, partly due to MOR's and the communities' lack of interest at that time (for full details see PCR, paras 4.03-4.12). 5. Logistics. Most of the vehicles, equipment and furniture have been procured and distributed. However, the supervision and documentation of the logistics component as illustrated in the PCR (paras. 4.13-4.20) has some- times deviated from established procedures, and some wastage has occurred. 6. Technical Assistance. Most of the training, IEC materials develop- ment, studies, fellowships and consultancy assignments have been undertaken as planned, both in MOH and POPCOM. The training and hiring of midwives has been the most significant contribution of the project. The Facilities Evalu- ation Study required as per the Loan Agreement would have been useful but was cancelled in December 1978 during the loan reprogramming. A Functional Analysis Study of MOH was undertaken in 1979-80 and its recommendations in early stages of consideration when superseded by the 1981 MOH reorganiza- tion. A systematic evaluation of relevance and utilization of technical assistance activities is required so that steps needed for improving the usefulness of this component (particularly of the MIS, statistics, and logistics studies) could be identified (PCR, paras. 4.21-4.24). 7. Accounts, Disbursement and Budgeting. As with the logistics comr- ponent, documentation of financial transactions could have been greatly improved: during the entire implementation period only one certified audit report (in 1981) has been submitted to the Bank. The difficulties of having timely budgetary release of GOP counterpart funds and an apparent misunder- standing of Bank requirements have caused delays. But since 1982 following the advice of Bank supervision missions, significant improvements were made in the accounting and budgeting procedures followed by the project, and some of the recommendations of the audit report have been implemented (PCR, paras. 4.25-4.30). 2/ As a matter of interest, the project-financed rural health facilities are the only health infrastructure which sustained only minor damage in the September 1984 typhoon affected areas. - 3 - 8. Fulfillment of Covenants'. A majority of loan covenants have been fulfilled. The major covenants not fully complied with pertain to the provi- sior. of adequate and timely budgetary resources, the maintenance of proper records during tt-e first few years of the project, their incomplete handover from the Project Management Staff (PMS) to MDH (in 1979-80), and the submission of properly certified annual audit reports (PCR, para. 4.31). 9. As illustrated in Chapter III of the PCR, many of the delays and problems of implementation stemmed irom three special features of the project: (a) the sudden discontinuation of the project implementation unit mid- stream, and problems of transition to the parent MOH; (b) a substantial overestimation of price contingencies at the time of appraisal (mostly as a reaction to the oil crisis of the early 1970s), the subsequent reprogramming of the loan, and the addition of several new activities; and (c) the lack of continuity of project administration (both in MDH and the Bank), resulting in serious dislocations of work, especially during the transition period (1979-81). Prr ject Impact 10. The most significant project activity has been MOH's hiring, training, and utilization of midwives under the Restructured Health Care Delivery System (RHCDS). It has helped improve the quality and availability of health services in rural areas, and this benefit is likely to be sustained over the long term. MOH's recent policy initiative of introducing a nation- wide Primary Health Care (PHC) system by end 1983 has been possible largely because trained midwives are now available in most parts of the country. POPCOM's IEC and Training divisions are also much stronger than they were when the project was initiated, and some of the improvement has been due to the inputs provided by the project. 11. Although its role was largely constructive and a useful dialogue has been established with MOR and POPCOM officials, Bank performance during design and implementation of the project could have been better. The severity of some implementation problems could nave been reduced with more attention given to supervision of the construction and logistics components, and to utilization of the facilities built under the project. Concluding Observations 12. Tn conclusion (see also PPAM, paras. 25-27), the following general observations can be made: (a) since the MOH rather than POPCOM became the lead agency for the "population project," and most of the funds were allotted to MOH's "hardware" activities, most of the attention was given to health rather than population objectives; (b) institution-building efforts might have been more successful if considerably greater caution had been exercised in phasing out the project unit (the PMS), and merging its functions with the present MOH; and (c) the Bank's supervisory role, though necessarily low-key, was critical, but was unevenly managed, especially during the early years of project implementation. Greater attention to project out- puts (rather than inputs), and to regular and timely feedback from the intended end-users could have improved project performance con- siderably. 13. The thrust of the first project is continued under the second (with emphasis on primary health care), for which Credit 923-PH in the amount of US$40.0 million was approved in June 1979 (PCR, para. 5.04 and PPAM, Annex 2 for a description of the components included under the second project3/). II. MAIN ISSUES 14. While the audit is generally in agreement with the PCR, some issues require further elaboration and comment due to their importance to this proj- ect as well as to other population projects audited by OED. These issues are discussed in the following section of the report. A. Donor Coordination 4/ 15. From the beginning the Bank tried to emphasize the population as- pects of its proposed activities but was somewhat frustrated in its efforts by the natural preference of GOP for grant money to finance its population activities. Also, both USAID and UNFPA had been actively involved in financing population activities in the Philippines for some time and agreed to continue providing grant-funding for POPCOM activities. Thus as the PCR points out (PCR, paras. 2.01-2.04) a serious dilemma arose. On the one hand, the Bank did not wish to be limited to a construction project only and needed population activities for its project justification (at the time Bank policy did not permit financing of health projects and population projects even with large health components were mainly justified on the basis of demographic criteria). On the other hand, however, these population activities were already largely financed by other donors who had earlier experience in the population field in the country. The audit believes, on the basis of discussions with project staff and officials, that relations between the various donors became more difficult than so diplomatically described in the PCR. Given the fact that their agencies financed population activities 3/ See also Staff Appraisal Report, Second Population Project (No. 2453-PH, dated May 23, 1979). 4/ Government in its comments (see Appendix) basically confirms the audit analysis on this issue. already, both USAID and UNFPA resisted the Bank's efforts toward formulation of a project which would place the Bank and POPCOM in a close, direct working relationship in implementing what would, after all, be a largely health-based set of activities. As a result, donor coordination of population activities became somewhat constrained.5/6/ In the end, a compromise was reached and it was agreed that POPCOM components would be separately funded by USAID and UNFPA, but would nevertheless be retained as part of the project descrip- tion7/ (PCR, paras. 2.04 and 6.02-6.03).8/ POPCOM was given, on paper at least, an overall coordinating role for the Bank's project. However, it was not until the first reallocation of loan proceeds in 1979 that the Bank and POPCOM had any real business relationship. B. Project Management 16. Shortly after the Loan Agreement was signed, a Presidential decree was issued establishing PMS, with extraordinary powers and privileges and reporting directly to the Minister of Health, to manage the implementation of the project (see also PCR, paras. 2.11 and 3.02-3.07). 17. While not entirely without precedent in the Philippines (a similar project management unit had been set up for the Philippines Second Education Project a year earlier), the autonomy granted to PMS was very unusual. The concept of a powerful, autonomous project unit was a familiar one to Bank staff, however, and they welcomed it, still thinking that POPCOM would 5/ While there was hardly any coordination regarding the execution of the various project components (the USAID and UNFPA component were small in relation to the overall costs, each only about 1%) during project execution, relations improved considerably with both UNFPA and USAID actively participating in later sector work. 61 Similar experiences were encountered during preparation and implementa- tion of the Indonesia First Population Project (Credit 300-IND), PPAR under preparation. 7/ This was covered in the preamble of the legal documents as follows: "Whereas....., (b) the United Nations Fund for Population Activities (hereinafter called UNFPA) has agreed to assist the Borrower in the financing of Part A (i) of the Project on the terms of conditions set forth in the Borrower's proposal approved by UNFPA by its letter dated March 21, 1974; (c) by agreement dated April 30, 1974 (hereinafter called the USAID Agreement) the United States Agency for International Development has agreed to assist the Borrower in the financing of Parts A(ii) and (iii) of the Project on the terms and conditions therein set forth; ...... (for project description see Annex 1). 8/ Nevertheless the components were not integrated in the project in the normal cofinancing sense during project implementation. - 6 - maintain the overall coordinating role provided in the Loan Agreement, ircluding the coordination of PMS activities.9/ 18. The PMS grew quickly and became isolated from the permanent MOB establishment. Its staff received total compensation averaging about 30-401 higher than that of the regular ministry staff, and PMS itself was afforded greater freedom from normal Government accounting and procurement procedures, making PMS accountable in effect only to the Minister of Health himself. 19. For project purposes, PMS enjoyed better office accommodation, new Bank-financed vehicles, and other support unavailable to regular MOB staff. PMS also had ample funds for the employment of consultants and for overseas training of its own staff. All this was ostensibly justified in the interest of efficient project implementation; the outcome, in the audit's view, was the opposite. 20. The PCR illustrates various instances of inefficiency. For example. when contractors failed to perform their contractual obligations on time, PMS granted further extensions rather than enforcing the penalties pro- vided under the contracts and even granted the contractors' requests for upward price adjustments following the delays (PCR, para. 4.11). Equipment purchased under the project could not be delivered to the long-delayed facilities for which it was intended and had to be sent to other, non-project health facilities instead (or kept in storage in Manilal0/). Due to "laxity" in PMS' control of this procurement and delivery process, some P7 million worth of Bank-financed equipment and supplies could not be adequately accounted for, according to a one-year study by the Philippine Commission on Audit. 21. The PCR describes a further number of aberrations in the PMS' management of project implementation, and it is not the role of the audit to comment on each and every one of these shortcomings. As the Government's original PCR does in fact say, the Bank's supervision of the project, particularly during the reign of the PMS, could have been much less lenient and permissive and might thus have been able to reduce some of the wastage, 9/ Section 3.02(a) of the Loan Agreement states: "The Borrower shall cause its Commission on Population to coordinate the work, in respect of the Project, of the agencies of the Borrower participating directly or indirectly in the execution of the Project". In addition, section 3.02(b) required the setting up of a Project Construction (audit emphasis) Unit in MOH. 10/ Some items stayed in storage for more than four years and were no longer useful (PCR, para. 4.16). Funds to construct a 40H warehouse were allo- cated under the second (1981) reprogramming (PCR, para. 3.12). -7- delay and downgradif of quality of facilities, equipment and supplies financed by the loan.11- C. Bank Supervision 12/ 22. As the PCR points out, Philippine project staff were unfamiliar with Bank policies and procedures. To make matters worse, however, the Bank's own staff and consultants responsible for supervising the project during the crucial early years were also not fully familiar with Bank poli- cies and procedures. For the first four years the project proceeded without the services of a Washington-based architect, and supervision visits were carried out by a consultant architect based in Australia who had never worked for the Bank before and who was inexperienced in dealing with small, widely scattered rural health facilities of the kind included in the project. PHN was also a relatively new but rapidly expanding department and some of its staff did not initially, in spite of the best intentions, have the kind of experience necessary to properly supervise a project of this kind. 23. Thus, as in many of the Bank's earlier population projects, an experienced lending institution with a reputation for excellence in financing construction programs found itself poorly served in entering a new sector. While the Bank had a wealth of experience and know-how in general, this experience with supervision of civil works and construction in other sectors was not easily transferable and as a result civil works supervision under population projects was initially not up to the high Bank standards applied in other sectors. 24. While the staff of the Population Projects Department were mainly interested in the software components of the early projects, Bank 11/ The audit issue relates to the functioning of PMS. Government in its comments (see Appendix) elaborates on project management in a wider perspective by referring to project implementation under three periods namely: (a) January 1975 to mid-1979 under PMS; (b) mid-1979 to mid-1981 during which the transition from PMS to MOH occurred: and (c) mid-1981 to March 1983 under MOH and during which IAMCC (Inter-Agency Monitoring and Coorodination Committee based at NEDA for the Population I Project) functioned. 12/ Government (see Appendix) comments as follows: -Frequent and fast turn-over of WB personnel assigned to the project was very prominent during the early and middle part of project implementation. Various WB Mission, especially during the first two above-mentioned periods of project implementation, were each time composed of different WB personnel. There was therefore no continuity nor effective supervision and monitoring of project progress until the IAMCC recommended to IBRD that future Missions should be composed of permanent regular personnel who were fully oriented with the project's implementation and progress to achieve both continuity and effective project supervision and monitoring. Besides their visits were irregular during the project life." -8- management's desire to achieve a major impact in population lending created a tendency for the Bank to finance a series of projects consisting of large construction and hardware procurement programs, inevitably oriented more toward public health than family planning. Most of these projects had similarly disappointing results and loss of focus on family planning objec- tives.13/ D. Project Impact 25. The PCR makes the statement (para. 4.22) that "the training and hiring of additional midwives ... have been the most significant contribution of the project". The audit agrees with this statement but notes that even this training was inadequate in its family planning content.14/ Moreover, the same, or perhaps better, training impact might have been achieved without the expenditure of US$43 million, most of which went to pay for buildings and equipment which are largely underutilized or used for purposes other than those intended under the project and which, in any case, could have little direct bearing on the project's main objective: supporting and extending the Philippines' family planning program. 26- Admittedly, the project helped to create a restructured health delivery system and to sustaiL a dialogue between the Bank and the Philippines on population policies and programs. But at what cost? This project, like mo:t of the other early "population" projects, included sub- stantive, program-related elements which were far too small in relation to the costly and, in virtually every case, overdesigned, underutilized and poorly maintained health infrastructure which accounted for most of the money spent. In the audit's view, the Bank could probably have achieved more impact with less lending, given a better focus on population objectives and greater relative emphasis on software vs. hardware in project design. 27. Thus, on the one hand certain project components have had substan- tial impact, but oz: the other hand facilities constructed under the project have been diverted to other uses or are underutilized, equipment has been diverted to other uses or is no longer in running condition and there are substantial problems with maintenance and repairs. Furthermore the PCR describes well the many problems with project implementation and institution building. Under these circumstances the PCR assessment of the project is open to debate, especially if the project is measured against its original 13/ See also Tenth Annual Review of Project Performance Audit Results, OED Report No. 5248 deted August 30, 1984 (paras. 4.90-4.93). 14/ As specifically mentioned by Bank staff during the Board presentation of the Philippines Second Population Project. -9- stated objectives.15/ The absence of firm data on the utilization of facilities makes a precise judgement on the project impact even more subjective and the decision not to undertake the facilities evaluation study must be regarded in retrospect as a mistake.16/ The potential for improved utilization of facilities and further improvements of health and family planning service delivery systems undoubtedly exists but the audit is less optimistic than the PCR as to when this might be realizedl7/ and therefore implicitly arrives at a different judgement at this stage about the project. The audit is under these circumstances in complete agreement with the PCR suggestion (PCR, para. 5.04) for a more comprehensive assessment of the program and project impact of the two Bank-funded projects at the time when the second project is completed.181 191 15/ -The project's main objective is to assist the Government of the Philippines in strengthening its population program and expanding it into the rural and semi-rural areas where almost 70% of the population live. Extended coverage of the family planning program is essential in order to enhance the possibility of a moderately fast decline in fer- tility, ......(Appraisal Report, Report No. 333a-PH dated May 22, 1974, Summary and Conclusions, para. i). 16/ While the original envisaged timing might have become inopportune due to construction delays, the study could simply have been delayed. 17/ These potential improvements might be regarded as benefits due to the second project, rather than the first. 18/ It is suggested that PCR work be planned with this objective in mind. 19/ Government zomments (see Appendix) as follows: "Due to the necessity of assessing project impact, WB should in the future consider making impact studies at the end of each project period as a functional part of the PCR with funding set aside for this specific purpose." - 11 - ANNEX 1 Page 1 PROJECT PERFORMANCE AUDIT REPORT PHILIPPINES FIRST POPULATION PROJECT (LOAN 1035-PH) DESCRIPTION OF THE PROJECT 1/ The Project coasists of: Part A: Strengthening the coordinating capability of the Commission on Population to conduct the population program of the Borrower, by means of: (i) establishment, in said Commission, of an Information, Education and Communication Division with the functions set forth in the agree- ment between the Borrower and UNFPA referred to in the Preamble of this Agreement; (ii) establishment, in said Commission, of a Training division with the functions set forth in the USAID Agreement; and (iii) establishment of Regional Offices of the Commission on Population with the functions set forth in the USAID Agreement. Part B: Extending and reinforcing the rural health and family planning delivery service of the Department of Health by establishing a new system of health service delivery in rural areas, including: (i) construction, equipping and furnishing about 160 buildings (Type A-) and about 50 buildings (Type "B-) to be used as Rural Health Units, including two houses for the staff of each of about 40 of such T1pe A units and one house each in all of such Type -B- units; / (ii) procurement of about 200 jeeps and spare parts for jeeps, and vehicle maintenance; (iii) employment of about 2,400 additional midwives to serve as midwife/ community health/family planning workers in said units and Barrio 1/ Schedule 2 of the Loan Agreement. 2/ Type -A" means a building adequate to serve municipalities with a population between 10,000 to 50,000 inhabitants; Type "B- means a building adequate to serve municipalities with a population between 5,000 to 10,000 inhabitants. - 12 - ANNEX 1 Page 2 Health Stations. It is expected that about 480 midwives will be employed during each of the 5 years following the date of this Agreement; and (iv) establishment of a core staff in Department of Health to organize the implementation of new procedures applicable to Rural Health Units. Part C: Construction, equipping and furnishing of facilities and provision of additional services for the Borrower's health and family planning training programs, consisting of: (i) about 11 Department of Health Regional Training Centers, for in- service health and family planning training of Government staff. Each center to have, besides teaching and administrative facilities (including an audio-visual system), a library and living accommoda- tions for trainzs and staff, and vehicles; (ii) additional materials and services, including travel, for about 9 workshops for staff of the Regional training Centers; and (iii) provisions of about 24 man/months of technical assistance and about 35 one-year fellowships for midwifery tutors. Part D: The employment of additional staff to establish a core staff for the Health Statistics Unit of the Department of Health; procurement of equip- ment for the statistical services of the said Department; and prcvision of technical assistance for the purposes and time set forth in the Annex to this Schedule, as such Annex may be amended from time to time by agreement between the Borrower and the Bank. This Project is expected to be completed by July 31, 1987. - 13 - ANNEX 2 Page 1 PROJECT PERFORMANCE AUDIT REPORT PHILIPPINES FIRST POPULATION PROJECT (LOAN 1035-PH) SUMMARY DESCRIPTION FOLLOW-ON PROJECT 1/ Part A: POPCOM (a) Constructing, furnishing and equipping seven regional office buildings, and thirteen contraceptive warehouses and vehicle main- tenance 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 main- tenance, evaluation and continuous development of MIS; 12 months in research 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 development, and data manage- menL; 4 6-month in research design and management; 3 1-month study tours, 9 6-month foreign, and 4 12-month local in IEC; 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 admini- stration; incremental salaries for training, IEC, MIS and research 1/ Taken verbatim from SAR Second Population Project, Report No. 2543-PH dated May 23, 1979 (para. 3.04). - 14 - ANNEX 2 Page 2 activities; vehicle and equipment operation and maintenance; dis- tribution 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 w1-ich are identified at a later stage of the project as important complement to POPCON program. Part B: MOH (a) Constructing, furnishing and equipping: (i) 75 health centers; (ii) 915 barangay health stations; and (iii) MOR space remodeling for IEC; (b) IEC and MIS equipment, including computer hardware, IEC 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 MOR'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, information systems develop- ment, 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 activi- ties: 18 months in financial and auditing matters; 6 months in MIS evaluation, maintenance, and upgrading; 27 months (foreign) and 17 months (local) in IEC; 70 months to design and implement an improved logistics system; 6 months in PHC design and implementation; and (iv) architect and construction management consultant fees; - 15 - ANNEX 2 Page 3 (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 important comple- ment to MOH components. - 16 - REPUBLIC OF THE PHILIPPINES Appendix NATIONAL ECONOMIC AND DEVELOPMENT AUTHORITY NEDA sa Pasig, Amber Avenue Pasig, Metro Manila Cable Addres: NEDAPHIL P.O. Box 419, Grenhills Tels. 673-l0-31 to 60 18 December 1984 Mr. Yukinora Watanabe Acting Director General Operations Evaluation Department The Norld Bank 1818 H Street, N.W. Washington D.C. 20433 U. S. A. Dear Mr. Watanabe: Re: Performance Audit Report: Philippines First Population Project (Loan 1035-PH) We appreciate your sending us a copy of the first draft of the Performance Audit Report on the Philippines First Population Project. The attached contains our comments and recommendations hereto forwarded for consideration in formulating the relevant conclusions for the final report. We hope you will find the attached useful. Very truly yours, A0* it &/A W& e0. VICENTE B. VALDEPENAS, JR. Minister for Economic Planning Director General Encl: a/s - 17 - Appendix COMMENTS ON TF-E DRAFT PROECT PERFORMANCE AUDIT REPORT: PHLPPINES FIRST POPULATION PROJECT (LOAN 1035-PH) We concur that while the audit report is generally in agreement with the Project Completion Report (PCR), the following Issues need further elaboration and comment: 1. Donor Coordination At the time that the project was conceptualized, WB had no Substantially separate financing for health. This led project formulators to confirms audit justify health components through their incorporation with popula- analysis; so tion activities. Since POPCOM had other sources for foreign c sc assistance, project formulators decided to put considerable funds for health activities where they were needed. Thus, population, although existing as the forefront of the project's objectives, was relegated behind health in terms of fund allocation and actual project implementation. The mentioned resistance of POPCOM's other donors to IBRD could have stemmed from the speculation that the project was not really a population project at the start of project implementation since considerable funds were allotted for health activities. These donors therefore could understandably not foresee or establish any coordination with an agency funding a largely health-based set of activities. 2. Project Management The audit issue From 1975 to 1979, the project was Implemented by the relates to the Project Management Staff (PMS) an Independent arm of the functioning of PM Ministry of Health (MOH) established by virtue of a presidential specifically. decree issued shortly after the signing of the Loan Agreement. In mid-1979, a new minister was appointed, abolished PMS and turned the project management over to the regular MOH staff. These comments The ensuing transition period even after another new relate to manage- Minister of Health bordered in inaction or unwillingness to take ment over a wider over project operations due to their lack of prior experience period. and proper training in Implementing a Bank-assisted project and Appropriate their unfamiliarity with the project and Bank procedures. More- footnote included. over, the absence of proper documentation of previous project transactions by PMS further aggravated the problem. The conduct of assessment workshop provided the project staff with a common understanding of the project's accomplishments and the critical activities that still needed to be undertaken. It also clarified the roles and functions of specific staff responsi- ble for specific sets of activities which were considered crucial to smooth operations. Towards the end of 1980 EDA through SSS was instructed to facilitate completion of the project and to explore means of effectively utilizing the projected US$6.988 M unexpended balance of the project. It spearheaded the reprogramming of the unexpended - 18 - Appendix project "savings" in coordination with MOH and OBM Staff by holding meetings resulting In solving project operations problems such as releases of funds through the Intervention of top level decision makers and loan amendment and reprogramming of the funds. Realizing the significance of having a monitoring body to continuously coordinate and stimulate project Implementation, the Inter-Agency Monitoring and Coordinating Committee (IAMCC) based at NEDA for Population I Project was established. Population I Project Implementation, therefore, could be divided Into three periods, namely: a) January 1975 to mid 1979 under PMS; b) mid-1979 to mid-1981 during which the transition from PMS to MOH occurred; and c) mid-1981 to March 1983 under MOH and during which the IAMCC functioned. 3. Bank Supervision Comment footnoted Frequent and fast turn-aver of WB personnel assigned to verbatim. the project was very prominent during the early and middle part of project implementation. Various WB Mission, especially during the first two above- mentioned periods of project implementation, were each time composed of different WB personnel. There was therefore no continuity nor effective supervision and monitoring of project . progress until the IAMCC recommended to IBRD that future Missions should be composed of permanent regular personnel who % ,re fully oriented with the project's implementation and progress to achieve both continuity and effective project super- vision and monitoring. Besides their visits were Irregular during the project life. 4. Project Impact Comment footnoted Due to the necessity of assessing project Impact, WB should verbatim. in the future consider making impact studies at the end of each project period as a functional part of the PCR with funding set aside for this specific purpose. The delay of more than three years after the original closing date Amended. mentioned in the Preface (1) was actually not a delay per se but three extensions of the closing dates from the original December 1979 first to June 1980, second to June 1981, and finally and third to December 1982. Under Highlights (v), it was mentioned that "the Bank was under Amended. pressure to channel its assistance through MOH rather than POPCOM". As mentioned earlier, MOH was recommended to become the lead agency because of the largely health-based activities of the project. - 19 - PHI.IPPIMES: FIRST POPULATION PROJECT (LOAN 1035-PH) PROJECT ODMPLETION REPORT Population, Health and Nutrition Department February 1984 -.20 - - 21 - I INTRODUCTION 1.01 The project was developed in 1972-1974 in response to the Philippines' expressed need for achieving a sustained fertility reduction in the next 25 years. The main objective was to assist the Government to strengthen its population program and improve its rural health and family planning delivery system. Although construction of 11 Regional Training Centers (RTCs) and 205 Rural Health Units (RHUs) constituted a major portion of the US $25.0 million loan, these were primarily a means for achieving a more extensive coverage of population-related activities of the Department (later Ministry) of Health (MOB). In addition, the national Commission on Population (POPCOM) was to be strengthened, by improving its training, information, education and communication (IEC) activities. 1.02 In the early 1970s the Philippine population was increasing at a rate of 3.0% per year, among the highest rate worldwide. The 1970 census reported a population of almost 37 million; double what it was 24 years earlier. About 45% of the population was under 15 years of age. High fertility (43-45 live births per 1000 population) had been almost constant over the past 70 years, while mortality had steadily decreased to approximately 10 per 1000 by 1972. Due to the high rate of population growth about half of the annual investments in the country were needed to maintain per capita income at its 1971 level of US $240 per annum. An effective population program was therefore urgently needed: a significant improvement in the standard of living could only be possible if the population growth rate declined sharply to about 2.0 per year (roughly 60% of the 1971 rate) by the year 2000. 1.03 The concept of family planning had been spread by private voluntary groups since the mid-fifties. These organizations had become more active in the 1960s with funds from foreign agencies (mainly the USAID, the International Planned Parenthood Federation (IPPF), and the Pathfinder Fund). In February 1969, President Marcos had signed an Executive Order establishing the Commission on Population with the primary function of formulating population policy and programs. In 1970 family planning became an official policy; and POPCOM was made the official coordinating body of some 25 agencies engaged in population and family planning activities. Included among these agencies was the Department of Health which, through its e-xtensive health infrastructure network, accounted for nearly one fourth of the 368,000 new acceptors recruited in 1971. However, a 1973 survey reported that only one third of the acceptors in the sample lived in rural communi- ties. Since more than two-thirds of the eligible women lived in these areas in 1970, this indicated a substantial under-representation of rural women in the program. 1.04 The major donor - USAID - provided about US $5.0 million a year for the family planning program; but local funds thus far had been minimal: P 349,000 (about US $50,000) in 1971, no direct funding in FY 1972, and a proposed P4.5 million in 1973. Total recurrent financial requirements were expected to rise to an annual level of P 81 million by 1976-1977 in order to meet the targetted 2.7% annual population growth rate by 1975. For this the volume of clinic activity compared to 1971 would have to increase by 30% in 1973 and would have to double by 1975. By 1980, 2.1 million women or almost 30% of all married women - would have to be practicing effective contracep- tion. The comparable acceptance rates for Korea and Taiwan in 1973 were in the 40-44% range; India and Egypt were in the 11-12% range. - 22 - 1.05 The accomplishment of these goals was expected to depend not only on the expansion of services, but also on the effectiveness of educational and proEntional- efforts to change people's attitudes toward family size. The training and IEC functions of POPCOK, the training of midwives, the improve- ments in logistics, equipment and transportation, and the strengthening of family planning services provided by the Department of Health through its Rags and BHSs (village level Barangay Health Stations) under the comprehen- sive Maternal Child Health/National Family Planning Office (MCH/NFPO) were, therefore, important elements of an overall strategy designed to reduce the fertility rate. II PROJECT IDENTIFICAION, PREPARATION AND APPRAISAL 2.01 Project Origin. The World Bank's interest in the Philippines population sector can be traced to the early 1970s. In March 1971 a two member Bank Mission spent three weeks in the country, obtaining information on the demographic situation and program developments. A year later, in February-March 1972 a seven-mber sector review mission spent four weeks comprehensively reviewing the ongoing population program and identifying components of a possible Bank-funded project. The major recommendations made in the sector review report (No.91-PE dated March 9,1973) included the following: restructure POPCOM's central organization; expand POPCOM's regional and field representation; strengthen POPCOK's IEC and training divisions; train 6500 paramedical and motivational personnel (midwives) over the next three years; and establish a National Family Planning Training Center, and one Regional Training Center in each of the 11 regions. 2.02 Project Preparation. These recommendations provided the basis for the population project; POPCOM bad been correctly identified as the lead agency in the population program. The importance of the Department of Health's human and organizational resources for delivery of health and family planning services was not overlooked; but these were seen primarily as - supportive activities, complementing POPCOM's primary function as a national policy making and coordinating body for the population sector as a whole. 2.03 Preparation activities proceeded smoothly until October 1972, when POPCOM's Program Committee, while agreeing in principle to the full package proposed by the Bank, indicated the possibility of some modifications in the POPCOM components, depending on alternative soarces of finance. This reflected GOP policy of meeting the technical assistance and current expenditure requirements with grant money. As a consequence, USAID and UNFPA were approached by the government. These agencies were already active in the population sector in the Philippines (USAID had provided US $25.0 million during the period 1967-73, while UNFPA had signed a US $3.3 million agreement in January 1972), and agreed to finance the POPCOM components fully. GOP, therefore wanted the Bank to finance mostly construction activities undertaken in the DOB. 2.04 The Bank was understandably reluctant to withdraw the POPCOM components from the project: it wished to retain direct influence over the population activities, and did not wish to be forced into a purely -brick and mortar- construction project. After considerable discussions between the three donor agencies and GOP, it was finally decided just prior to Negotiations in mid-1974 that the POPCOM components would be funded by USAID and UNFPA, but would nevertheless be retained as part of the project description. - 23 - 2.05 Besides the strengthening of POPCOM, the project also sought to expand and restructure the rural health service delivery system (by expanding the role of RRUs and midwives). In 1972, 730 rural health units out of some 1,500 then functioning were providing half day-a-week family planning clinical services for the 70. rural population. However, deficiencies in the physical facilities were comion: a survey in mid-1972 had revealed that 270 RHUs needed new buildings and 360 needed to be rehabilitated (their life expectancy was 5 years or less). About one fifth of the buildings did not have proper water supply and almost half did not have electricity. Transportation was also poor: only 467 vehicles (55%) of the 851 with the RHUs were in running condition. Since Bank policy did not permit the funding of on-going government a.tivities (like maintenance of buildings and vehicles), it was decided that the project should build and equip 207 new RHUs, purchase 200 vehicles, train 2400 midwives, and improve logistics, statistics and information processing systems of the Department of Health. 2.06 Instead of the multiagency project coordination committee originally suggested for the project, it was deciJed that each agency would coordinate its own components. Overall "coordination- would, however, still be provided by POPCOM (as per the loan agreement dated July 31, 1974, section 3.02 (a)). A project construction unit (PCU) was to be set up in DOE for coordinating the health related components. A small group of project staff (a construction unit director, a project architect, an accountant, an equipment specialist and staff for site selection) were to be employed (section 3.02 (b) of loan agreement). These were to be assisted by architectural and construction management consultants (section 3.02 (c)). However, the detailed organization and staffing requirements were not worked out, nor was attention given to the linkages needed between the PCU and DOR's training, logistics, statistics, and information management systems. 2.07 Project Appraisal. An appraisal mission visited the Philippines in March-April 1973. After extensive discussions with POPCOM, DOE, USAID and UNFPA over the next several months, an acceptable project package was finalized. Although the "softer" (training, IEC) activities of POPCO were still retained, the cost of these activities was small (2% of total project cost), and was to be covered by grants from USAID and UNFPA. The bulk of the Bank loan was for DOR construction, equipment and vehicles. Training of midwives and improvements in DOR logistics and procedures were part of a proposed restructured health delivery system, and though relatively smaller in terms of cost, were nonetheless important components. 2.08 With the change in emphasis from POPCOM activities to DOR infrastructure, it was found necessary to field a separate civil works mission in July-August 1973 for completing the appraisal of construction components. Two consultants (architect/planners) and a Bank staff member prepared general guidelines and cost estimates. The appraisal report (No.333a-PH dated May 22, 1974) indicated the number of RTCs, RHUs and staff houses to be constructed, the proposed area and schedule of accomodation for each category, and an estimated per square meter cost. Only overall cost estimates were provided, and for equipment and furniture these were arrived at in the absence of detailed lists of items to be procured and their cost breakdown. Also, the duties of consultants (executive architects and construction management consultants) remained unclear, the personnel requirements for undertaking the logistics and procedural improvement - 24 - components were not identified, and it was not indicated how these project activities would draw upon or complement the ongoing procurement, training, and administrative functions of the Department of Health. 2.09 Negotiations and Approval. Since the shift in project emphasis was not entirely welcome (at least from the Bank's point of view, although GOP and other donors had been keen on it since 1973), and since the changes had been accepted somewhat late in the preparation phase, it was decided to resolve the pending issues during Negotiations in May 1974. Details were left to be sorted out during implementation. 2.10 Board approval for the loan of US $25.0 million was obtained on July 2, 1974 in a very positive atmosphere, with several Directors urging the Bank to expand population sector activities more rapidly. Only two conditions for loan effectiveness were stipulated: the establishment of a Project Construction Unit (PCU) and the employment of director of the PCU and a project architect. 2.11 Project Effectiveness. The Government issued Presidential Decree No. 568 on October 22, 1974 creating for 5 years a Project Magement Staff (PKS) within DOE, with responsibilities for administering the non-POPCOK components. The new Executive Director of PMS (who had earlier participated in the Negotiations as Chief of Planning Service, DOR) was given the autcrity to sign applications for withdrawals. PMS then appointed, with Bank approval, a part-time Project Architect (who was also Dean of the University of the Philippines Architectural Paculty and Architect for the Bank supported Education Projects). Two young Architects were appointed to provide additional support. The process for selecting Executive Architects (EAs) and Construction Management Consultants (CMCs) was also set in motion. By virtue of the Presidential Decree, PMS was permitted to offer salaries that were higher than those prevailing in civil service jobs of similar rank. The loan was declared effective on November 13, 1974; the closing date was expected to be December 31, 1979. 2.12 Project Description. There were four main components of the project, as per the loan agreement: Part A for strengthening the coordinating capability of POPCOM, both at central and field levels: the establishment of an Information Education and Communication (IEC) Division was to be funded by UNFPA (US $0.4 million); and POPCOM's regional offices were to be funded by USAID (US $0.5 million). Part B for expanding and reinforcing the rural health and family planning services of the DOR: about 205 Rural Health Units (about 160 Type A RHUs serving municipalities of 10,000 to 50,000 population and about 45 Type B RHUs serving smaller municipalities) were to be constructed, equipped, and furnished. About 40 of the Type A units in the more difficult areas were to have one house for staff attached to them and one house was to be provided for each type B unit. In addition 200 jeeps and spare parts for existing and new vehicles were to be procured and 2400 midwives were to be trained (it was expected that 480 additional midwives would be employed in each of the next 5 years). A single radioltelephone link between RHUs and the Barangay Health Stations - 25 - was also to be provided (the BSs were to be rehabilitated by the government and were not funded by the project); and the loan was to finance on a declining basis a part of the salaries of a core staff in DOH to organize the implementation of new procedures applicable to the RIMs. Part C for constructing, equipping and furnishing eleven Regional Training Centers under the DOB: each center was to have, besides teaching and administrative facilities, a library, living accomodation for trainees and staff, and vehicles. The loan was also to finance some teaching materials and technical assistance services (workshops, fellowships, training) for the staff of TCs, training of midwife trainers and 3 months pre-service training of midwives. Part D for developing an improved statistics system In the DOR, by financing on a declining basis salaries of a new health statistics unit, providing needed equipment, and 6 months of technical assistance. Funds were also to be provided for study tours, for 18 man-months of technical assistance for developing logistics of drug distribution and new RHO procedures, and for financing an evaluation study of project facilities and programs (to be started by July 1976, as per section 3.06 (a) of the loan agreement). 2.13 The loan proceeds were to be allocated as under: Category Allocation Z of Ezpend- (US $ Million) iture to be financed I Civil Works 6.9 M 39% II Vehicles, spare parts, 3.9 M 100% equipment & furniture III Technical Assistance, 2.5 M 100% including professional services IV Recurrent incremental 2.8 M (on a declining costs (vehicle main- basis) tenance & salaries) V Unallocated (provisions 8.9 M for price contingency) T 0 T A L :US$25.0 M 50% of total project cost - 26 - III KEY ASPECTS OF IPLEMENThELON EXPERIENCE 3.01 Activity targets set at appraisal, and subsequeitly during successive reprogramming of unutilized funds, have been met. (See also Annex I which lists detailed targets versus accomplishments). However, most activities (except training of midwives) were delayed or ran into unanticipated difficulties which apparently stemmed from the following: (i) Organizational issues: the sudden discontinuation in mid-stream of the project implementation unit, and problems of transition to the parent Ministry of Health; (ii) Reprogramming of funds: a substantial overestimation of price contingencies at the time of appraisal, the subsequent reprogramming of the loan, and the addition of several new activities; and (iii) Discontinuities in project administration: lack of continuity in project administration (both in MDE and the Bank) resulting in a 2 year period of uncertainty (1979-1980) while the project activities and organizational arrangements were being redefined. 3.02 Organizational Issues. The decision to implement the project through the PMS was not unusual: several Bank projects worldwide, including the Education projects undertaken in the Philippines in the 1970s, were organized along similar lines. The presence of a large construction component required the establishment of a separate project construction unit (PCU), largely because the Ministry of Public Works was already overloaded and the Ministry of Health had no prior experience in managing a large infrastructure oriented donor-assisted project. The expansion of the PCU into a full fledged PMS was, however, a major organizational change, the full implications of which were realized only gradually; it was sanctioned by a Presidential decree, on the advice of the Minister of Health, and the Bank did not raise any objections. The gradual duplication of functions between PMS and MB, particularly in areas in which PNS proved later to be weak (accounting, logistics, MIS), and the special status accorded to PKS created major impediments to the smooth flow of work, both for the project and the parent ministry. 3.03 The staff of PMS seem to have functioned in relative isolation from the MOH proper. Several procedural omissions seem to have occurred: for example, records of delivery and supplies were incomplete, accounting and auditing regulations were not followed, vouchers were not stamped "paid" upon payment, equipment ledger cards were not maintained, and transfer receipts were not used for documenting delivery of goods. In civil works, the PMS failed to identify problems of construction, equipment and furniture delivery, and handover. 3.04 The reasons for these omissions were both organizational and managerial. In civil works, for example, there was a long chain of reporting relationships between field and central staff, and included contractors (and some local sub-contractors), field supervisors, construction management consultants, executive architects, project architects (project staff, consultants and Bank), and finally the PMS Executive Director. In procurement and distribution, the relevant departments and staff of MOE were not fully involved, partly because the managerial style adopted by PMS apparently did not encourage close coordination with central and regional - 27 - staff of MOR, thus creating problems of logistics, quality control, and under-utilization of project facilities and equipment. 3.05 These problems remained unnoticed during the early years of the project, but began to surface in 1977-79 as part of the preparation of the second Bank-funded project. It was realized that PHS had grown too large, had begun to duplicate MOB's functions, was largely isolated from the regular staff and activities of the parent ministry, and had paid insufficient attention to GOP procedures for logistics (procurement), accounting, auditing and construction supervision. Since the second project was expected to be implemented from January 1980, using regular MDR departments and staff, and PMS's original term was due to expire on December 31, 1979, it was decided in mid-1979 to discontinue the PMS from January 1980. 3.06 In late 1979 some MOH staff were designated to begin working with their PMS counterparts, but due to the inability and unwillingness of both PMS and MOH staff to work together, not much progress could be made. In January 1980 most of the senior officers of PMB were allowed to retire or resign (partly because PMS salaries were much higher than comparable MDE staff), and only a handful of relatively junior staff could be retained on short-term consulting contracts. The ensuing period was therefore marked by extreme caution bordering on inaction, with NOR staff either unable (due to lack of proper training in Bank procedures - a one day seminar had been conducted) or unwilling to take charge. Gradually, and partly due to repeated follow up by Bank staff, various officers of the MOH began to recognize their new responsibilities towards the project. A skeletal force for the Construction Unit was maintained for supervising the remaining construction activities, including the 25 pilot BHSs added to the project as part of the reprogramming done in December 1978. 3.07 During the following year stewardship of the Project shifted from one officer to another in the MOB - from the new Project Coordinator appointed in October 1979 to the Chief, Office of Health Education and Personnel Training, to the Assistant Secretary for Finance and Management Service, and lastly in December 1981 to the Chief of the Planning Service. With the termination of services of contractual employees in June 1980, management of the project was finally in the hands of regular MOH staff. In June 1981, just prior to the present Health Minister's appointment (he was earlier the Deputy Minister), MOH entered into an agreement with the National Economic and Development Authority (NEDA) establishing an Inter-Agency Monitoring and Coordinating Committee (IAMCC) to monitor the activities of the project and to provide timely feedback to the Project and component zoordinators (two full-time technical consultants were seconded by NEDA to MOE for this purpose). Under the Project Coordinator appointed in December 1981, missing records were pieced together from available information, outstanding payments were made, and other pending activities were completed to finally bring the project to a close in early 1983. 3.08 Reprogramming of Project Funds. The second special feature of the project was the reprogramming of funds and addition of new activities during implementation, first in December 1978 and then in June 1981 (Annex II). The original project had been designed in the aftermath of the first oil crisis of the early 1970s, and during Negotiations in May 1974, the Appraisal estimate of total project cost of US $30.0 million (with Bank loan of US $15.0 million) had been revised upwards to US $50.0 million (Bank loan of US $25.0 million). This sharp increase in costs was primarily due to the provision of physical and price contingencies at several stages of cost - 28 - estimation: first for each component and then for the overall base costs. As a result the loan agreement provided as mAch as US $8.9 million (35.6% of the loan) as unallocated funds, over and above the provisions already made for inflationary cost increases for each component. 3.09 By March 1978, however, it had becoi clear that the expected price increases were not likely to occur, and that the total project cost would not exceed US $40.0 million. Almost US $8.1 million (i.e. roughly the entire unallocated amount) was likely to remain undisbursed, even though some cost overruns could be expected in other categories (civil works by US $0.9 million, vehicles and equipment by US $0.1 million, and technical assistance by US $0.28 million, offset partly by savings of US $1.5 million in incremental recurrent costs). Only US $6.3 million (25% of the loan) had yet been disbursed, against an appraisal estimate of US $20.58 million. 3.10 Meanwhile, the preparation of the second project had necessitated a closer look at the needs of the health and family planning sectors. The following were identified as the main constraints to program effectiveness, as of December 1978: weaknesses in the training programs, particularly deficiencies in the preparation of trainers; managerial problems in providing health services at the mnicipal level (i.e., rural health units or main health centers - RHUs/MHCs); inadequate supervision of family planning and health outreach services; a low level of community participation in these programs, partly due to inadequate coverage of service delivery and lack of information and education; and basic structural problems in POPCOM and MOR, requiring further organizational diagnosis and change. Based on this assessment, it was felt that several high priority activities could be undertaken by GOP, if funds from the first loan could be made available through an amendment. 3.11 Accordingly, many new activities were added to the first project. These included feasibility studies to guide implementation of the second project; an organizational diagnosis of the Ministry of Health for identifying dysfunctions; construction of 25 village level BHSs with communi- ty participation on a pilot basis; training courses and staff development fellowships; vehicles for supervision; and reproduction of urgently needed IEC materials and manuals for POPCOM and MOR. In addition, the disbursement percentage for civil works was increased from 39% to 47%. In all, a total of US $6.1 million was thus reprogrammed, and the loan closing date was extended to June 30, 1980. 3.12 Unfortunately for the next two years organizational arrangements for the project remained ineffective, as has been discussed above. The period June 1979 to June 1980 was particularly troublesome: construction of REUs ran into problems with contractors and peace and order problems in one of the regions (Region IX); and BHS construction was delayed due to budgetary reasons and difficulties in obtaining the cooperation of the local community, the MOR, and other ministries (primarily the Ministry of Local Government and Community Development (MLGCD). Nevertheless, some progress was made, particularly in the technical assistance component (studies, fellowships, training, IEC), both in MOE and POPCOM. By mid 1981 most activities were nearing completion, although unallocated funds still remained. A second reprogramming in June 1981 of US $6.5 million added several new items: provision of water supply facilities to Bank-funded RTCs and EUs, construction of a new NOR warehouse, procurement of additional vehicles and equipment, and technical assistance. The civil works disbursement was again increased from 47% to 70% of construction undertaken after July 1981; and the loan closing date was further extended to December 31, 1982. - 29 - 3.13 Discontinuities in Project Administration. The problems due to changes in organizational structure and reprogramming of the loan could perhaps have been minimized if a third factor had not been present: discontinuities in project administration, both in GOP (MOR, POPCOM) and in the Bank. Over the 8 years of project implementation, personnel turnover was considerable: 3 Ministers of Health, 3 Executive Directors and 4 Officer-in-Charge of POPCOM, I PMS Executive Director, 4 Project Coordinators in MOR, and 5 Project Officers from the World Bank. The transition period from 1979-81 was particularly difficult, with the entire PMS staff being discontinued within a period of 6 months, along with several staff changes in each of the other agencies involved. To compound the problem further, many of the personnel changes also signified major changes in administrative capabilities, management styles, and professional orientation. The resulting discontinuities in implementation policies and procedures, besides delaying project activities, affected staff morale adversely, causing severe implementation problems. IV PROJECT IMPLEMENTATION AND PERFORMANCE 4.01 Start-up. PMS was set up directly under the Minister of Health, as a largely autonomous unit, with its own staff, budget, and operating procedures. Although some staff were contracted from MOH and other GOP departments, PMS sought to create a distinctive identity for itself (even its new premises were some 4 miles away from the much older Ministry compound). In the absence of any overall staffing or salary limits determined at Appraisal, the PMS was able to engage a large number of contracted staff and consultants: within the first year of its operation, staff size had grown to 45 employees (12 officers and 33 support staff). Over the next three years total strength (including staff from other GOP agencies) averaged around 100 people, most of them non-technical. Salaries (including honoraria, allowances, etc.) offered to PMS staff were much higher than those given to regular MDR staff at comparable levels. 4.02 The growth of and functions assigned to PMS during its early years can be partly explained by the special status and freedom given to PMS senior staff. In the period following the introduction of Martial Law in 1972, an action orientation" was apparently at a premium, and PMS's Executive Director shared the Health Minister's desire to quickly get the project off the ground. The Presidential Decree establishing PHS had already provided exemption from certain GOP procedural requirements; additional discretion was obtained under Ynisterial orders so that PMS was able to devise its own operating procedures for construction supervision, logistics and procurement, disbursement, accounting and auditing, and dealings with suppliers. Although GOP and Bank procedures for all these activities were required to be strictly followed, laxity of controls and inadequacy of monitoring of PMS activities seem to have occurrud during the first few years (1974-77) of project implementation. As a result, record keeping and asset accounting procedures did not get high priority. Details of how the work was carried out, the unanticipated problems, and project benefits under PMS and thereafter are discussed below by project component/activity. A. CIVIL WORKS 4.03 Civil works constituted 65% of total project costs as per the Appraisal report, and 27.0% of the loan (excluding price contingencies). - 30 - Initial start-up problems of finalizing construction sites, selecting executive architects (BAs) and construction management consultants (CMCs), and delineating their responsibilities for design and construction delayed civil works by over 1 year. However, once the work started, 88% of it was reported to be completed within three years. The actual pace of construction of RTCs, RHUs, Staff Houses, and BHss, and changes in sites, areas, and costs of construction are shown in Graph No.1 and Tables 3.1 to 3.3 respectively (See Annex III). 4.04 The following overall assessment can now be made: delays in construction were at start-up and due to unusual problems faced in two of the twelve regions (paragraph 4.09); over one third of the RHUs were built at locations not included in the Appraisal report; substantial changes were made (with Bank approval) in the areas built and costs of construction (per building and per square meter); and construction supervision by CMCs and PMS, quality control, and utilization of facilities could have been substantially improved. These issues are discussed further under four sub-headings: construction areas and costs; construction progress and supervision; assessment of civil works; and utilization of facilities built. 4.05 Construction areas and costs. The actual floor areas built differed from Appraisal estimates by as much as +89.80% (for RHU type B) to 27.79% (for RTCs; Table 4.2); and costs per square meter were higher than Appraisal estimates (including contingencies) by about 25% for RHUs and 77.3% for RTCs. These actual costs were nevertheless the same as those for GOP-funded RHUs built during the same period (Table 4.3). Cost variations among regions for the same type of buildings-were substantial: compared to the Appraisal estimate of 15% provincial cost variations, actual costs of RHUs varied by as much as 53% (of the lowest RHU cost) within the same province and by 70% within the same region. Presumably, differences in building design and location, and between contractors, were responsible for much of this variation. 4.06 Construction progress and supervision. The appointment of 7 EAs and 3 CMCs was finalized in January and June 1976 respectively - over 18 months behind schedule. Construction designs were approved in late 1976, and 9 general contractors were appointed in February 1977. Since a large number of small units (205 RHUs) were to be built in widely dispersed areas all over the country, it was considered necessary to appoint several firms of EAs, CMCs and contractors who were familiar with or had ongoing projects in different regions. Unfortunately, however, this also created problems of non-standard (and mostly over-sophisticated) designs and non-uniform costs (no standard design for each building type had been made); and created a long chain of supervisory relationships, thus making it difficult for PMS staff to effectively control civil works programs. Since construction work was considerably delayed, the contracts of CMCs had to be extended (in March 1978) on a (expensive) man-hour basis, and several "change orders" for construction schedules (partly due to delays caused by shortages of cement, transportation difficulties in remote areas and local peace and order problems) had to be approved. 4.07 As per the Appraisal Report's estimate, 50% of all civil works (construction of 11 RTCs and 205 RHUs) was to be substantially completed by the end of 1976. Records, however, show that by the end of 1976 activities were still at the pre-construction stage; actual construction started only in March 1977. The original plan of the PMS to complete the construction of the - 31 - RTCs and RBUs by March 1978 was not realized. The construction figures in December 1978 showed that 9 RTCs (81%) and 160 RHUs (77.66%) were substantially completed (roughly a slippage of about 23%). (Graph No. 1, Annex III). 4.08 By 1979, at the time the project was turned over to the Ministry of HLalth by PMS, construction progress could be roughly placed at 88% (182 RHUs and 11 RTCs), although some units were not yet formally turned over by the contractors and accepted by the Ministry of Health. At the end of 1980, or a year after the original project completion date, 9 more RHUs were completed bringing the :otal performance of civil works to about 92%. The remaining RB"i in Region VI and 6 RHUs and RTC in Region IX were finally completed during the last quarter of 1982 and first quarter of 1983. The construction activities added as part of the loan reprogramming i.e., the renovation of the MIS building, installation of water facilities, construction of 14 pilot BUS and construction of MOB warehouse were completed in 1980, 1982 and 1983 respectively. 4.09 Special problems faced in two of the Regions were partly the cause of delays after 1980. Due to peace and order problems in Region IX, the completion of the RTC and 8 remaining RHUs was handed over to the Office of the Commissioner for Islamic Affairs and the local military authorities for completion. In Region VI, the construction of the 8 remaining RHUs was completely abandoned by the contractor in 1980 due to severe cash flow problems. MOH then entered into a Memorandum of Agreement with the Ministry of Public Works and Highways, but this agreement could not be implemented: after a lapse of over 9 months MDH re-negotiated with the earlier contractor and construction was completed in February 1983. 4.10 The construction of 25 pilot BHSs (added to the project in December 1978) also met unanticipated difficulties. The expected community participa- tion did not materialize (apparently due to MOR's lack of interest and capabilities in social preparation of communities, at that time), and the number had to be reduced to 14, since only this number of plots had been donated by the cut-off date. These BUSs were mostly built by local contractors (this has important implications for the second project under which 915 BHSs are required to be built with community participation). Installation of water facilities in 7 RTCs and 137 RHUs was also delayed for over two years (the original contracts had not included this important requirement, and release of government funds took time). However, the renovation of an MOR building for MIS and other project staff, and the construction of an MOB warehouse (included in the project in 1981) were satisfactorily completed on schedule. 4.11 Assessment of Civil Works. An assessment done in 1982-83 of 55 RHUs (in 5 regions), all RTCs, and all BHSs highlighted the following points: (i) the over two years' delay in civil works was partly due to long periods of extension granted: the extensions ranged from 41 to 774 days (approximately 26 months) with some units granted as many as 5 extensions; (ii) the contract in Region IX was allowed to be rescinded without any formal action taken until 1981 to recover the cash advances paid (legal action is now being taken); and in Region VI since the CMC's contract did not stipulate a date for termination, and since payments to contractors were - 32 - not linked to construction progress, the CMC continued to charge for supervision even when no construction was ongoing (the situation was remedied after several months); (iii) instead of penalizing contractors for delays, price adjustment requests were approved; total conotruction costs went up by about 12Z; (iv) construction plans and designs were not handed over to the user agencies until recently; as a result, in many RTCs and RHUs plumbing and electrical fixtures which were due for repairs were left untouched; (v) some RHUs were accepted 6-12 months after construction; this was due to some confusion as to who was authorized to accept the completed building; (vi) the majority of the RHUs completed as of 1982 had defects which could have been corrected by the user; local health officers did not repair leaking roofs, provide missing doors, window knobs or grills, nor add/repair non-function- ing plumbing and water systems; (vii) many of the RHUs were burglarized, stealing door knobs, electrical bulbs, fuse boxes, plumbing fixtures and doors. In Region VII, the RRUs were ransacked by 'harglars who took away expensive items such as microscopes and other medical equipment; and (viii) the general quality of work done, materials used, and construction supervision provided were inadequate. The GOP budget still does not provide sufficient funds for maintenance and repairs needed now. (The RBUs built under the second project recognize this constraint and are apparently simpler units built to a higher standard.) 4.12 Utilization of Facilities Built. The assessment done in early 1983 highlighted several points: (i) only four (Regions 8, 9, 10 and 11) of the twelve RTCs were being used solely for training purposes; the rest had been either partially or totally converted into regional health offices. The facilities most frequently taken over for office use were the administrative wing, dormitory, and all auxiliary services (roughly 50% of the built area). As a result, the original objective of providing live-in training programs cannot be met until alternative arrangements are made by the Regional Offices; (ii) the most underutilized rooms in RHUs are the social welfare, recovery and dental rooms (roughly 15% of built area). Very few RHUs admit lying-in patients in recovery rooms either due to lack of knowledge by the public that such a service is available or due to the reluctance of medical personnel to stay beyond office hours; - 33 - (iii) a few RHUs are being used for alternative purposes - of the RHUs visited four were being used as emergency hospitals, one as a municipal session hall, and two as temporary residential quarters; (iv) despite the appraisal report's stipulation that designs be standardized, each EA was allowed to provide his own design; as a result many RTCs and RHUs appear to be too large, sophisticated, and do not seem to be suited to local environmental conditions; and (v) most of the staff houses are not being used at all or are used as resting places for office staff; they have not been able to attract and retain professional staff in remote areas. (The second project has omitted these facilities). B. LOGISTICS 4.13 The implementation of activities included in Category II of the loan agreement is discussed below, under the following subheadings: procurement of equipment, furniture, vehicles; delivery and distribution; inventory of equipment; communications system; and system improvement. 4.14 Procurement of equipment, furniture, vehicles. It was only in 1976 that the PMS prepared lists and cost estimates for furniture and equipment. Six major suppliers were selected. Upon review of the records in 1982 and 1983, it was discovered that not all of the required equipment and supplies had been purchased, especially for RHUs. One reason for this may be the packaging of equipment for bidding purposes: unrelated RHU equipment items were included in the package, possibly leading to disinterest of the suppliers in the smaller items. Cases of over purchase were also found (e.g., LPG stoves and refrigerators); and PMS supplied some items not only to the 207 RHUs funded under the project but also to some 1172 others. (Bank approval was obtained after the fact, in 1978-79). 4.15 Examples of poor quality of items purchased were also found: procurement orders for ambulances and utility vehicles were given to the lowest evaluated bidder, but the brand of ambulances purchased was not durable and was already being phased out of the market. A year after delivery the majority of these ambulances were not in running condition; the regional offices had provided some funds for repair and spare parts, but these were not enough. By the end of 1982, only 57 of the 122 vehicles were in usable condition. 4.16 Delivery and distribution. Several lroblems can be cited: (i) Under PMS's method of diszributing equipment directly to the sites, there was inadequate documentation of receipt of goods. Although Project Implementation Officers had been designated in the regions, their roles were not clearly defined; it was only after the transition in 1979-81 that the new project management channelled equipment and vehicles through the Regional Health Officas. - 34 - (ii) Delay in civil works implementation disrupted the smooth distribution of furniture, equipment, and vehicles intended for RTCa and RRUs. Despite the delays in construction, PMS's Logistics Division went on with its programmed purchases and distribution. This resulted in maldistribution of goods; where project-sites were not ready to receive them, the goods were given to non-project RHUs. (iii) There were delays of as much as 6 to 18 months in the delivery of some items. Project management was not strict enough in enforcing compliance with the provisions of contracts. (tv) PMS had no storage facilities for the supplies, equipment and furniture delivered to Manila. A semi-government storage and transport agency was used. In 1979, however, due to lack of funds for shipping the goods, and inaccessibility of the sites, deliveries were further delayed. Storage fees and delivery charges were accumulated through the years and the pending accounts were settled onlyin 1983, after the new Project Accountant had ensured that the necessary documents were submitted by the transport agency. By this time, the supplies that had been in the warehouse for four years were no longer useful. (v) Some of the equipment proposed by MOH and approved by the Bank was not very useful in the field. One such item was the gas refrigerators, many of which are not being used in RKUs which now have electricity. IL appears that the gas tank is much too costly to maintain; and some regions received refrigerators without the gas tank. (vi) Verification of the incidental expenses claimed by some suppliers was not possible, because the bid documents supporting the contracts were not traceable; some insurance papers and other legal documents are similarly not available. 4.17 Inventory of Equipment. In 1978, PMS conducted spot visits to Regions 2, 3, 5 and 8 to inspect the delivered furniture and equipment; the other regions were not covered. Again, in 1979, PMS tried to update the memo receipts and to collect all outstanding receipts of goods, and in preparation for the hand-over an inventory of PMS Central Office equipment, furniture, and goods in the warehouse was prepared. However, this list was not attested to by the Auditor. Inventory of equipment and furniture was also done for the regions, but again the lists were not attested to by the Auditor. 4.18 Then in 1982, the natioral Commission on Audit (COA) was contracted to conduct an inventory and reconciliation of project equipment and furniture. This activity took almost a year to complete and included: a nationwide physical count of project equipment in all twelve regions and in the MOH Central Office; establishment of accountability for equipment as of June 30, 1982, based on available records; and reconciliation of results of the physical count against the existing records. A total number of 28,284 items were counted at the 1982 sites covered (this included most of the 1172 non-Bank funded RHUs to whom some equipment had been supplied under PMS). The COA Inventory Team strongly recommended better internal controls In the area of documentation, accounting, and physical control over property; and some of its preliminary recommendations have now been implemented. - 35 - 4.19 Communications system. A radio network was developed in conjunction with the Bureau of Telecommunications and the supplier, and was installed in 1977. Since then it has enabled MOH to realize savings in communication costs and time. Seventy additional single side band radios were procured for provincial hospitals in 1982-83 with the unspent balance, and thirteen single side band radios were procured in 1982 for POPCOM's Central and Regional offices. Installed in 1983, this equipment is helping to monitor field activities of the outreach project and of other FP related activities of POPCOM. 4.20 System improvement. The PMS, in consultation with a logistics consultant, adopted the Imprest Replenishment System for use in MOR so as to ensure uninterrupted flow of materials and supplies to the BHSs and RHUs; manuals were developed and the system was tested in five provinces. In 1977 field data was collected and Provincial Health Officers were consulted to determine possible alternative strategies to make the logistics system workable. A revised logistics manual was issued in 1978. However, the new procedures were not institutionalized in the Ministry of Health upon hand-over of the project in 1979. The outgoing PMS staff did not ensure proper hand-over, and their MOH counterparts were quite unenthusiastic about taking charge of the documents and goods being given to them. In 1982 a new Logistics Coordinator was appointed to improve the system, and has made some progress in getting all the documents together. C. TECHNICAL ASSISTANCE 4.21 Technical Assistance for MOH and POPCOM are discussed separately below. For details see Annex I. 4.22 MOH (I) Training. The training and hiring of additional midwives has allowed the MOH to introduce a restructured health services delivery system, and has been the most significant contribution of tl.. project. Training activities funded under the project were all undertaken, largely on schedule, with 90% of the targeted number trained. Training 1- now provided at the Regional Training Centers built under the project, and classroom instruction is supplemented by field training. The quality of training provided is generally satisfactory, training courses are relevant and cover both FP and health delivery, and have helped improve the MOH's outreach activities considerably. The trained midwives are expected to play a very important role in the government's recent national program of primary health care. (ii) Consultancy services. Technical advisory services have been used; however, the utilization of the outputs of the3e consultancy services has varied. For example, as discussed earlier, a consultant was hired to develop and improve the logistics and supplies distribution, but the usefulness of his scheme and procedures ceased after the turn-over of the project from PMS to MOR; the part-time architect hired for the construction of the pilot BHSs submitted the necessary designs and manuals but did not undertake any fieldwork; a few PMS personnel were retained as consultants, but the results obtained were disappointing since relationships continued to be strained and there was limited exchange of information. - 36 - (iii) HIS. Consultancy services, studies and fellowships were provided for MIS related activities. Of the various information systems developed, only those for RBU and hospital operations are partially operational, while those for finance, physical and human resources have not gone beyond their respective initial surveys. Some further progress is now expected under MOR's program for decentralizing health services delivery. (iv) Other studies. Various studies were proposed under the project (see Annex I). Of these studies only the facilities evaluation study was not undertaken; its cancellation in 1978 was partly due to the unfinished construction activities. Of the studies undertaken: GOP's Health Sector Study is awaiting official action on the recommendations made; the Evaluation of the RHCDS has provided the MDR with data on the population coverage by midwives, and the effectiveness of training given to RHU personnel; results of the Evaluation of MHO Training Courses were submitted l years after the targeted time, and were no longer useful since by this time MOK bad already gone nationwide with the implementation of primary health care. 4.23 Some of the recommendations of the Functional Analysis Study (FAS) have helped in making the MOH more responsive to field requirements. MOR has taken the following actions: reinstitution of staff conferences to discuss specific program and implementation requirements of support units; in the preparation of the 1984 Budget, finance officers from the regions were consulted; and a committee of key MOR personnel was formed to look into the MIS needs, and to recommend new forms that would be relevant and useful for the implementation of MOR programs, particularly PUC. Other recommendations still need to be seriously considered. These were echoed in the recommenda- tions of GOP's Health Sector Study. The underlying themes in these recommendations underscore the need for a more efficient health services network, a more effective logistics system, regulation of production and distribution of health personnel, greater participation of implementors and community members in planning, incorporation of field data in planning targets, clear delineation of roles and responsibilities of various health-related agencies, and change in the attitudes of both MOH personnel and the community from a service-consumer relationship to shared responsibility for health. 4.24 POPCOM. The December 1978 loan amendment provided $ 1,934,440 for POPCON's FP activities, and for laying the groundwork for the implementation of the second population project. The activities were focused on training, development of a population MIS, population related studies, and IEC. Details of progress made are given below. (i) Training. The establishment of regional offices helped decentralize training activities. Activities such as the training of Master Trainers, their planning workshop, and the local course for Master Trainers were completed. Skills transfer was the basic aim of developing these trainors, and on the whole this has been done. However, two of the four master trainers trained abroad have resigned from POPCOM. The remaining two are being utilized in various training programs in the regions. (ii) IEC. The IEC activities were delayed by lack of GOP funds during the earlier years of implementation. Unutilized project funds were re-programmed in 1981 for undertaking the development/production/ - 37 - replication of FP related posters, brochures, and other IEC materials, which have been distributed to the various reirtonal population offices who in turn utilize them as supplementary materials in their population campaigns. However, no evaluation of the usefulness of these materials has yet been done. (iii) MIS. The development of a population HIS was contracted to an outside agency. Computer time and the fellowship for Data Dictionary development were not availed of because these activities were too premature at the time they were proposed. Funds for fellowships were used for a study tour which provided four MIS staff with insights into the status of MIS utilization in population programs in ASEAN countries (unfortunately two of the 4 HIS staff resigned soon after the tour). Implementation of the component information system of POPCOM has been useful for research, service delivery, manpower and training. OI the whole, the POPCOM MIS has been more successful than that of the MDK. (iv) Other studies. Various studies were commissioned. The Condom Marketing Scheme (Phase II) looked into the feasibility of using sari-sari stores as outlets for commercial distribution of condoms. Since results of the study did not favor this marketing scheme, POPCOM is now studying other schemes along with the attitudes of the target population towards contraceptives. The pilot learning modules which were revised and printed under the prcject have been distributed to various clinics and have filled in the gaps in refresher training courses. D. ACCOUNTS, DISBURSEMENT AND BUDGETING 4.25 ACCOUNTS. The accounting system followed during the early years of the project was inadequate. During 1975-79, although the PMS formally issued an Office Order for the purpose (No. 57 dated March 20, 1976), the cost accounting system proposed was in fact not used by PMS for cost control, appraisal of project performance, nor formulation of policies. No certified audit reports were submitted to the Bank, even though these were required under the Loan Agreement. Similarly in 1980, although accounting records and documents of PMS were to be turned over to the Financial Management Service (FMS) of MOR, and the cashiering function was to be handed over to the MOH Cashier (as per Ministry Orders No. 320 s.1979 and 356 A s.1979 respectively), many of the documents remained with the PMS staff (who had been appointed as a consultant for finance). This consultant continued to prepare reimbursement applications, vouchers for payment, and requests for allotment. This unusual procedure seems to have been a result of Office Order No.3 s.1980 issued in January 1980 by the new Deputy Director of the project. The discretion given to the consultant did not promote cooperation and coordination between her and the regular Ministry personnel. It was only in 1982 that preparation of applications for reimbursement and direct payments were done by MOH's regular staff. Since some records still remained with the earlier consultant, other documents had to be retrieved from the Office of the Auditor and the World Bank to provide project staff with pertinent data. After repeated follow-up by Bank supervision missions, disbursements were updated, pending accounts were paid, and financial status reports were prepared. - 38 - 4.26 Although the PMS was required to adopt standard government procedures for accounting of financial transactions it failed to adhere to existing rules and regulations. The following are examples of the kinds of omissions made: contracts and purchase orders had no obligation reference number to indicate the year the expenditure was incurred; expenditures incurred were not accompanied with appropriate supporting documents; and there was improper recording of acquisition of property (lack of information regarding date of acquisition, unit cost, invoice number, description and person accountable). Also, under PMS, funds for current operating expenditures were sub-alloted to the regions through deputized disbursing officers. These officers were authorized to make payments to creditors within their jurisdiction. This procedure presented problems after the turn- over: records maintained by PMS did not separately show expenditures incurred by the regions. Upon turn-over of the project from PHS to MOR, the regular goveri. ent accounting procedure was installed by the newly designated Project Accountant, and considerable improvements have been made since then. 4.27 DISBURSEMENT. During the 8 years of project implementation there were nine persons authorized to sign applications for withdrawal, including the Financial Consultant who was not a regular Ministry official. Table 4.1 shows the projected and actual schedule of disbursement of the loan. By December 31, 1979, the original completion date, only 48.4% of the US $25.0 million loan was disbursed. By the second closing date (as per amendment in December 1978), only 53.4% (US $13.3 M) had been disbursed. By December 31, 1982 which was the third closing date, 79.8% (US $19.9M) of the loan had been disbursed. The Bank agreed to accept withdrawals up to May 1983. As of the closing date May 31, 1983, 93.4% (US $23.35 m) of the Loan had been disbursed, thus leaving a balance of US $1.65 million which was returned to the Bank. Total project cost was around US $43.0 million (instead of the US $50.0 million estimated at appraisal), with the Bank funding roughly 58Z of this amount (compared with 50% envisaged at appraisal). 4.28 Several problems have been encountered during implementation: failure of PMS to make all the necessary applications for reimbursement; failure of PMS to indicate the expenditure period covered by each application; and excessive delays in processing payments (up to four years). The pending amounts were later applied for by the Project Accountant (in 1982) to cover payments made to CMCs, EAs and other contractors and suppliers. However, not all the suporting documents were available, and when statements made by PMS regarding disbursement and expenditures were compared in April 1983 with Bank records, it was found that US $848,000 of payments made by PMS for Technical Assistance still remained unapplied for. Since PMS had not indicated time periods, names and other specific information regarding activities such as training, type of consultancy, etc. it is difficult to establish that all the expenditures incurred have now been applied for reimbursement; some late disbursement applications have now been processed by the Bank. Of the US $43.0 million spent on project activities, about an equal share has been spent by the GOP and IBRD. As far as IBRD's share is concerned, most (64%) of the funds were provided for construction and procurement of equipment, in conformity with the loan allocation schedule. 4.29 BUDGETING. As per Presidential Decree No. 568 dated October 22, 1974, the total funding requirements of the project (P166 million) were appropriated for five years from 1974 to 1979, thus providing the ready availability of corresponding funds from the Bureau of Treasury. These funds were to be spent according to the project expenditure schedules, and in cases - 39 - of amendments in project activities or expenditures a special budget as to be submitted and approved by the Ministry of Budget (HOB). However, in 1975 in order to improve the national budgetary system and in compliance with Presidential Decree 1177 (Budget Reform Decree) the national budget was required to be presented annually to the parliament (Batasang Pambansa) for approval. The provisions of PD 568 (for the project) were amended accordingly. Beginning 1974 the PMS prepared annual budgets based on projected plans of operations which then served as the basis of quarterly releases of allotments and authority for the project to incur obligations. 4.30 During the early years of project implementation GOP apparently assumed that the IDA amount need not be budgeted; this misunderstanding caused under-funding of 50%, a situation which was later corrected. In addition, project implementation was delayed by shortfalls and delays in the release of the budget. Various factors contributed to this situation: delayed submission of budget proposals; non-inclusion of supporting documents for the budget proposal; and internal constraints in the Ministry of the Budget. A case in point was the funding situation in 1979 and in 1981. For 1979, the request for funds was not submitted in November 1978 as required, and therefore funds were released only after the second quarter of the year. For 1981, the special budget proposal was submitted in September and funds were released only in December 1981. Since the the Special Budget is taken from the Foreign Assisted Support Funds, and being a lump sum appropriation requires clearance from the President, it makes releases of the special budget discretionary and unpredictable. Difficulties in the release of the budget were also due in part to MOB's failure to submit a proper inventory of project equipment, and to the late submission of justifications for the proposed equipment. E. FULFILMENT OF COVENANTS 4.31 The majority of the covenants of the Loan Agreement have heen complied with (for details see Annex V). The following covenants have not been fully met: () Instead of POPCOM coorditating the work of the project, MOH (through the PMS) took over this function. After PMS was discontinued in December 1979, a Project Coordinator was appointed in MDR. (ii) Project records were not properly maintained and handed over by PMS. Reconstruction of records based on documents available in MOH has now been essentially completed. However, gaps in information still persist. (iii) The Facilities Evaluation Study which was to have been started in 1976 was cancelled in December 1978, partly because the bulk of construction was not completed until 1979-80. This study could have been very useful. (iv) Adequate GOP funds have not been available on time, especially during the early years of project implementation. (v) Annual auditing of project accounts has not been done except in 1981. An audit is now under preparation for submission to the Bank. The report on inventory and reconciliation of - 40 project equipment report showed that the usual accounting and auditing procedures were not followed. Section 6 of PD 568 had apparently exempted PMS advances, expenditures, and disbursements from procedural requirements and other restrictions imposed by law and GOP rules and regulations. (vi) Maintenance of project facilities has been inadequate due to shortage of GOP funds for this item. (vii) The rehabilitation of BHSs is a continuing GOP responsibility, but a comprehensive program i3 still at the early stages of consideration. V. PROGRAM PERFORKANCE 5.01 Over the past decade, the national population has increased from roughly 40.0 million to almost 50.0 million in 1982 (an average annual rate of 2.6%). The proportion of married couples of reproductive age using contraception is estimated to have gone up from 0.18 in 1970 to 0.45 in 1982. However, the contraception effectiveness is about the same (71-73%), indicating that renewed efforts are now needed to reduce fertility rates further. The total fertility rate of 4.2 in 1982 was the highest in ASEAN countries; and in 1980 only 34% of contraceptive users employed the more effective methods, compared with 85% in Thailand, which had a comparable contraceptive prevalence rate. Despite program efforts to improve the availability and quality of services throughout the country, marked differences still persist. Services are more easily available and accessible in urbanized areas; and this disparity is reflected in regional variations in program effectiveness: the poorer and less urbanized areas show little or no decline in fertility, and they have a higher current fertility and lower- contraceptive practice. 5.02 In health, improvements in health status over the last two decades have been considerable, and the outlook is encouraging. Life expectancy has increased to 62 years, higher than many other countries at a comparable level of GNP; the mortality rate was 7 per thousand in 1982. The restructured health delivery system introduced under the project, especially the hiring and training of midwives and the construction of new RHUs and RTCs, has helped improve the quality and availability of health services. 5.03 GOP appropriations for POPCOM have remained relatively stable during the 1970s (at around P50-55 million in real 1972 pesos), but funding was increased sharply in 1981 and 1982 (See Graph No.2 Annex VI). During the same period total foreign assistance for POPCOM went down drastically; but there has been an upswing in 1981 and 1982, mostly due to USAID. While GOP appropriations for the Ministry of Health more than doubled during 1972-1982 in real terms (1972 pesos), MOH's expenditure on family planning special projects declined somewhat; this item constitutes only 0.64% of the total MOH budget of P2,149.80 million (1982 figures). In view of this relative scarcity of funds for population activities it is important that the avail- able health and family planning delivery services be used more effectively. 5.04 A component-wise evaluation of project activities has already been given in Section IV. There can be little doubt that if the facilities, equipment and services provided under the project are fully utilized, the - 41 - project could generate significant benefits. In addition, the second population project (started in January 1980, with emphasis on primary health care) can be expected to continue the basic thrust of the first project. Since the second project is expected to be completed by 1984, a more comprehensive assessment of the program and project Impact of the two Bank-funded projects would be appropriate at that time. VI. BANK PERFORMANCE 6.01 It can be expected that, as in the case of MOR and POPCOM,the Bank too would have both positives and negatives to its credit. Overall, Bank performance has been fair: its role in design and implementation of project components has largely been constructive, a useful dialogue has been established with GOP health and population officials, and Bank staff have played a significant catalytic role in getting the project completed. However, in retrospect it appears that for certain components (notably civil works and logistics), implementation problems might have been better anticipated and possibly prevented, and closer supervision of field activities might have improved project benefits and utilization. Details of these problem areas have been discussed earlier. The following discussion of Bank performance attempts to place these issues in the context of broader concerns regarding the Bank's objectives, policies, procedures, and supervision. 6.02 Bank objectives. This being the first Bank-group population project in the Philippines, the Bank was naturally anxious to make an entry into sectoral activities at both policy and implementation levels. Much of the preparation effort in 1972-74 went into establishing links with POPCOM and in creating a viable Bank presence at national policy-making levels along with other donor agencies (particularly USAID and UNFPA). The fact that these other agencies were already active in the sector meant that the government was receptive to suggestions by donors for strengthening health and population-related activities. At the same time it was not easy to reconcile the different emphases placed upon health versus POPCO1 components. It was only after extended discussions spread over two years that the Bank accepted GOP's emphasis on improving the health service delivery system as the major focus of the project. Although the POPCOM components were to be fully funded by other donor agencies, they were nevertheless retained in the project description. 6.03 The reason for the latter decision was that the Bank wished to retain a "direct influence- over national population policy, and did not wish to be pushed into a largely infrastructure-oriented project. In view of Bank staff's professional interests at that time, and since considerable investments of time and effort had already been made as part of the population sector review, this was understandable. However, with the change in emphasis of the project, Bank staff were required to give mach greater attention to the construction of buildings and procurement of equipment/ furniture than they might have been willing or trained to provide. The Bank's concern for including additional POPCOM components surfaced again in 1978 and 1981 (when during reprogramming of the loan, training and IEC components were added to the POPCOM part of the project). 6.04 Bank policies. Even after a greater emphasis on health infrastructure had been accepted, Bank policy could not accommodate GOP's - 42 - recommendation that a large portion of project funds be used for rehabilitation of existing buildings, vehicles and equipment. Although the population sector report had concluded that rehabilitation of 360 existing buildings and construction of 270 new RHUs were needed, the project included only new construction. Similarly, in 1979 when it was noticed that most Bank-funded facilities could not be properly utilized due to inadequate provisions for water supply (this item had been left out of the construction contracts), quick remedial action could not be taken since maintenance and rehabilitation of existing facilities were considered to be the government's responsibility, and could not be funded by the Bank. It was only after a two-year delay that this item was included in the project (as part of the second reprogramming in 1981). As a result many of the "completed" RHUs could not be properly handed over, and therefore remained unoccupied or severely underutilized. A similar problem was faced in vehicle procurement: after most of the 122 Harabas utility jeeps broke down within 1-2 years of service, project funds could not be used for their maintenance (the purchase of spare parts had been cancelled; the Bank had had "no objection"). As a result most of these vehicles are now not in operation. 6.05 Bank procedures. This being the first Bank funded project imple- mented by MOH, government staff do not appear to have been fully prepared for Bank lending procedures (for disbursements, procurement, accounting, and auditing, especially). Neither PMS staff nor the MR officials who took over from them in 1980 seem to have been particularly careful about proper record keeping and documentation as a prerequisite for smooth disbursement and efficient project monitoring. While the major responsibility for this omission can perhaps be placed on the implementing agencies, it is possible that some of the later problems could have been avoided if greater efforts had been made by Bank staff to ensure familiarity and compliance with essential Bank procedures. (A one day seminar was organized in 1980). 6.06 The second procedural question is much larger, and stems from the requirement that Bank staff start preparing follow-on projects while the previous ones are ongoing. Though this is understandable in the context of the Bank's lending program, a formal mid-term evaluation of the first project is not required before the second one is finalized. A comprehensive assessment of progress and problems would have been particularly appropriate in 1978-79 when a reprogramming of the first loan was being undertaken concurrently with the appraisal of the second project. Instead, the Facilities Evaluation Study (which could have entailed such an assessment) was cancelled, and various other studies were added to facilitate the design of the second project. While the latter project did undoubtedly build upon the experience of the first project, not enough emphasis was given to considerations such as utilization of services and facilities. 6.07 Bank supervision. It is difficult to separate the effects of Bank supervision from the actions due to project management. Nevertheless, some overall impressions can be formed: the frequent turnover of Bank project staff resulted in avoidable discontinuities in relationships and inconsist- encies in project-related decisions; supervision, at times, seemed too removed from field realities and appeared to accept self-evaluation reports submitted by PMS without investigating corroborative documentation; Bank staff relied unduly on consultants (both as members of supervision missions and for assisting project management, especially for construction and logistics activities), and gave them authority in excess of accountability for design znd implementation decisions; and greater emphasis seems to have been given to disbursement than to results obtained from the project. Even - 43 - at the time of project completion no systematic evaluation studies were available for assessing project impact, or utilization of project inputs (construction, equipment, training, technical assistance, and studies). Overall, however, Bank supervision has played a constructive role: in following up with GOP's Ministry of the Budget for obtaining recurrent funds, in drawing attention to issues requiring high-level decisions on a priority basis, and in generally keeping project progress on track. 6.08 The frequency of Bank supervision missions, their composition, timing, duration of stay, and intervals between missions (see data sheet) are perceived by GOP to have been appropriate. Missions were undertaken (mostly during the last three years of the project implementation period), for follow-up of disbursement/budgetary issues, providing architectural/ construction support, and assisting project staff in strengthening the logistics, accounting and monitoring systems. Workshops were held for reviewing project progress, identifying key implementation steps, and planning future courses of action. All these special efforts have been very worthwhile, and have contributed substantially to removing bottlenecks in project implementation. VII CONCLUSIONS 7.01 Overall, the following conclusion seems justified: as a first Bank-funded population project in the Philippines, the project has been worthwhile. Project progress has improved over the years as lessons from past experience became avaiable. Almost all of the physical targets set at appraisal and later (in terms of number of buildings constructed, vehicles and equipment supplied, numbers of midwives trained, IEC materials produced etc.) have been met. With the project inputs now in place, and with the dialogue between the Bank and GOP well established, it should be possible to f,:rther streamline and restructure the health and family planning service delivery system in the country. 7 02 Some additional observations are perhaps in order. First, as discussed earlier, during preparation Bank staff pushed hard for a project more evenly balanced between population and health activities, but the GOP preferred an emphasis on health services. After extended discussions it was decided that POPCOM's IEC and Training activities would be funded by UNFPA and USAID respectively; but in accordance with Bank preferences, these components were nevertheless retained in the project description, and (as per the loan agreement) POPCOM was given the overall coordination responsibility for the project. It was hoped that POPCOM's influence would help maintain an emphasis on family planning; but in fact the emphasis had already shifted to health, with none of POPCOM's activities funded initially by the Bank. The situation was sought to be corrected during the reprogramming of the loan in 1979, (and under the second project which became effective in 1980), but these efforts achieved only marginal results. 7.03 In the Philippines, in contrast with some of the other population projects initiated by the Bank in the early 1970s (e.g. Indonesia, Malaysia) the Bank ended up having to support the MOB rather than POPCOM for a population" project; and this might have adversely affected its ability to push for a greater emphasis on population issues. Equally important, the project focused on hardware (buildings, equipment, furniture), which is less -44- critical for Affective delivery of PP services than it is for health; and this enabled 1WR officials to give less importance to the population objective. 7.04 Second, project designers had expected that the PMS would develop new systems for HIS, logistics, and training which could then be "transferred" to NOR for building up the latter's institutional capabilities. However, having set up a separate project implementation unit with few links with the MHR, little attempt was made to reduce the negative consequences of PMS duplicating the functions of several ministry departments and competing with them for power and resources. The problems of dismantling PMS and of transferring its functions to MOH were thus inevitable, though their severity could have been reduced by a more careful and gradual handover. It also appears that PMS's possibly *ell-intentioned efforts to quicken the pace of project activities and disbursements (by devising its own simpler" procedures) sacrificed the needed accountability and quality control mechanisms. 7.05 In retrospect (and with the benefit of hindsight), it appears that somewhat closer Bank supervision might have been worthwhile during the initial few years. After PMS was discontinued, Bank concerns for quick disbursement and low supervision coefficients might have discouraged the time consuming and staff-intensive efforts needed for institution building activities within the MOH. Effective mechanisms for reporting, monitoring and accountability were not built into project procedures (except during the last two years after new project staff took over and the IAMCC was established). The opportunity to conduct a formal "mid-term" evaluation of the project was also not availed of in 1979, and the facilities evaluation study was cancelled. Perhaps greater attention to project outputs (rather than inputs), and to regular and timely feedback from the intended end-users could have improved project performance considerably. Annex I - 45 - Page 1 of 9 TARGETS VERSUS ACCOMPLISHMENTS TARGET ACTIVITIES ACCOMPLISHMENTS AND COMEENTS POPCOM (USAID/UNFPA funding) 1. Escablishmet of an IEC Division Completed in 1974. Difficulties in selection of technical expert to head IEC. IEC activities streamlined. Regionalization of materials production effected. 2. Establishment of a Training Completed in 1974. Operations Division started only in Jan. 15 due to difficulties in getting qualified personnel. 3. Establishment of Regioaal Completed and operational in Offices 1973. NOR 1. Construction of: 1.1 Rural Health Units (RBU) 1.1.1 143 Type A Completed 206 as of February 1983 1.1.2 64 Type B In Region 1, 2 units were deleted; in Region VIII and IX, 1 unit each was added. 1.2 Housing for RHU Staff 1.2,1 54 for Type A Completed by 1979 1.2.2 24 for Type B 1.3 Twelve Regional Eleven completed by 1979 Training Centers (RTC) One completed in 1982 (Region IX) 1.4 Twenty-five Pilot 14 Units completed as of 1982 Barangay Health Stations (11 units were dropped due to difficulty in securing plot donation) 1.5 Water Facilities for 138 completed for RHUs (68 previously RTCs and RHUs installed) 1.6 MOH Warehouse including Completed in 1963 site development 2. Renovation of MIS Building Completed in 1981 3. Furnishing, equipping, supply of: Completed as of 1983 3.1 205 RHUs Equipment also provided for 88 3.2 12 RTCs non-IBRD RIUs and 1172 non-IBRD 3.3 25 Pilot BHSs BHSs. Equipment for 14 pilot BHSs delivered in 1982. - 46 - Annex I Page 2 of 9 TARGET ACTIVITIES ACCOMPLISHMENTS AND COMMENTS 4. Procurement of other equipment 4.1 Radio Communication 4.1.1 12 RHO-SSB Installed as of 1979 4.1.2 70 MO-SSB Installed in 1983 4.1.3 18 POPCOM-SSB installed in 1983 (5 units deleted in 1982 due to reduced budget release) 4.2 Clinical and paramedical equipment 4.2.1 1400 Sphygmomanometers Delivered in 1983 4.2.2 1300 Microscopes -do- 4.2.3 500 Paramedic Kits -do- 4.2.4 50 Operating Tables Delivered in 1982 4.2.5 50 Operating Lamps -do- 4.2.6 3000 Midwives Instrument Delivered in 1983 Sets 4.2.7 207 Dental Units Installed in 1983 4.2.8 207 Dental Compressors Installed in 1983 4.2.9 535 Sanitary Inspectors' Delivered in 1982 Kit 4.2.10 35 Addition Dental Cancelled. Supplier initially Units with Compressors unwilling to supply same brand at same price. By the time supplier agreed to such terms, the project had terminated. 5. Procurement of: 5.1 About 700 vehicles Completed: POPCOM 161 vehicles MOH 597 vehicles 5.2 45 Motorized boats Only 25 units were procured 20 units deleted as per Minister's recommenda-ion. Funds used for additional 100 tricycles. 5.3 367 Motorcycle with sidecar Delivered in 1983 6. Hiring and training of 5,000 mid- 6831 midwives were recruited wives to serve in rural barangays and trained 7. In-service health and FP training The number trained as of 1980 of GOP staff were: 1317 MHO 1153 MHO 1590 PHN 1516 PEN 3270 PHM 2827 PEM 2340 RSI 2181 RSI 8517 7677 (90.1%) 8. Provision of additional materials The following materials were and services for about 9 workshops provided as of 1980: for staff of the RTCs including 1097 REU Manuals trips and travel per diem. 1113 PHN Manuals 8338 PHM Manuals 1593 RSI Manuals Annex I -47- Pages 3 of 9 TARGET ACTIVITIES ACCOMPLISHMENTS AND COMMENTS 354 Training Guides 96 REHCDS Training materials Completed were Orientation Courses for: Regional Health Directors, Chiefs of RTCs, and PI0s; Training Programms for Regional Training Staff; Perceptor Courses for Assistant PHOs, Supervising PHNs, MOs, PENs, RUK. 9. Technical advisory services for Completed in 1980 OHEPT on organization and train- ing method- (12 man-mouths) and for development of the midwife community health training programs for RTCs (12 man- months) 10. Fellowship for midwifery tutors Completed in 1979 and Public Health Nursing Super- visors in RHUs (33 one-year national fellowships) 11. Technical advisory services for 11.1 RHU procedures Completed in 1978 (6 man-months) Output was REU operations 11.2 logistics and supplies manual distribution (12 man-mos.) Completed in 1979 11.3 health statistics (6 man- months) 12. Study tours for 3 senior MOH One nurse sent to US for nurses study tour 13. Facilities evaluation study Cancelled. Construction not completed by 1978. 14. Salaries for core staff and Completed 1979 equipment to undertake add- itional services in Health Statistics in MO -48- Anne I Page 4 of 9 TARGET ACTIVITIES ACCOMPLISHMENTS AND COMMENTS POPCOM (As per Amendment, 1978 1. Consultancy and Fellowships: 1.1 For the development of a population MIS 1.1.1 a) Senior management Completed in December 1981 information consultant contracted out to Informatics (4 man-months) International, Inc. Has 1.1.2 b) Systems analyst provided groundwork for present (18 man-months) activities of POPCOD HIS 1.1.3 c) Computer Programmer (30 man-months) 1.2 For computer services for MIS Not availed of because there development (32 computer hours) were no computerization re- quirements at that time. 1.3 Senior training consultants Completed in March 1980. Two to assist in POPCOM's Program Consultants served.as primary (4 man-months) resource persons for 0.D., research and evaluation, management of training function. 1.4 One fellowship for an MIS Staff Not availed of because it to train on Data Dictionary was too premature to under- Development (3 weeks) take activity since frame work for MIS was still being developed at that time. Converted to study tour. 1.5 Four specialty fellowships for Completed in August 1979. Master trainors (3 months each) One Master Trainor resigned from POPODM without render- ing service due. One re- signed after rendering service. Third still with POPCOM (Training Division) Two representatives from participating agencies still with their respective agencies. 1.6 Fellowship for one POPCOM Completed in April 1979. senior staff on management Skills acquired utilized in skills (3 months) analyzing project proposals submitted to POPCOM; in helping other agencies in planning their proposals. 2. Studies: 2.1 Condom Marketing Research Completed in November 1979. Scheme Phase II (10 months) Conducted by Population Center Foundation. POPCOM followed recommendation which did not favor using Annex I 49 Page 5 of 9 TARGET ACTIVITIES ACCOMPLISHMENTS AND C NBWMTS sari-sari store as outlet for commercial distribution of condoms. 2.2 Project preparation activities Completed in Mardh 1978 for Population Project II 3. Training: 3.1 Planning workshops for Master Completed in October 1979. Trainors (7 days) Training design not finiabed during workshop. Outputs utilized. 3.2 Master Trainors Course for Completed in March 1980. 20 participants (44 days) Majority of participants still tapped as resource persons in subsequent training courses. 4. IEC: 4.1 A Resource Book on Guidiance Completed in June 1980. and Counselling for Volu2- Distributed to sterilization tary Surgical Sterilization centers. (10,000 copies) 4.2 Revision and printing of Pilot Completed in September 1980. Learning Program and hodules Conducted by Population for Population Programs Center Foundacion. Modules Professionals distributed to clinics. Self- study materials substitued for lack oc refresher training courses. 4.3 Replication of Rural Service Completed in July 1980. IEC Delivery Scheme IEC materials materials were target group for use in rural extension specific. Able to segment programs various occupational groups in rural areas (sugarcane workers, farmers, fisherman) 4.4 Undertaking an organizational Not implemented since diag- diagnosis of the IEC set-up nosis was not identified as required by POPCOM a need by POPCOM. 4.5 Programmed mass communication Not implemented despite pre- campaign on population dimen- parations made since funds sions not promptly released by MOB. 4.6 Material development production Completed in December 1980. in support to services delivery Three radio stations from linked operations of population Region IX with a contract field workers each of P20,976 claimed only payment of P3,496 each. 4.7 Thirteen regional assessment for Not implemented because of local elite/opidion leader sup- problems of budget release. port/non-support of FP program and their media habits, affi- liation, etc. - 50 - AnnezI Page 6 of 9 TARGEr ACTIVITIES ACCOMPLISHMENTS AND COmErS 4.8 National IEC workshop of about Activities undertaken but 60 national and regional iEC utilizing other sources and services staff from POPCON of funds because of and participating agencies re: difficulty in release of implementation of expanded IEC funds. Program under POP I and II 4.9 Training of 50 selected Completed September 1979. scriptwriters on family Scriptwriters now being planning used for other IEC popu- lation campaigns. MOR (as per Amendments, 1978) 1. Consultants and Fellowships 1.1 Architects and Construction Part-time architect hired Supervisors for 25 Pilot from January-December 1981. BRS buildings 1.2 Senior training consultants to Man-months shareq with assist in MOH's Master Trainors' POPCOM utilized same Program (4 man-months) consultants as POPCOM's. Thus savings realized. 1.3 Senior Consultant to assist Consultant hired in 1979 to in the MHO Training Program provide technical assistance (2 man-months) in the development of MHDR curriculum. 1.4 Senior health administration/ curriculum. management consultant/s to Consultant hired for systems assist in MOK's functional analysis. analysis (2 man-months) 1.5 Development of a nutrition MIS under NNC Completed in 1980. Contracted to Economic Development 1.6 NNC/MIS development (8 Foundation computer hours) Not availed of since there were no computer needs at 1.7 Three week fellowship for one that time. MIS Staff to train on Data Not funded by project but by Dictionary Development the World Health Organization. 1.8 Four 3-month specialty fellow Completed in August 1979. ships for MOR Master Trainors Five sent from NOR. Master Trainors trained other trainers (Central Staff and regions) who in turn trained provincial trainors. -51- Annex I Page 7 of 9 TARGET ACTIVITIES ACCODPLISEMENTS AND OMMENTS 2. Studies 2.1 Functional Analysis of MOR Completed in 1980. Conducted by UP College of Public Adlmninstration 2.2 Mapping Exercise Completed in 1981 Conducted by 2opulation Center Foundation 2.3 Information Systems study Completed in 1980. for a combined information Conducted by Suma system for health, population Computer Service Corp. and nutrition. 2.4 Computer Feasibility Study Completed in 1980. Conducted by Summa Computer Service Corp. 3. Training 3.1 Seven day planning workshop Completed in 1979 for MOR Master Trainors 3.2 Skill training Courses in Completed in August 1979 FP methods for 360 nurses and midwives 3.3 Five day course for 3500 Trained 1936 out of the midwives in pill dispensing 3500 midwives 3.4 Refresher courses for 360 Trained 222 out of the medical back-up personnel 360 physicians for FP services. 3.5 Seven-day workshop for 36 Completed in March 1979 national/regional/provincial Trained 35 out of 36 training and supervisory targetted staff. staff on Purok leader approach to FP promotion 3.6 Purok approach activities 3.6.1 Two-day workshop with Completed in March 1979. 18 municipal health Formulated guidelines for workers to plan a implementation, manuals for pilot program purok leaders, and worksbeets for training of midwives and Sarikaya workers. 3.6.2 Seven-day workshop Trained 24 Barangay Health for 24 barangay mid- Midwives in May 1979 wives and 24 BKWS 3.6.3 Informal sessions with Completed in July 1979. 240 Purok leaders Greater awareness on the part of the Purok leaders regarding referral system for FP. 3.6.4 Evaluation of Purok Completed in May 1980 Approach Conducted by UPIMC. Evaluation' used for improvement of train- ing worksheets and for succeed- ing pilot test regions. 52 -AnneZ I - Page 8 of 9 TARGET ACTIVITIES ACCOMPLISHMENTS AND ODMME§TS 3.7 Training Courses for 100 Completed in May 1980. Municipal Health Officers Conducted by PREK 3.8 Evaluation of Training Completed in 1982 Courses for MHO Conducted by UPESC 3.9 NFPO MAninistration of PP Completed. Action teams training and service super- which were formed for this vision purpose are now integrated in PHC organization. 3.10 Three workshops regarding One Workshop conducted under development of MIS system the sponsorship of Suma at MOR, POPCOM and NNC Computers. TECHNICAL ASSISTANCE (as per 1981 Re-programming) MOE 1 Health Sector Study Completed in 1982. Conducted by UP Institute of Public Realth 2. Training in Microscopy Cancelled. Not approved by the Bank. 3. Inter-Agency Monitoring and Functional until March 11983 Coordinating Committee 4. Computer Cost Benefit Analysis Completed January 1983 5. Encoding of PHC, ROIS, HOIS data Discontinued in December 1982 as per recommendation of the WHO study. 6. Processing of encoded PEC, Discontinued in December 1983 ROIS, HOIS data as per recommendation of the WHO study. 7. Development of Computer Discontinued. Not a priority of Management. 8. Project Completion Report Completed in May 1983 POPCOM 1. Projects 1.1 Pre-Harriage Counselling Project Completed in April 1980 1.2 Mass Production of Kuwento ng Completed in June 1982 Pag-ibig 1.3 Mass Replication of Film Completed in August 1982 Materials for PPP 1.4 Development/production of Completed in November 1982 10 Prototype Poster-Comics Used as supplemental material for regions. Evaluation on the usefulness of these materials in population program still to be done. 53 Annex I Page 9 of 9 TARGET ACTIVITIES ACCOMPLISEMENTS AND CODMMENTS 1.5 Development/Production of Completed in October 1982 Manmals on the Developmeut/ Production of IEC Materials 1.6 Mass Production of Pill Completed in December 1982 Brochure 1.7 Mass Production of Questions Completed in December 1982 and Answers on FP 1.8 Mass Production of Brochure Completed in January 1983 on Vasectomy and Tubal Ligation 1.9 Mass Production of Brochure Completed in December 1982 on Guide for Newlyweds 1.10 Mass Production of 1983 Poster Completed in March 1983 Calendar on Natural Family Planning 1.11 Mass Production of Ovulation Completed in March 1983 (Cervical Mucus Method) Chart 1.12 Mass Production of Posters on Completed in March 1983 1.12.1 The Pill 1.12.2 Natural FP Methods 1.12.3 Sterilization 2. Fellowship 2.1 In country fellowship in Basic Not implemented due to dis- Management for 7 senior POPCOM approval of curriculum pro- Staff posed. 2.2 Observation Study tour for 4 For two weeks. November 11- senior staff of MIS 21, 1981. However two of the 4 staff resigned from POPC(M soon after the tour. Gave insight into extent of MIS use in population in other ASEAN countries and other alternative MIS de- sign re: population 3. MIS - Implementation of component Completed in December 1981. information system of POP00M Useful for research, service delivery manpower and train- ing. System still being utilized but computer facilities of POPOOM not sufficient. NCC computer processing time utilized. Refinement of system now being done based on comments of end-users. Used as supplemental material for regions. Evaluation on the usefulness of these materials in population program still to be done. 二兀’‘。：. ‘一‘仔一 LOAN ALLOCATION9 BY CATEGORY AND YEAR OF REFF.OGRAMING Amount of the Loan Allocated % of Expenditures to be Financed Category (Expressed in Dollar Equivalent) 1974 Dec. 1978 June 1981 1974 Dec. 1978 June 19 81 1. Civil Works 6,900,000 9o5OO,OOO 9,500,000 39% 472 702 11. Vehicles, spare 3,900,000 6s500,00O 8,000,000 100% of fo- same as 1974 same as 1974 parts, equipment reign axpen- and furniture ditures or 100% of the ex-factory cost 11. Technical assi&- 295OOtOOO 407OOtGOO 4w7lOjO0O 100% 100% 100,14' Ln tanceo including professional services IV. Recurrent incre- 2,800,000 1,016,400 1,261,012 902 during NONE NONE mental cost (vehicle the first maintenance and year after salaries) the date of thi%agree-O,, men and 7 50% and 30% raspectively during each of the sub- saquent yeard V. Unallocated 809001000 31283l580 1*538,988 T 0 T A L 25s000,000 25s000t000 25v000,000 -56'- CONSTRUCTIOM PROGRES8 RC 6HS R U/SH 15 300 2 12 250/1 RTC 10 200 12RHU 19 06 5 160 5 ir 147 0 1975 14 977i". Cýl16 LEGEND: Rural Health Unit (RHU) Regional Training Center (RTC)--------- Staff House (SH) Barangay Health Station (BHS) -s'- - 59 - Annex III Table 3.1 TABLE 3.1: CHANGES IN RRU LOCATIONS Number not Region Orig. Plan Actual Built in original list I 17 19 10 II 11 22 11 III 22 10 1 IV 35 35 4 V 20 20 4 VI 17 17 6 VII 3 3 0 VIII 18 19 9 IK 13 14 10 X 36 20 3 XI 13 9 2 XIlI/ - 18 9 TOTAL 205 206 69 Z of actual locations not in original list - 33.6% 1/ After Appraisal, Region XII was carved out of the area covered earlier by Region I. - 60 - Annex III Table 3.2 Table 3.2: CHANGES IN FLOOR AREA BY TYPE OF BUILDING TMPE OF FLOOR AREA (K2) Z REDUCTION/ BUILDING ACTUAL INCREASE AE* MINIMUM MAXIMUM AVERAGE RTC 2180 1311.05 1992 1574.17 -27.79% RMU "A" 330 213 297 262.86 -20.34% RRU "B" 94 106.8 231.84 178.42 +89.80% SH - 1 62 71.61 90.25 78.15 +26.05% SH - 2 124 132 179.38 151.04 +21.81% BES NA 64.38 64.38 64.38 NA * Appraisal Estimate - 61 - Annex III Table 3.3 Table 3.3: COST OF CONSTRUCTION PER SQUARE METER (in US) BANK - FUNDED GDP - FUNDED APPRAISAL TYPE OF BUILDING EST1MATE* ACTUAL 1974 1976 1979 1976 1979 RTC 1256 1904 2227 - - RHU 1456 1636 1796 1500 1800 BRS NA - 1140** - 893 Notes: *Including contingencies **1981 figure - 62 - Annez IV Table 4.1 TABLE 4.1 SCHEDULE OF DISBURSEMENTS Last Revised Cumulative Fiscal Year Appraisal Estimate Actual as percent of and Quarter Actual Estimate 9/30/82 total loan amount FY75 December 31,1974 0.35 March 31, 1975 0.86 June 30, 1975 0.02 1.01 0.08 FY76 September 30, 1975 0.12 1.70 0.48 December 31, 1975 0.18 2.04 0.72 March 31, 1976 0.25 2.86 1.00 June 30, 1976 0.36 4.07 1.44 FY77 September 30, 1976 0.74 5.75 2.96 December 31, 1976 1.37 8.46 5.48 March 31, 1977 1.90 11.52 7.60 June 30, 1977 2.45 13.80 9.80 FY78 September 30, 1977 3.20 16.39 12.80 December 31, 1977 4.59 18.36 18.36 March 31, 1978 6.29 20.58 25.16 June 30, 1978 7.33 21.81 29.32 FY79 September 30, 1978 8.58 23.09 34.32 December 31, 1978 9.39 23.38 37.56 March 31, 1979 10.10 23.80 40.40 June 30, 1979 11.46 24.36 45.84 FY80 September 30, 1979 11.78 24.85 47.12 December 31, 1979/1 12.11 25.00 48.44 March 31, 1980 12.78 51.12 June 30, 1980/2 13.26 53.04 FY81 September 30, 1980 14.62 58.48 December 31, 1980 15.58 62.32 March 31, 1981 16.02 64.08 June 30, 1981 16.10 64.40 FY82 September 30, 1981 16.43 65.72 December 31, 1981 16.88 67.52 March 31, 1982 17.17 68.68 June 30, 1982 17.70 18.2 70.80 - 63 - Annex IV Page 2 of 2 TABLE 4.1 SCHEDULE OF DISBURSEMENTS (cont'd) Last Revised Cumulative Fiscal Year Appraisal Estimate Actual as percent of and Quarter Actual Estimate 9/30/82 total loan amount FY83 September 30, 1982 19.10 22.0 76.40 December 31, 1982 19.94 25.0 79.76 March 31, 1983 20.74 82.96 May 31, 19833/ 23.35 93.40 /1 Original closing date. /2 Closing date as per project amendment on 12/12/78 f/ Loan closing date -64- Ane V COMPLIANCE wITE LOAN CONDITIONS Section No. Covenant Status 3.01(b) Acquisition of land for civil Completed works 3.02(a) Coordi-ation of project by Final project activities of POPCOK POPCCK and MDO were overseen by NEDA monitoring committee. 3.02(b) Establishment of Project Con- Construction and procurement struction Unit in MDR; employ- services of MR carried out ment of Project Architect and appropriate duties after PMS supporting staff. was discontinued in Dec. 1979. 3.02(c) Employment of Architectural Completed. Consultants and Construction Mnagement Consultants. 3.02(d) Construction Contracting Completed 3.03(a) Insurance of imported goods Standard government insurance policies apply 3.04(b) Maintenance of project Poor performance due to records problems arising from handover of project management services to MR. Reconstruction of records based on available documents completed 3.05 Establishment of Barrio MOR/MPUR has constructed 680 (Barangay) Health Stations BBS In support of the project (BKS) in areas where Rural Health Units constructed. 3.06(a) Appointment of consultants Study cancelled in Dec. 1978 to undertake study on costs, Bulk of construction not effectiveness and utilization completed until 1979-80 of facilities under the project by July 1976 3.06(b) Continued evaluation of Being done by POPCOM family planning program according to Schedule 5 of Agreement 3.07 Training of Graduate Nurses Completed in public health, & employ- ment in Regional Training Centers & as supervisors in rural health programs. 4.03 Annual Auditing of Not complied with except in project accounts 1981. Audit under preparation for submission to the GOP and Bank 4.04 Establishment of a special Completed committee to review train- ing of midwives in the country 4.05(a) Maintenance of project GOP funds for maintenance facilities not adequate 4.05(b) Survey of BHS physical faci- Rehabilitation program ities & submission of rehabi- still under consideration. litation program by July 1976 G12I4 240. 2. - 65 - PCOPCOM FUNDINiG (IN 1972 P MILLION) 7M2 75 76 47.1 4C <,0 ja! -2:i 48° 2.y.z '8.7 IIC 1972. 197.3 J97. 197$ /97é 977 '978 /9>? l9qw /9& /982 ,.BRO 14007〔PCRI .i 妒AA開r&,”痲5 ! 】 、，