Philippines - Urban Health and Nutrition Project

Documeåt of The World Bank FOR OFFICIAL USE ONLY Report No. 11702-PR STAF APPRAISAL REPORT REPUBLIC OF THE PBILIPPINES URBAN RATTR A=D NUTRITION PROJECT MAY 14, 1993 P.. 1, i Population and Ruman Resources Division Country Department I East Asia and Pacific Regional Office This document has a restrcted distribution and may be used by reciplens only in the performance of their officia d~ties. Its contents may not otherwise be disclosed without World Bank authofrimton. CURRENCY OUBIALN Currency Unit - Philippine Peso (P) US$1.00 - P25.5 (as of January 1993) AIDAB - Australian International Development Assistance Bureau BHW - Barangay Health Worker BNS - Barangay Nutrition Scholar CHO - Zity Health Office DBM - Department of Budget and Management DECS - Department of Education, Culture and Sport DILG - Department of Interior and Local Government DOF - Department of Finance DOH - Department of Health GIS - Geographic Information System GOP - Government of the Philippines HIS - Health Information System IAA- Inter Agency Agreement ICB - International Competitive Bidding IDA - International Development Association IEC - Information, Education and Ccamunication IMR - Infant Mortality Rate LCB - Local Competitive Bidding LGU - Local Government Unit MIS - Management Information System MOA - Memorandum of Agreement MCH - Maternal and Child Health MDF - Municipal Development Fund MHO - Municipal Health Office NGO - Non-governmental Organization NCHS - National Center for Health Statistics NCR - National Capital Region NNC - National Nutrition Council PCU-UHNP - Project Coordination Unit - Urban Health and Nutrition Project PEN - Protein-energy malnutrition PHC - Primary Health Care PIHES - Public Information and Health Education Service PPAR - Project Performance Audit Report TB - Tuberculosis UBSP - Urban Basic Services Program UHNP Urban Health and Nutrition Project UNICEF - United Nations Children's Fund FISCAL Yer January 1 - December 31 FOR OFFICIAL USE ONLY Contraceptive Prevalence Rate The percentage of married women of reproductive age who are using a modern method of contraception at any time. Dependency Ratio. Population 14 years or under and 65 years of age or over as percentage of active population (aged 15 to 64 years). Indicates proportion of population that needs economic support. Incidence Rate Number of new cases of a specific disease during a given year divided by the estimated population at tid-year times 1000. Infant Mortality Rate Annual number of deaths of infants under one year per 1,000 live births during the same year. Low Birth Weight (LEW) Infant weight at birth less than 2,500 gr. LBV may be associated with either pro-term (less than 37 weeks gestation) or full-term but small for dates (38 weeks or more) of gestation. Maternal Mortality Ratio Number of maternal deaths per 100,000 births. attributable to pregnancy, childbearing, or puerperal complications (i.e. within six weeks following childbirth). Morbidity Any departure, subjective or objective, from a state of physiological or psychological well-being. In this sense, sickness, illness, and morbid conditions are synonymous. Prevalence Rate The number of cases present at a given time divided by the estimated population at the same time times 1000. Risk A probability that an unfavorable outcome related to morbidity or mortality will occur within a stated period of time or age. Total Fertility Rate The average number of live children that would be born per woman if she were to live to the end of her childbearing years and bear children according to a given set of age-specific fertility rates. The Total Fertility Rate often serves as an estimate of the average number of children per family. This document has a restricted distribution and may be used by recipients only in the performance of their offical duties. Its contents may not otherwise be disclosed without World Bank authorization. - 11 - REPUBLIC OF THE PRILIPPIN S URRAN EKALTH AN NUTRIICN PI.iECT Table of Content~ Pa m o. DEFINMTONS . . . . . . . . . . . . . .. . . . . . . l CREDIT AND PROJECT SUbARY . . . . . . . . . . . . . . . . . . . . . . . v .BåCKGRaUN . ... .. . .. . .. ... . . . . . . . . . . .i A. Country Background . . . . ............... . 1 5. Country Developmant Goals and Strategy . . . . . . . . . 1 C. Kealth, Nutrition and Urban Development Strategies and Program . . . . . . . . . . . . . . . . . . . . . 2 D. Urban Health and Nutrition Sectoral Issues . . . . . . . . . 4 E. Project Background . . . . . . . . . . . . . . . . . . . . . 6 F. The Role of Foreign Assstance . . , . . . . . . . . . . . . 12 G. Rationale for Bank Group Involvement in the Proposed Projeot 15 I. TRE P5OEC . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 A. Project Goals and Objectives . . . . . . . . . . . . . . . . 16 3. Geographic Scope . . . . . . . . . . . . . . . . . . . . . . 17 C. Strategy . . . . . . . . . . . . . . . . . . . . . . . . .. 18 D. Project Description . . . . . . . . . . . . . . . . . . . . 21 III. PROJECT COSTS. FINANCING- PROCURE ~IT AND DISURSEElTS . . . . . 29 A. Cost Estimates . . . . . . . . . . . . . . . . . . . . . . . 29 5. Financing ........... . . . . . . . . . . . . . . 33 C. Procurement . . . . . . . . . . . . . . . . . . . . .. . . 33 D. Dibursöments . . . . . . . . . . . . . . . . . . . . . . . 37 he r-port Is bnd en the findings of prämpMlet and appratsa missons to the pillpins in N~reb 199 and January 1993. the Priemt Tem Inctudd nsars. 8. Schyer, Senfor PbIk etth Specatlist - Tak Munmger, A. umwr. Senor #nuemmnt specatist, and Mn. C. Fögt, Population SpecIalIst, N. We- festld, Ser papulatfon pesltst. C. eu, OpertOusm lochnoelos, and the fllfufin consutant pbmlatlst*: nsr. 8. Cpu, 8. C~#rd, C. Samun, m. Teplulto and A. Uittlum. mss. A. Larsön and m. wittaker represented the Autratlåu Interntinel Demtpmmnt Asstan e buremu. Peer revIers were am. i. fiulre (PmN), Nutritimn, E. Schrelber (LASM>) Services and ur. T. Uchura (Alm>, Seatuton. The Report u s teerl d by Renrs. d. shIlAumr (Chief, AIM. and C. £. Nhdsw (Diretor, lA1). IV. Za T z.~L~ZaIN ........ . . . ... .. .. . .. 38 A. Status of Project Preparation . . . . . . . ........ 38 B. Organization, Management, Financing and Sustainability . . . 39 C. Accounts, Auditing, Reporting and Supervision . . . . . . . 43 D. Monitoring and Evaluation . . . . . . . . . . . .. . . . . 44 V. PROJETBENEFITS AND RISKS . . . . . . . . . . . . . . . . . . . 45 A. Benefits.......................... .45 B. Risks . . . . . ...................4.......... 45 C. Impact on Women . . ....... . . . ....................... 46 D. Environmental Aspects . . . . . . . . . . . . . . . . . . . 46 VI. AMMMS Z&LME MjZM20M=ONflPJ . . .. .. .. .. .. ...47 TABLES IN TIE TEXT Table 3.1 - Project Costs...... . . . . . . . . . . . . . . . ... .. 31 Table 3.2 - Procurement Arrangements . . . . . . . . . . . . . . . . . . 32 Table 3.3 - Financing Plan .. .......... . . ........... 33 Table 3.4 - Project Costs by Procurement Arrangements . * . . . . . . . . 34 Table 3.5 - Disbursement Categories . . . . . . . . . . . . . . . . . . . 37 ANNEIES Annex 1 - Demography and Epidemiology of the Urban Areas Annex 2 - Department of Health Reorganized Structure Annex 3 - Local Government Revenues Annex 4 - Current Donor Activity in Urban Health and Nutrition Annex 5 - Interventions and Objectives Annex 6 - A Study of the Urban Poor in Quezon City Annex 7 - Health Service Targeting Annex 8 - Incremental Staff Annex 9 - Guidelines for Facility Development Annex 10 - List of Items to be Procured Annex 11 - Training Annex 12 - Component 2: Institutional Development Annex 13 - Organization and Management of UHNP Project Annex 14 - Community Partnership for Health and Nutrition in Urban Areas Annex 15 - Women' s Health and Family Planning. Annex 16 - Operations Research on Nutrition P rvix 17 - Basic Services to be Provided and Technology Options for Environmental Health in Urban Poor Communities Annex 18 - Project Components by Year Annex 19 - Estimated Schedule of Disbursements Annex 20 - Implementation Schedule -Iv- Annex 21 - Draft Memorandum of Agreement (KOA) between the Department of Health and Local Government Unit and the Department of Interior and Local Government Annex 22 - Fund Flow Under Municipal Development Fund Annex 23 - IDA Supervision Plan Annex 24 - National Capital Region Naps Annex 25 - Selected Documents Available in the Project File dag IBRD No. 24774 *V* AMfPMUG Q MP H ILIV=NR MMBA HRALTH AND NUTRTin nwsJcT 6RBTAND PUOLETSNN Bgreve: Republic of t Philippines Awm : SDR 50.5 Million (US$70.0 million equivalent) U=a: Standard with 35 years maturity Conancing: GovOrOment of Australia, US$3.1 million equivalent DescrtiSn: The project would directly address poverty alleviation through the following objectives: a) to improve the health and nutrition status of alum-dwellers in the urban areas of Metro-Manila, Metro-Cebs and Cagayan de Oro; b) to build the capacity of city and municipal governments in these areas to plan, finance a I implement coat-effective alum health and nutrition programs; c) to help slum commuities to identify their own health, nutrition and environmental problems and participate in planning, IMplementing and monitoring appropriate interventions; and d) to help the Department of Health develop policies and strategies which would Improve the outreach and cost-effectiveness of health and nutrition delivery systems. The project would support the following components: (1) Service Delivery, to Improve the outreach, range, quality and cost-effectiveness of priority health and nutrition services, through improvements in health risk assessment and client targeting systems, additions/mprovements to health staffing and facilities, and provision of additional equipment, contraceptives, drugs and supplies and food and micro-nutrient supplements; (ii) Institutional Development, to improve the capacity of project local governments to plan, manage, monitor and evaluate their health programs, and of DON to support local governments, through strenthening msnagement systems and planning and evaluation capacity; training technologies, programs and infrastructure; and communications technologies and programs; (iii) Community Partnerships for Health, to support community mobilization and commuity-based health and nutrition service delivery, through financing grants to strengthen local NGOs, to develop community/h- /local government fora, and to Implement joint comunity/local government/GO sub-projects in health and nutrition; and (iv) Policy Research and Ivaluation, to support operations research studies testing alternative service delivery models for key interventions, and studies to evaluate project progress. * vi - Benefi The proposed project would assist GOP in developing operational models for health and nutrition service delivery and community empowerment in urban slum areas. It would test innovative approaches to client targeting, to training and communication methodologies and to nutrition service delivery which have potential applications on a national scale. It would build DOHas capacity to fulfil its new role after devolution of providing support to, rather than management of, the health departments of local governments. Within the project area, the project would directly benefit about 0.9 million slum households in the three target cities with better access to health and nutrition services. It would increase the capacity of the 21 local governments in the project area to plan, manage, monitor and evaluate their health and nutrition programs. It would build local communities' awareness of their health, nutrition and environmental problems, and involve them in a pro-active way in seeking solutions to them. Isaks: The main risks foreseen are (i) whether LUs would be committed to implementing the project and able to provide and sustain the financing ret!ulired for the project; (ii) whether LUs with newly devolved responsibilities would have the capacity to manage the proposed project; (iii) whether implementation would be delayed through shortfalls in and slow release of project funds by the central government; and (iv) whether all 21 LGUs would agree to participate in the project, as well as as the likelihood that project outcomes would not be uniform in all 21 LGUs. Since many of the project's activities are community-based, it is unrealistic to assume that project objectives will be fully achieved in all communities. With regard to the first risk, strong commitment to project goals was generated by the participative approach to project preparation; this would be formalized through the proposed central/local government NOAs, which would bind local governments to implement the project as planned. With regard to the second risk, LU managerial capacity would be strengthened by project institution-building activities; in addition, the flexible approach to implementation which is proposed would allow scope to deal with managerial problems as they arise. With regard to the third risk, the current GOP/Bank project and program prioritizing and restructuring exercise would help to ensure that central government funds are concentrated on fully funding a limited number of priority projects, including the proposed project. Also, the proposed system of releasing project funds in six-monthly tranches into the Municipal Development Fund would help to ensure an adequate cash flow. Fourthly, all 21 LUs participated in project preparation and the project design includes financial incentives in grant form for communities to participate in the project. - VU1 - (USS tilluen) I Total Foreign ase Estimated Cost Local Foreign Total Exchange Costs A. Service Delivery Vomen"s Health 4.5 6.4 10.9 59 s child*s Health 4.6 4.7 9.3 so 12 TB Control 4.7 0.8 5.5 14 7 Service Upgrading 10.8 5.3 16.0 33 21 Incremental Service Delivery Staff 9.8 * 9.8 13 Subtotal Service Delivery 34.4 17.1 51.6 33 69 8. Institutional Development Area Based Planning 0.4 - 0.4 2 1 Information, Education & Counnication 1.5 0.7 2.2 31 3 Training & Hunan Resource Development 1.3 0.2 1.6 15 2 Management System Improvement 0.6 0.5 1.1 47 2 Admin. Facility Upgrading 4.1 1.S 5.5 27 7 Project Management & Coordination 2.9 0.7 3.6 19 5 Subtotal Institutional Development 10.9 3.6 14.5 25 19 C. Comamunity Partnership for Health Planning Grants 1.0 0.1 1.1 8 1 Institutional Grants 0.1 0.1 Project Grants 3.7 * 3.7 5 Subtotal Comunity Partnership for Health 4.8 0.1 4.9 2 6 0. Research & Evaluation Baseline & Evaluation Surveys * * - EnvirnrntaL Health Development 2.4 0.2 2.7 9 4 Women's Health & Famlty Planning - 0.4 0.5 90 1 Nutrition Development 0.3 0.3 1 - Operations Research 0.5 - 0.5 1 Subtotal Research & Evaluation 3.3 0.6 4.0 16 5 Total BASELINE COST 53.4 21.5 74.9 29 100 Physical Contingencies 0.8 1.0 1.9 SS 2 Price Contingencies 4.0 1.4 5.4 27 7 Total PROJECT COSTS 58.2 24.0 82.2 29 110 Financing Plan: Local Foreign Total Goveraent of The Philippines Central 0.7 0.7 Local 8.0 - 8.0 sMbtotL 8.7 8.7 Canufanity Contributions 0.4 - 0.4 IDA 46.9 23.1 70.0 Goverreaent of Australia 2.2 0.9 3.1 1i 58.2 24.0 82.2 EstimatedDisbursements: IDA FY 199i 21m 1112 Annual 0.2 4.9 10.5 14.7 16.1 13. 7.0 3.3 Cumulative 0.2 5.1 15.6 30.3 46.4 59.7 66.7 70.0 Economic Rate of Return: Not Applicable REPUBLIC OF TE PHILIPPlNES URBAN HEALTH AND NUTRITION PROJECT 1. BAGROM A. Country Backgroud 1.1 At the beginning of the 1970s, incomes in the Philippines were at levels comparable to those in Korea, Taiwan, Indonesia and Malaysia. During the 1980s, these countries averaged growth of over six per cent a year while the Philippines grew at less than one per cent a year. Poverty reduction in the Philippines has lagged behind these countries partly because of slower growth, and partly because growth was concentrated in a higher wage formal sector protected by minimum wage legislation; in the dualistic Philippines economy, growth did no more than trickle down to the majority of people working in the low productivity agriculture and informal sectors. A combination of slow growth and economic and political crises during the 1980s left the Philippines in 1992 with a real per capita income 7.2% lower than in 1980. 1.2 Similarly, while health, nutrition and fertility conditions in the Philippines have improved since the early 1970s, progress has been far slower than in other East Asian countries. As a result, the Philippines infant mortality rate, which was comparable to those of China and Thailand in the 1970s has not improved, and is now roughly twice as high as their rates. Slow growth in the incomes of poor people and the government' s difficulty in financing adequate health and nutrition programs for the poor has resulted in minimal improvement in health status. In addition, in the early 1980s, budgetary constraints, coupled with low levels of commitment to preventive health care for the poor, resulted in the urban poor suffeting from both lack of public services and from the income effects of economic crisis. High rates of fertility, linked to weak commitment to family planning programs, have also contributed both to slow per capita economic growth and, directly, to relatively high death, disease and malnutrition rates among women and young children. B. Country Develoment Goals and Strategy 1.3 The National Economic Development Authority has completed a draft of the Medium Term Development Plan, 1993-98, which will be sent to Congress shortly. There are two broad themes in the Plan: (i) the need of the Philippine economy to strive for world competitiveness; and (ii) the need to provide people with the economic means to gain control of their lives. The Plan's three overall human development goals are to: a) enable the majority of the population to meet their basic minimum needs; b) provide focused basic services at a level which shall allow them to manage and control their resources as well as benefit from developmental interventions; and c) harness the productive capacity of the country's human resource base toward international competitiveness. - 2 - 1.4 The draft Five Year Plan, unlike previous Plans, presents broad programs and strategies, but not as yet detailed sectora! chapters or investment plans. The broad strategies proposed for poverty alleviation, equity promotion and human resource development include: focusing social services on the poor; developing and maintaining social safety nets; directing public resources and efforts at basic social services, disadvantaged regions and specific groups; expanding schemes to promote the physical well-being of the homeless population; promoting balance among population, resources and environment; improving and strengthening the mechanisms for planning, policy formulation and implementation of social development programs; and providing the necessary infrastructure facilities to facilitate and improve delivery of basic social services. C. Health. Nutrition and Urban Develoment Strateies and Programs 1.5 Health and Family Planning Strategies and Programs. The Department of Health (DOH) has been the principal health policy-making and implementing agency of the Government. DOH policies have undergone a series of significant shifts in the last decade. In the early 1980s, the Government initiated a new national community-based primary health care program to improve the outreach of health services to the poor. This program had achieved near national coverage by 1985. It involved a decentralization of program management and budgeting to the provincial level; the strengthening of the para-medical mid- wife cadre to a coverage of about one per 10,000 population; and the creation of cadres of voluateer 'Barangay Health Workers' (BHWa) in each village and slum, with the aim of a ratio of one BRW for every 20 households. Simultaneously, previously vertically organized disease control programs, for example for TB and malaria, were largely dismantled in the expectation that they would be implemented on an integrated basis as part of the PHC strategy. 1.6 The new strategy had mixed results. It increased outreach and community involvement, but the disease control programs deteriorated rapidly, leading among other things to a significant resurgence of malaria. It proved too much for the decentralized primary health care system to maintain the technical integrity of these programs on top of the demands of the maternal and child health (MCH) program, and in 1987 a vertical logistic support and technical supervision system for tha disease control programs was reinstalled. The BHW cadre, expanded by this time to over 60,000 volunteers, also suffered from weak support. Poorly trained and supervised workers had difficulty in handling the multiplicity of interventions; many volunteers dropped out. In response, in the late 1980s the DON introduced an 'at risk' approach in which partnerships between the DOH, communities, health workers and NGOs were to identify the highest risk communities and families in their area and concentrate resources on them. 1.7 These changes were part of a broader health sector strategy developed by the Aquino Government in 1987. This Government increased resource allocations to the health sector from 2.7% to 3% of public expenditures, succeeded in raising immunization coverage--at least temporarily--from 23% to 80%, improved program performance in diarrheal disease control, and launched a program for control of acute respiratory infections with assistance the Bank (para 1.50). In order to use limited resources more cost-effectively, the Government also a4opted a new drug policy expected to rationalize drug use and moderate price increases, and revised its resource allocations to community health so as to minmize regional disparities and to focus resources on those most in need. 1.8 In the cities, the Aquino Government took two major initiatives to develop health services in the slums. A decision was taken to legalize health service delivery to all slums, irrespective of the residents' land tenure status. And the Government created a new Health Region covering the National Capital Region (ACR), also known as Metro-Manila, as a way of strengthening the public health programs of the City Health Offices and channeling additional technical and financial support to the metropolitan area. Discussions on the proposed project were begun followipg this decision, with the idea that the project would be an additional vehicle to address health and nutrition problems and increase resource transfers to slum communities. 1.9 The Ramos Government which took office in 1992 has broadly endorsed these strategies, and proposes to consolidate and build on them. It has developed two major new health policy thrusts. The first is a program to implement the devolution of health services which was mandated by a new Local Government Code legislated by the Aquino Government in 1992. This devolution is much more radical than the decentralization program of the early 1980s. From early 1993, the budget for and management of health services will shift from DOH to the 75 provinces and 60 chartered cities and about 1,500 local governments. The role of DOH will shift from being that of manager of the nation's public health programs to being a source of advice, traini-g and tnechnical assistance to local governments who will henceforth have implementation authority. The aim is to make services more responsive to local peoples' needs by putting them under the control of their own representatives; but the rapid pace at which this strategy is being implemented raises issues about government' capacity to manage these programs, and hence to sustain program performance over the near term (para 1.16). 1.10 The second major policy thrust is to give much greater priority to women's health and in particular to women's reproductive health issues. This stems from recognition that one reason for high maternal mortality and morbidity levels is that health care for women has taken second place to interventions targeted at infants and children. It stems also from a commitment to widen women's choices with regard to the adoption of family planning--a program which for years has lagged behind other MCH seivices in the Philippines. Family planning is to become a core intervention under the new health policy, because of its potential simultaneous benefits in terms of improving women's health; reducing child mortality (by as much as 25%); and reducing the high fertility levels that currently abshrb much of the benefits of economic growth. 1.11 Nutrition Strategies and Program. The main agencies active in nutrition are the National Nutrition Council (NNC); the DOH; the Department of Education, Culture and Sport (DECS); and a variety of NGOs. The NNC is responsible for developing nutrition policy and coordinating interventions in the sector. The DOH is responsible for health and nutrition education; micro- nutrient distribution programs; growth monitoring and food supplementation of - 4 - malnourished pre-school children and pregnant and lactating women. The DECS is responsible for food supplementation programs for school age children. The NGO sector runs a wide variety of small scale income generation, health and nutrition promotion and food supplementation programs, especially in the poorer urban barangays. 1.12 Nutrition has traditionally been a very small share of DOH spending, and no major nutrition policy or program initiatives were taken by the department during the early 1980s. DOH's main nutrition policy initiative under the Aquino Government was the development of a national Comprehensive Nutrition Program for the years 1992-96. This program focusses on strengthening and expansion of the micro-nutrient deficiency and PEN control programs. However, funding for the implementation of these programs has not yet been secured. 1.13 Outside the DOH, the food price stabilization and subsidy program run by the National Food Authority plays an important role in ensuring the food security of the urban poor. The Government is currently reviewing whether and in what form this program should continue, in view of the current fiscal difficulties and the program's high costs (about three billion Pesos in 1992), which are largely due to the fact that it is not targeted tightly on the poor. 1.14 Urban Development Policies and Programs. The Philippines lacks a declared national urban development strategy. A 1992 review of the urban development sector by the Housing and Urban Development Coordination Council noted the lack of a planned location-specific response to the problem of urban and in particular metropolitan growth; poor coordination of public sector interventions, especially environmental concerns; and an inadequate response to the special problems of urban poverty. Since in the future under devolution urban planning would be the responsibility of city governments, the review recommended a national urban development plan, which would provide a framework for city planning and would balance national, metropolitan, local and sectoral concerns. D. Urban Health and Nutrition Sectoral Issues 1.15 Under-financing. Inadequate human, physical and financial health care resources have been allocated to poor urban communities. This inequity is the result of chartered cities throughout the country failing to allocate comparable budget support (on per capita terms) for their independent health departments than did the Department of Health (DOH) for the provinces and municipalities whose health activities were its direct responsibility. And even though past per capita allocations to the 13 municipalities in Metro Manila were higher than were those for the four Metro Manila chartered cities, the rapid influx of population into these smaller, poorer municipalities surrounding the city core overwhelmed their resources and resulted in the growth of slums without even the most basic primary health care, water and sanitation services. Following the return to budget stringency in 1991-93 after a period of real growth in health sector allocations from 1986-90, resources from the DON have not been adequate to fill the investmpt gap in the urban areas. la .*1 -5- 1.16 Imnolications of Devolution. There is a danger that budget stringency coupled with the devolution of health services to local governments could result in even greater Inequities for the poor. The new legislation has devolved over 401 of DOH s budget and over 701 ef its field staff to local governments on a formula basis which does not take into account the variation in size of their alum communities and severity of their health and nutrition problems. Local governments now will plan, finance and manage health services independently of the center. Some will not have the money to provide adequate services in the slums; others may lack the commitment. One risk is that, unless local governments give far greater priority than they ever have in the past to health and nutrition, allocations for health may fall. A second risk is that, even if health allocations are maintained, health resources may be diverted away from preventive toward curative care. A third risk is that public health service quality may fall because the health management systems of local governments are weak. 1.17 Inefficiency of Resource Use. In this situation, there is a clear need to increase the efficiency with which existing personnel, facilities and other resources are used in reaching the urban poor. The issue is how to target resources more effectively on those clients at greatest health and nutritional risk, in two dimensions. The first is geographic, given both that slum populations are scattered among better off populations, and the large variations in health r4 ek between households in the same slum. The second dimension is over time; individual risk varies greatly at different points in the reproductive cycle, with, for example, poor women being at much greater risk in the period before, during and after delivery. 1.18 Need for Greater Community Self-Reliance. Another issue facing the Government is how to facilitate, learn from, and 'scale up' past efforts to organize and empower communities to achieve greater self-reliance and ownership in addressing health problems in their own communities. Here, devolution of health services to the local governments should provide greater opportunities to achieve effective partnerships between NGOs, other local private resources, government and the communities to achieve this important objective. 1.19 iorkloads of Staff at the Peripherv. Reaching the poor requires outreach by para-professional workers into the community. Successive Governments have much increased the numbers of aid-wives to clients; the policy is now a ratio of 1:5,000. One issue is whether this ratio can be achieved and sustained by local governments in urban areas, and whether this ratio is in fact adequate to deliver a full range of health and nutrition services. A related issue is what contribution can be made to the outreach efforts of aid-wives by volunteer community workers. On the one hand, such workers can strengthen links with the community, and may provide services for one to two hours a day. On the other hand, they are not under the control of the health system, so that accountability for service quality is hard to ensure; and the training and support of an average of 16 volunteers itself adds significantly to the workload of a mid-wife. 1.20 Organization of Women's Health Services. Modern methods of family planning are not widely available in the project area. Where health centers -6- offer contraception, a full range of methods is seldom available, thus limiting women's freedom of choice, and leading to high rates of abortion and low birth weight, and a high health toll from obstetric complications. Most births take place in the home, assisted, often unhygienically, by untrained traditional mid-wives. A large proportion of normal births also takes place in hospitals, rather than in the Lying-In Clinics, thus unnecessarily straining the bed capacity of tertiary institutions. The issues are how to deliver an integrated package of women's health education and servicqs on an outreach basis, since low awareness means that clinic-bt aed services would not be spontaneously sought; and how to design a referral system to ensure that complications of pregnancy and child-birth find their way rapidly to the appropriate levels of care. 1.21 Organization of Nutrition Services. Reliance on an all-volunteer community outreach system has posed particular problems for reducing protein- energy malnutrition (PEN). Nothers do not easily recognize moderate malnutrition in their children in the absence of a regular weighing program; yet growth monitoring programs are labor-intensive, and difficult to organize with high quality. DOWHs growth monitoring program (Operation Timbang) only attempted to weigh all children once a year, and in practice has had less than 75% coverage in urban slum areas even with that frequency. Thus, some malnutrition is never discovered; and most malnutrition in children under two is discovered only some months after it has set in, making it harder to correct. The issue is how a high quality PEN control program should be organized in a system which relies heavily on volunteer workers. 1.22 A second set of problems relates to food supplementation of those with PEN. The main supplement available for malnourished children--the bulgur wheat and peas donated by the United States Government under Public Law 480-- is not found very palatable by them, and is also too bulky for weaning age children to consume much of. Also, the current supplementation strategy tends to supplement too little, and too late. Ration sizes are too small to lift children quickly out of malnutrition, and supplementation is limited to too few of the moderately malnourished children--only the bottom 20% or so. With regard to the timing of supplementation, there is more emphasis on child rather than maternal supplementation, despite the high prevalence of low birth weight; and the bulk of supplements go to children over three, whose stunting is hard to correct, rather than to correct wasting and prevent stunting among t': -.nJer threes. The issues are: Who should get supplemented out of government as opposed to family -'od resources? How much should they get? And for how long? E. Proiect Background 1.23 Introduct On average, health and nutrition conditions in the urban areas of the Philippines are better than in the rural areas. But conditions in many of Philippines' urban slums are worse than those in the poorest rural areas of the country. This is partly because the slums are an exceptionally unhealthy environment; partly because slum-dwellers find it difficult to access the clinics and hospitals which serve those with higher social status and the ability to pay; partly because Government has invested less in outreach services and demand creation in the slums than in rural -7- areas. Without significant further investment in the slums, health conditions there will continue to deteriorate, driven by persistent in-migration and worsening pollution. 1.24 Urban Growth and the Slums. While the Philippines' population more than doubled since 1960, the urban population more than tripled. The urban areas grew by 46% between 1980 and 1990, while the rural population grew less than 17%. Today, the urban population totals 26.2 million, of whom 12.9 million live in the 60 chartered cities. The three areas of Metro-Manila, Cebu and Cagayan de Oro which are targeted by the proposed project contain 9.2 million people- -roughly 15% of the total Philippines population of 63 million. About one half or 4.6 million people in the targeted cities live in slums, most of which are on vacant private and public lands near commercial or residential areas, along creeks or rivers, factory walls or sidewalks, railroad tracks, garbage dumpaites, or even cemeteries. Other than the availability of vacant lots, proximity to sources of livelihood is the primary reason for settling in these sites. 1.25 Slum-dwellers can be classified into squatters or non-squatters based on their land tenure status. While land is generally legally owned in non-squatter communities, uncontrolled sub-tenancies frequently lead to serious overcrowding, services are poor, and housing is generally physically deteriorating. Squatter settlements or shanty towns, on the other hand, usually begin as illegal settlements on public or private land. Because of their illegal status, structures are haphazardly planned, and housing is makeshift. The future of squatter settlements depends on local political conditions. Sometimes, occupied land is sold to the squatters, leading to subsequent upgrading of housing and services. More often, occupancy remains illegal, and Government therefore excludes these areas from water supply, power, and sewerage program coverage. 1.26 In the slums, water is generally bought from ambulant peddlers or from better-off neighbors with piped water connections. A few settlement communities may have communal faucets, and some resourceful households may organize illegal water connections. Excreta disposal is generally through the "wrap and throw* method, leading to pollution of the creeks in which excreta are thrown. Creeks or rivers are also often used directly as toilets for children and adults alike, while small children often defecate in the streets or pathways. 1.27 The health authorities recognize the risk that continued neglect of squatter communities poses to the health of the whole urban population. Most slums are therefore recognized as legitimate clients and targets of government health services. Most slum-dwellers live within reasonable reach of a public health facility. However, the impact of these clinic-based services is reduced by the absence of an effective outreach system; and there are anyway limits to what health services can do in the absence of other basic services such as water supply, drainage, and excreta disposal systems. 1.28 Getting health services to slums is also complicated by the variation in size of slum communities and their rapid rates of growth. Some communities may be small pockets of poverty consisting of less than 20 -8- households squeezed within a residential, commercial, or business area, while others may be quite large, with as many as 3,000 households. Slum communities can sometimes grow overnight, as happened, for example, after the eruption of Mt. Pinatubo. The uncontrolled growth of slum communities and the resulting high population densities pose severe constraints to attempts to improve living conditions. In particular, ver-crowding makes it very difficult to put up additional service delivery facilities. 1.29 Metro-Manila comprises 4 cities and 13 municipalities with a total 1990 population of 7.9 million. Overall, between 1980 and 1990 Metro-Manila grew at an average rate of 2.9% per year as compared to a national average of 2.3% per year. But the demographic characteristics of the 17 cities and municipalities vary widely, from Pateros with 51,000 people and a density of 4,900 per square kilometer to Manila with 1.6 million and a density of 41,400. Between 1980 and 1990, the peri-urban municipalities of Las Pinas, Muntialupa, Taguig, Kaloocan and Valenzuela grew at an average annual rate of more than 4.5%, while the core city areas of Manila and San Juan actually decreased in size (see Map No.1). The proportion of the population living in alum conditions ranges from 30% to 70%, with the slums in many of the poorest, peri-urban municipalities experiencing the fastest growth. These municipalities lag far behind the others in the services and resources they can make available to the poor. 1.30 Metro-Cebu, which includes the cities of Cebu, Mandaue and Lapulapu, is the second largest urban area of the Philippines. Its population is nearly 1 million, of whom 53% are slum-dwellers. Although the average population density of Metro-Cebu is much less than Metro-Manila, just nine per cent of the total area, including slums in the older parts of Cebu City and along the waterfront, contain half of the city's 80 barangays and over two thirds of the total population. The cities of Mandaue and Lapulapu also have substantial slums. 1.31 Cagayan de Oro is a much smaller but rapidly growing city in the Mindanao region; its population has been swollen by a large influx of displaced people. The city Government has very limited resources to address the problems of slum-dwellers, who number about 100,000 or 30% of the population of 340,000. 1.32 Health and Nutrition Status and Trends. The main causes of death in urban as in rural areas continue to be infectious and preventable diseases, especially pneumonias and diarrheas (often compounded by malnutrition) among young children, and TB and heart disease among adults. Maternal mortality is a concern, around 80 to 90 per 100,000 live births nationally and probably more in the slums. One study of 78 hospitals showed that a quarter of maternal deaths were related to induced abortion. As in other countries, high child death rates from infectious disease are strongly correlated with low educational levels among mothers; and also with poor environmental sanitation- -both particular problems in 3lum areas. 1.33 Changes in the infant mortality rate (IMR) are a useful indicator of health conditions overall. In the early 1970s, the Philippines had an IM of about 64 per thousand live births, comparable to that of China or Thailand. -9- But between 1970 and 1990 the decline in IMR in the Philippines was the lowest of all the major Asian countries, reflecting the country's uneven commitment to and success with economic development and anti-poverty programs. There is controversy about recent levels of IMR. In 1990 it was probably in the region of 60 nationally (as against 31-32 in Thailand and China). In Metro-Manila it was probably about 50--a metropolis-wide average which hides higher rates in slum areas; however there has been no survey of infant mortality in the slums. Since urban mortality data do not distinguish between the slums and better off urban areas, the overall decrease in death rates reported in the urban areas during the 1980s is somewhat misleading. There is some evidence that, nationally, death rates have declined slightly for the non-poor and risen for the poor, suggesting worsening conditions in the slums. 1.34 Child disease patterns and causes of death in the slums are typical of the early stages of the epidemiological transition. High incidence of measles, diarrheas and respiratory infections reflect both poor environmental conditions and the inadequacy of health outreach services. However, in a pattern becoming common in slum areas throughout Asia, a large proportion of all deaths is now caused by chronic, degenerative diseases more typical of a late stage in the epidemiological transition. Cardio-vascular diseases, injuries, cancers, and asthmas are among the ten leading causes of morbidity and mortality for adults; they are attributable to a mixture of sedentary life-styles, poor nutrition, widespread smoking, high levels of air and water pollution, and the stress of coping with precarious livelihoods in the slums. Over-crowding also leads to a very high prevalence of TB--more than three times the national average in the denser slums. 1.35 Fertility levels in the slums are high; though no special survey has been done in slum areas, the total fertility rate is probably around four. This has led to a high dependency ratio; 45% of slum-dwellers are under 15. Contraceptive prevalence is low, with probably no more than 20% of women of reproductive age using modern methods. It is estimated that about a third of reproductive age women have an unmet need for contraception, which helps to explain the high levels of illegal abortion (para 1.32). Child-bearing begins young; one 1991 survey in Quezon City found that over half of women slum- dwellers had their first child by the age of 21, and one fifth before they were 18. Pregnancies during adolescence and pregnancies which are too closely spaced increase the number of complications and emergencies associated with pregnancy and delivery, as well as leading to gradual maternal depletion. Pregnancy and childbirth are the leading cause of hospitalization in the project cities. 1.36 As with health data, urban nutrition data are aggregates which tend to hide the malnutrition problem among the poor. Nevertheless, it is clear that iron-deficiency anaemia is highly prevalent in urban as well as rural areas, affecting almost half of all pregnant and lactating women, over a third of children under six, and half to two thirds of all infants. Vitamin A deficiency is much less widespread, but still a significant problem. Clinical Vitamin A deficiency (Bitot's spots) affected just under one per cent of children in Metro-Manila in 1987, and sub-clinical deficiency 1.6%. But a survey of two particularly depressed barangays in Navotas, Manila found rates in 1987 that were five times the city average. * 10 1.37 Severe protein-energy malnutrition (PEM) has declined from 2% in 1982 and 1987 to 1.4% nationally and to less than one per cent in the NCR in 1989/90--the latest survey. This declining trend has probably been paralleled in the urban slums, despite a temporary rise during the economic dislocations of the 1990s, which particularly affected the urban poor. Severe PEN is no longer a major public health problem in the urban slums in general--especially since the Philippines reference standard tends to overestimate levels of severe malnutrition compared to the internationally accepted NCHS standard. Nevertheless, a study in the Navotas area of Metro-Manila indicated severe malnutrition levels of 2-3%, a figure which may be more representative of the situation in particularly depressed slum areas. 1.38 But moderate malnutrition--which recent research has shown to have significant adverse effects on both children's susceptibility to illness and on their learning ability in school--remains a serious public health problem throughout the slums. The 1989/90 survey showed moderate malnutrition rates (less than 75% of standard weight for age) of 10.8% in the NCR, as against 14.4% nationally. But the Navotas survey found rates of 16-18% in two depressed barangays. The only other large scale data set available is the service statistics from an annual growth monitoring program called Operation Timbang. These are poor in quality, but tend to confirm that moderate malnutrition in the slums remains as bad as or worse than in rural areas, and very variable from slum to slum. However, in the case of moderate malnutrition, the Philippines standards andU,testimate the extent of the problem as compared to the NCHS standards; NCHS standards would more than double the prevalence of this form of malnutrition. It can therefore safely be said that moderate malnutrition affects at least a third of under six children in the slums in general, and well over 40% of children in the worst off slums. 1.39 When the child malnutrition data are disaggregated by age, they show that the problem is quite heavily concentrated in children under two. This is a common developing country pattern, and one which suggests that the causes of malnutrition are less food insecurity than behavioral and maternal and child health factors. This peaking of malnutrition in the under twos is partly the consequence of poor weaning practices; partly due to the upsurge in disease as children begin to take food other than breastmilk; partly the legacy of poor maternal nutrition. Nationally, 18% of births are of low birth weight children, indicating a serious PEN problem among women of reproductive age, in addition to the high prevalence of anaemia from which they suffer. The high percentage of low birth weight babies also reflects the high percentage of babies delivered to adolescent mothers, and cumulative maternal depletion from close spacing of pregnancies (para 1.35). 1.40 Further information on the demographic and epidemiological characteristics of the target cities is given in Annex 1. 1.41 Service Structure in the Project Area. Health services are managed out of City and Municipal Health Offices (CHOs and MHOs) reporting to the mayor and council of the local government. The organizational structure for health service management varies significantly between cities and municipalities. Annex 2 illustrates, for comparative purposes, the health * 11 - organizational structures of Quezon and Kalookan cities, and of the MOs of Taguig and Pasig. In the cities, hospitals are self-managed and not administratively integrated with the CHOs as they are in the rural areas. In Metro-Manila, four District Health Offices (DNOs) provide support and guidance to the 13 HOs, and are in turn supported by the National Capital Regional Health Office. In Cebu and Cagayan de Oro, Regional Health Offices support the CHOs and MOs directly. 1.42 In both cities and municipalities, primary and secondary services are delivered through a network of Health Centers, Lying-In Clinics and Social Hygiene Clinics. Health Centers serve around 30,000 people, but this average varies widely. A typical Health Center is staffed by physicians, nurses and/or midwives; some also have dentists and microscopists (usually a medical technologist). The ratios of health staff to client population vary widely from jurisdiction to jurisdiction. The Health Centers provide a broad range of health services, including maternal and child health services, family planning, clinical consultation, health education and counselling, immunization, disease surveillance, and nutrition services, among others. 1.43 Lying-in Clinics are designed to provide basic maternity care. However, they have a low capacity to deal with complications of pregnancy, hence the level of self-referrals to hospitals is high. Social Hygiene Clinics provide diagnosis and treatment of sexually transmitted diseases; because of the social stigma attached to these clinics, their clients are almost exclusively commercial sex workers. Below the Health Center, BHWs and Barangay Nutrition Scholars (BNS) assist with community mobilization and health and nutrition education, and take turns in helping at the Health Center. BNS are paid an honorarium of about P300 (US$12) per month. Cebu City is unusual in paying its BHWs P500 (US$20) per month; most jurisdictions provide no financial incentives to their BHWs. 1.44 Program Funding. Health expenditures vary greatly between cities and municipalities, for three reasons. First, prior to devolution chartered cities received less support from the central government than did urban municipalities. The distribution of funds after devolution will reverse this pattern, with the cities benefitting disproportionately from central funding. The result will be that peri-urban municipalities with large and fast growing slum populations will receive proportionately less per slum-dweller than the cities, making it even harder than it has been in the past for them to provide even basic health and nutrition services to the influx of population. 1.45 Second, health expenditures also vary depending on local revenue- raising capacities. For example, total locally raised revenues will be about P723 (US$29) per head in 1993 in Manila as compared to P495 (US$20) per head in Cebu--reflecting the different resource endowments of the two cities. Finally, low health expenditures in some jurisdictions are not just the product of local resource constraints and low support from the center, but are also due to relatively low priority for health care on the part of local government. For example, health expenditures as a percentage of total revenues vary from 8.3% and 6.5% in Manila and Quezon Cities to 2.9% and 1.3% in Cagayan do Oro and Mandaue. Thus, for a combination of these four reasons, per capita health expenditures vary from P86 (US$3.4) and P60 (US$2.4) per - 12 - head in Manila and Quezon cities, to P24 (US$0.9) and P9 (US$0.4) per head in Cagayan de Oro and Mandaue. Annex 3 contains tables illustrating each of these dimensions of health spending for the project cities and municipalities. 1.46 In summary, it can be said that many low spending municipalities could do more for health by bringing their spending as a percentage of revenues in line with other jurisdictions. But this would be a still inadequate response to their requirements for additional slum health and nutrition services, which, at least in the medium term, can only be met by greater support from central government than their entitlement under the Local Government Code. Given that the growth in their slum populations is mainly due to in-migration, and is therefore not essentially a local problem, such external support appears to be justified. F. The Role of Foreign Assistance 1.47 The Bank's Role. The Bank Group's involvement in the Philippines health sector began with two Population Projects (In. 1035-PH and Cr. 923-PH) in the 1970s. The Project Performance Audit Report (PPAR 5544) for the first project noted that the increase in quantity and quality of the mid-wife cadre- -the main project intervention--had proved a sustainable investment and facilitated the decentralization of PHC services begun under the Second Population Project. The PPAR (No. 9380) for the second project, which began in 1979 and ended in 1988, criticized the Bank for acquiescing in a number of changes in the original design, which led to a greater emphasis on building PHC infrastructure during implementation than on improving family planning-- the main aim of the project. Both Population Projects suffered from disbursement lags due to cumbersome government financial procedures for budgeting, accounting and funds release. 1.48 The Bank has a long history of involvement with slum communities in the Philippines dating back to the 1970s. The Manila Urban Development Project (Loan 1272-PH/1282-PH) was approved in 1976, followed by the Second Urban Development Project in 1979 and the Third Urban Development Project (Loan 1282-PH) in 1980. All three projects emphasized providing shelter and basic services to the urban poor through the upgrading of slum areas and the development of new sites for housing construction. The first and third projects focused on Metro Manila while the second combined investments in the capital with expansion of the shelter program to three regional cities. Implementation was carried out through national government agencies with the National.Housing Authority (NHA) taking the lead. 1.49 While all three projects achieved successful physical results, doubts have been raised on the sustainability of this approach. First, poor cost recovery called into question NHA's ability to replicate the sites and services and slum upgrading operations on a broad scale. Second, completed facilities were not adequately maintained because responsible agencies, such as the local governments, were not directly involved in the execution of the project. Third, these projects involving multiple objectives and sectoral institutions proved to be extremely complex to implement. Subsequently, the Bank moved to a clear sectoral focus, addressing the overall needs of the housing sector through a Housing Sector Loan (Loan 2974-PH) and providing - 13 - local governments the option of carrying out slum upgrading under the First and Second Municipal Development Projects (Loans 2435-PH and 3146-PR). When offered the choice, local governments have opted to utilize their share of loan proceeds for income-producing investments (such as public markets), as these investments are expected to result in clearly defined revenues to offset the debt service requirements. Borrowing for social services, including health and education, for slum communities has had little priority. 1.50 The Philippines Health Development Project (Ln. 3099, for US$70.1m), became effective in 1990. It has four main components, each on a national scale: a) expansion and improvement of the malaria, schistosomiasis, TB and MCH programs; b) institutional strengthening of DOH through Improvements in information systems, planning and budgeting procedures, communications, training and evaluation mechanisms; c) establishment of a program of grants for organizing and implementing partnerships for community health projects between DOR, local governments and NGOs; and d) establishment of a national health policy committee and secretariat within DOH. This project has introduced a number of new activities on which the proposed urban project will build. These include the scaling up of DO's acute respiratory infection control program; the development of new case-finding techniques for TB control; the pioneering of new area and risk based targeting methods for health interventions, coupled with health information systems which help to track high risk clients; new training and communications technologies for health workers, such as the use of desk-top video; and the pioneering of community/government/NGO health partnerships. 1.51 While the Health Development Project has suffered from some delays in funds releases, these have been less than other projects in the Philippines portfolio, and disbursements are slightly ahead of forecast. The last supervision mission rated it as having moderate problems, and being likely to achieve its development objectives. One reason for relatively smooth implementation of this project so far is a high degree of understanding of and commitment to project goals and implementation on the part of Government, which stems from the participative process of workshops involving major stake- holders which was used during project preparation. 1.52 The Bank's first sector work in health and family planning began in 1990, following a Government request for technical assistance for the family planning program. The mission's findings were expanded into a major sector report, New Directions in the Philippines Family Planning Proaram (October 1991), which was well received by DOH. The report reviewed the history of the population program, analyzed its likely health impact, recommended ways to strengthen it, and argued for additional funding. The report provided an analytic base for the Government's adoption of a health rationale for family planning, noting that, even if family planning were limited to women at highest health risk (i.e. those under 20, over 35, with four or more children, and those within 15 months of the last birth), this could lead to a 25% decline in infant mortality. It also concluded that family planning efforts focussed primarily on such clients could have a significant impact on fertility. The Government proposes to base expansion of the family planning program on the rationale and strategies set out in the report. - 14 - 1.53 The Bank is currently completing a sector report on the management of risk during the rapid adaptation to a heavily devolved system of public health. This report will assist the DOH and local governments in management of health programs so as to sustain health status and program performance during the early years of the devolved system. 1.54 The Government has approached the Bank for support for a first Women'a Health and Safe Motherhood Project beginning in 1995. This project would support implementation of the Goverment's new policy of greater priority for women's health and especially for family planning (para 1.10). DOH has already established a National Task Force on Women's Health and a strong Philippines Family Planning Program Steering Committee, which will help to build national consensus in these areas and oversee project preparation. It is anticipated that this project would focus on the creation of demand for and delivery of services for family planning, pre- and post-natal care, safe births, and control of sexually transmitted diseases, on a national basis. The Government also plans a Child Development Project in about 1996, which, among other things, would help to develop and implement the DONH's Comprehensive Nutrition Program (para 1.12). 1.55 The proposed project would build upon the lessons learned to date. First, the project is focused on health improvements, one of the main benefits of slum upgrading, with the Department of Health as the technical agency, avoiding multiple objectives and project complexity. Second, the local governments and NGOs are being brought into project preparation and implementation so that there would be continued support to the slum communities after the project is completed. Third, the project will strengthen the capacity of the city and municipal health departments to ensure that momentum built up under the project will be sustained. 1.56 The Role of Other Donors. The main foreign-assisted urban health and nutrition project is the UNICEF-financed Urban Basic Services Program (UBSP). This began as a demonstration project in 1983, and from 1994-98 will move into the cities and municipalities targeted by the proposed IDA project. UBSP has a strong community empowerment focus. It has two main components: direct services, including maternal and child health care, nutrition and control of sexually transmitted diseases; and support services, including pre- school care, adult literacy classes, parenting skills for adolescent girls, and support services for street children. The first of these components is similar to the service delivery component of the proposed IDA-assisted project; however, the UNICEF funds available--US$4.65m for the period 1994-98 for more than 25 cities--are insufficient to meet the needs of the cities targeted for UHNP. 1.57 A smaller health project funded by the Italian government is being implemented in the UHNP cities of Manila, Quezon and Kalookan. US$320,000 budgeted for the two years of the project left to run will be spent on institutional development of the city health offices; training of health personnel and BHWs; and organization of primary health care committees. Further details of both UBSP and the Italian Institutional Support Project are given in Annex 4. - 15 - G. Rationale for Bank Group Involvenent in the Proposed Proect 1.58 The Bank's Country Assistance Strategy for the Philippines revolves around five themes: (a) maintaining the stabilization program; (b) deepening the structural adjustment program; (c) deepening the sectoral reform programs; (d) alleviating poverty; and (e) obtaining greater effectiveness in utilizing existing aid commitments. The proposed project, which is aimed at improving the health and nutrition status of slum-dwellers, among the most disadvantaged people in the Philippines, is a core element of sections (c) and (d) strategy. 1.59 Within that framework, there are four specific rationales for the proposed project. The first is that the project would finance preventive health and nutrition activities which the Government and foreign assistance agencies (other than the Bank) are not financing in the current period of extreme budgetary stringency. As noted above (para 1.15), the urban sams have had an inequitable share of investment in health infrastructure. With continuing growth of the slums, there is every prospect that poverty and ill- health will increase in these areas unless this inequity can be corrected through additional investment. Similarly, without the proposed project, the Government will not have the resources to finance the relatively expensive interventions required to deal with malnutrition. The Bank ie the only source of assistance with adequate resources for such a project. 1.60 Targeting resources as efficiently as possible becomes even more Important during periods of fiscal stringency. The second specific rationale for the proposed project is tha: it will improve the resource targeting systems in use in the health sector, including the introduction of a) new technologies for area-based targeting, based on the use of Geographic Information Systems; and b) the development and application of the concept of reproductive cycle targeting, in which health and nutrition interventions, and scarce worker time, are concentrated on women and children at the most vulnerable points in the reproductive cycle. Efforts under the project to target nutrition interventions tightly on those most in need could also form an important safety-net for the very poor if, as is currently under discussion, the Government decides to scale back food subsidies financed by the National Food Authority. Evidence from other countries suggests that targeted nutrition programs of the type to be tested under the proposed project can have a greater impact on nutrition outcomes than generalized subsidies which cost many times as much. 1.61 The proposed project will also be the first to be Implemented in the social sectors after enactment of the Local Government Code. Bank Group support at this time will assist both central and local government to address the redesign of health service management systems required by devolution. Also, foreign assistance resources will be among the limited financial resources left under the control of the central DOH after devolution, and it will be essential for such resources to be used to maximum effect to a) redress inequities which will arise for those local governments whose own- plus-devolved resources do not match the scale of their slum health and nutrition problems; and b) to catalyze additional spending on slum health by local governments, through the provision of matching grants. The third * 16 - specific rationale for the proposed project is that it provides a timely vehicle for the Bank to assist the Government both financially and intellectually in implementing devolution in ways which will have the most positive impact on the poor. 1.62 Finally, preparation of the proposed project is Lelping to lay the foundations for implementation of improved targeting methods and devolved service delivery on a national scale in later projects. Most immediately, this would be in the Government's proposed Women's Health and Safe Motherhood Project in 1995; and then in the proposed Child Development Project, tentatively planned for 1996. Preparatory studies for the Women's Health Project have already been carried out (para 1.52). During negotiations, the Government provided assurances that by December 31, 1994 a study on pre-school child development in the Philippines would have been carried out under terms of reference satisfactory to IDA. II. THE _PROJEC A. Proiect Goals and Obiectives 2.1 The project would have four broad, qualitative goals in the areas of health and nutrition impact, institutional development, community self- reliance, and policy and research, as follows: (a) to improve the health and nutrition status of slum- dwellers in the project cities; (b) to build the capacity of city and municipal governments to plan, finance and Implement cost-effective slum health and nutrition programs, in partnership with communities, NGOs and the DOH; (c) to help slum communities to identify their own health, nutrition and environmental problems and participate in planning, Implementing and monitoring appropriate interventions; and (d) to help DON develop policies and strategies which would improve the outreach and cost-effectiveness of health and nutrition delivery systems. 2.2 Annex 5 contains a detailed set of specific objectives agreed with DOH during project preparation, related to each major project intervention. The annex notes in each case whether the objective is a process, intermediate outcome, or impact one, depending on what is most appropriate and feasible to measure; and whether progress toward the objective would be measured through the collection of service statistics and reports, or through intermittent sample surveys. Of these objectives, progress towards six would be monitored on a priority basis in the early years of the project, because they focus on - 17 - critical areas and because measurable change can be expected with4n 2-3 years of implementation if the project strategy proceeds as planned. These would be: (a) registration of 90% of pregnant women for counselling and services by the end of the first trimester of pregnancy; (b) distribution of iron tablets against anaemia to 100% of registered pregnant women throughout at least the last four months of pregnancy; (c) availability of a full range of family planning services at project area health facilities; (d) growth monitoring of 90% of children in at least nine out of their twelve first months of life, with related nutrition counselling for mothers, (a) reduction by 25% in the incidence of pneumonias (acute lower respiratory infections) in the 0-2 year old population; (f) a short course chemotherapy compliance/completion rate of 80% for sputum-positive TB cases. B. Geographic Scoe 2.3 The scope of the project was defined in two stages. First, the project cities were chosen: Metro-Manila and Metro-Cebu as the Philippines' two largest urban areas, containing the country's largest slum populations; and Cagayan de Oro because of the rapid rate at which its urban problems are compounding, and the local government's very limited resources for dealing with them. The situation of Cagayan de Oro provides an opportunity to address slum health problems before they reach the extreme levels found in the two major metropolitan areas. Taken together, the project cities contain over 70% of the slum population of the country. 2.4 In a second stage of geographic targetin&, within the target cities project-financed outreach services would focus on disadvantaged groups living in slums, so as to make most equitable use of project resources. This target population vas identified by extensive ocular surveys during preparation, covered 401 of the target cities, which made it possible in these areas to identify the geographic locations of slums, their population size, and the type of slum settlement. Identifying these groups on a geographic basis was felt to be more appropriate than adopting an income criterion for targeting, since incomes are difficult to establish, and income by itself does not capture the full range of factors defining poverty, which relates also to environmental conditions and access to services. Annex 6 details the field survey methodology used, and the typology of slum communities which emerged. 2.5 The findings of these surveys were used to estimate the numbers of slum-dwellers in the rest of the target cities. These estimates will be . 18 - refined through further surveys to be undertaken before project effectiveness. Based on the estimates available at the time of appraisal, the target population of the project would be just over four million in Metro-Manila, just over 500,000 in Metro-Cebu, and just over 100,000 in Cagayan de Oro. The project would therefore benefit about 4.6 million slum-dwellers out of a total urban population in the three cities of about 9.2 million. Annex 1 gives breakdowns of the current target populations by city and municipality, and a forecast of the projected populations over the life of the proposed project. C. strata 2.6 The project would adopt four main strategies to achieve the above goals: a) increase resource flows for primary health and nutrition services in the slums and target these resources more tightly on priority interventions and clients; b) use training, technical assistance and selective financial support to strengthen the capacity of city and municipal health offices in their new role after devolution to plan, manage, finance and improve the quality of slum health and nutrition services; c) build on the experience of existing projects and programs, including the on-going Health Development Project, with mobilizing communities through the development of community health partnerships with local governments and NGOs; and d) finance research to test alternative strategies for service delivery in urban slum areas. 2.7 Increasing and targetin; exoenditures. Project funds would be used to improve the ratio of health facilities and health staff to slum populations, and to support incremental recurrent expenditures targeted (i) on the highest priority interventions, (11) on the areas and people at greatest health risk, and (iii) on the points in the reproductive cycle when women and children are most vulnerable to death, disease or malnutrition. This prioritizing and targeting would be carried out as follows. 2.8 Scarce worker time and recurrent budgets would be concentrated on a limited number of priority interventions almed at the most important diseases and hazards in the slums, and chosen on the basis of their cost-effectiveness. They include ante-natal and post-natal care; safe birth practices; family planning; immunization; control of diarrhea, acute respiratory infection, TB and sexually transmitted disease; prophylaxis against micro-nutrient deficiencies; growth monitoring, counselling and supplementation to prevent and treat PEK among pregnant women and young children; and control of environmental hazards such as refuse and excreta in streets and water sources. - 19 - 2.9 Geographic Information System technology would be used to identify the plum areas at &Zatest health risk, a task on which a start has already been made under the Health Development Project. This technology allows different data sets for demography, epidemiology and environmental health risk to be transposed from table to geographic map form and overlaid on each other, so as to identify high risk areas with population groups where several risk factors combine. Project resources for health infrastructure strengthening would be targeted on these areas as first priority, so as to maximize efficiency and equity. In adition, several of the priority health interventions would be targeted on an area basis, especially those for TB (particularly prevalent in high population density areas) and sexually transmitted diseases (particularly prevalent in red light areas). 2.10 The majority of MCH interventions under the project would be targeted on pregnant and lactating women and young children during their most vulnerable periods in the reproductive cycle. Following this reproductive cycle targeting, which is new to the Philippines, the project would aim to focus outreach services on picking up mothers for registration within their first trimester of pregnancy and following them and their children, with appropriate counselling and interventions, through the child's fifth year. Annex 7 gives details of the specific interventions and the points at which they would be made available during the reproductive cycle. This approach would increase service efficiency and equity by concentrating scarce worker time on high risk clients at the most vulnerable periods in their lives. It would also help to build a continuing relationship between client and service provider which would do more to build clients' capacity for self and family care than is possible through the current approach of unsystematic service encounters. 2.11 Health and clinical family planning services for non-pregnant reproductive age women would be made available on a self-referral or s]- targgting basis at local health centers, whose capacity would be strengthened under the project. These health centers would provide a small number of project interventions, such as those for the clinical contraceptive methods and sexually transmitted diseases, which cannot be delivered on an outreach basis. Clients needing these interventions would be counselled by outreach workers about the services available to them at the nearest health facility. 2.12 Strengthening management and financing cavacity in the cities. Success of the above efforts will depend on whether the city and municipal governments which will control plans and budgets following devolution will have a) the managerial capacity, b) the political commitment and c) the funds to run effective slum health services. The strategy would be to use project resources to build a new relationship between DOH and local governments in which DOH would move from a controlling role to a support and assistance role. Through DOH, the project would strengthen managerial caacity at the local level. The proposed interventions are detailed in the description of the Institutional Development component (paras 2.24-2.36). 2.13 But local governments must have the will as well as the ability to allocate resources to deal with the health and nutrition problems of the poor. One risk is that some local governments will give low priority in their - 20 - budgets to health, or will allocate health resources more to curative hospital care than to public health interventions. The project strategy to build political commitment in this area would be to increase demand from communities for better services, and to offer matching grants from the central DOH as an incentive for local governments to make appropriate allocations of their own resources. Finally, as noted in para 1.16, some local government jurisdictions with high population densities or rapid infmigration will not benefit from the Local Government Code's devolution of funds formula in proportion to their numbers of poor clients. The project strategy would therefore be to allocate project central funds, whose distribution would remain at the discretion of DOH, not only to match local contributions, but so as to redress such inequities. 2.14 Building community involvement and self-reliance would be an important project objective for several reasons. Building community awareness of health, nutrition and environmental problems would be the first step in increasing demand for services; and building community organizations able to act as effective advocacy groups would help ensure that local governments allocate enough resources to the slums. Second, actively involved communities can help identify and prioritize local problems; can ensure that the design of services meets their needs; can take an active part in service delivery and education, extending the effectiveness of health workers; and can help monitor service quality. Third, building community capacity and self-reliance is a development goal in itself, and would be essential for sustaining program services and benefits after the end of the proposed project. 2.15 The project strategy for building community involvement and self- reliance would have three thrusts. First, the project would support the Government's strategy of using community health volunteers as partners of paid service providers in the provision of IEC and some basic services. This would involve increasing the number of active community workers to the Government's target ratio of one for every 50 slum households, the provision of basic equipment and supplies, and their training and support by local health center staff or NGOs. In view of the uncertainties surrounding the workload which volunteers can effectively undertake (para 1.19), a functional task analysis of mid-wife and BHW tasks would be undertaken during the first half of the project under the policy research component (para 2.44). 2.16 Second, the project would further develop and extend to the urban slums the concept of community health partnerships between community groups, local governments and NGOs which is being successfully pioneered in the Health Development Project. In this concept, communities are shown how to assess their own health, nutrition and environmental status. plan interventions jointly with government and non-government sectors, take part in implementation, and monitor progress. Geographic Information System technology would be used in this process as a communication device to inform communities about their health and environmental risks and mobilize their involvement. Details of this approach are given in the description of the Community Health Partnership component (paras 2.37-2.41). 2.17 Third, funds would also be available under the Community Health Partnership component to extend and test on a larger scale in eacheity the - 21 - concept of $community trust groups' developed under the UNICEF-assisted Urban Basic Services Project (para 1.56). These volunteer groups of women, with minimal financial support from government or an NGO, assist working mothers by providing day care services and child development activities in the home of a group member. A similar approach is being financed by the Bank in Colombia under the Community Child Care and Nutrition Project (Report No. 8028-CO, 1990). 2.18 Operations research. The most cost-effective strategies for reaching slum communities are unclear in the case of several interventions. particularly environmental health, nutrition, and some women's health interventions. In these areas, detailed under the Policy Research component (paras 2.42-2.49), the project strategy would be to support operations research to test alternative service delivery strategies. By the time of the proposed project midterm review, there should be sufficient experience for the Government to determine whether they have implications for changes in health policies or strategies, and which approaches would be worth financing on a larger scale during the second half of the project. 2.19 Links with GOP/Bank human and urban dev.1onment strategies. The proposed project strategy directly supports the aims of the OP Medium Term Plan to meet the population's basic needs and target the most disadvantaged. The participative approach proposed under the Community Partnership component would also support the Plan's community empowerment thrust. The proposed project would also directly support the Bank's country strategy objectives of assisting in poverty alleviation, human resource development and family planning; and the Bank's two related priorities of using processes which foster community and O participation, and of promoting the role of women in development. In the absence of clearly defined urban health development strategies, the project would a) support the creation of a new Urban Health Technical Service within DOH, responsible for defining urban health policies and programs; and b) test out slum health improvement strategies which might be replicable outside the project area. D. Prolect Descrition Component One: Service Delivery (USS51.6 million) 2.20 The project would aim to increase the range and outreach of key services, tighten their targeting on priority clients, and improve their quality. Project strategies to improve targeting were described in the previous section. Project interventions to improve service quality through training, monitoring and managerial improvements are described under the Institutional Development component. The service delivery component would focus on increasing the range and outreach of service interventions as follows. 2.21 The priority interventions to be delivered under this component were summarized in para 2.8. Targets and indicators for each intervention are given in Annex 5. For most of these interventions, the technical approaches are already well established in the national health program, and existing protocols would be followed. But in the case of protein energy malnutrition - 22 - interventions, alternative approaches to service delivery would be tested under the Policy Research component (see para 2.46), and then implemented project-wide under the Service Delivery component after the midterm review. Certain women's health interventions, such as those for sexually transmitted disease screening and treatment and selected cervical and breast cancer screening, woulA also initially be implemented on an operations research basis. 2.22 Service delivery would follow the existing structure of clinic facilities and outreach arrangements; however, additional facilities and staff would be provided to fill gaps in the network as described below. The service delivery component would finance in each of the three cities: (a) Salaries of additional doctors, dentists, public health nurses, public health midwives, medical technicians, nutritionists and sanitary inspectors. Annex 8 shows the estimated numbers and costs of additional workers to be financed under the project; (b) construction and equipping of about 55 new Health Centers, Health Stations and Lying-in Maternity Clinics; replanning and upgrading of about 57 existing clinical facilities of the above types in under-serviced areas; the cost of building maintenance for these facilities; and the cost of consultant services for preparation of plans, specifications and estimates, contract documents, and for construction supervision. Annex 9 gives details on the guidelines for facility development. A more detailed description of this component is available in the implementation volume. This accompanying project implementation volume contains a detailed list of the facilities included in the project by location, type of equipment Improvement, schematic drawings, and costing criteria. The Memoranda of Agreement (para 4.12) to be signed with Local Government Units would stipulate that facilities to be constructed should be on land already owned by the Government; that agreed criteria would be followed to ensure that facilities to be built or upgraded would be accessible to project beneficiaries; and that staff and budget should be earmarked by the local government unit (LOU) for building maintenance; (c) procurement and distribution of equipment and materials for out-patient consultation, referral services and the management and monitoring of service performance at the above types of facility in the project area, together with equipment and materials for outreach services. Equipment and materials lists and costs for a typical newly established facility and outreach service of each type are given in Annex 10. In existing facilities and community health services, the project would finance replacement of missing or unserviceable equipment and materials, as determined by the baseline equipment survey; (d) procurement and distribution of contraceptives, of drugs and related supplies for the project health interventions, and of vitamin and mineral supplements for the project micro*nutrient * 23 * Interventions for target clients. Annex 10 gives the contraceptive mix on which initial budget were based; this will be revised in the light of implementation experience. Annex 10 details the main types of drugs and food and icro-nutrient supplements to be procured under the project; and (e) procurement and distribution of a new, cereal-based calorie supplement for (I) an estimated 30% of pregnant women at risk of having a low birth weight baby, and (ii) an estimated 30% of 6-24 month old children whose growth is faltering or who are severely or moderately malnourished, defined according to the NCHS reference standard. Component Two: Institutional Development (USS14.5 million) 2.23 This component would support improvements in the capacity of the 21 city and municipal health departments to plan, manage, finance, Implement and evaluate their public health programs. In indirect support of this objective, the component would also strengthen the capacity of the central, regional and district levels of DOH to provide technical assistance, training, communications and logistical support to these units. The main items to be financed would include construction, restoration and equipping of administrative and training facilities, communications and information hardware and software, equipment, vehicles for field units, planning seminars, staff training, technical assistance, project staff on contract, materials and incremental operating costs. Activities in six areas would be supported as follows. 2.24 Management Systems Improvement. The project would strengthen management of the three Regional and four District DOH Health Offices and the 21 city and municipal health offices covered by the project by developing, testing and implementing administrative systems for: (i) personnel, (ii) budgeting and financial management, (iii) facilities and equipment inventory and maintenance, (iv) logistics and procurement. (v) accounting and (vi) health information systems. In each of these areas, new procedures, systems and manuals will be required to Implement the increased responsibilities given to local government units after devolution. Technical assistance would be provided for organizational and systems analysis, systems development, training and implementation. Particular attention would be paid to modifying the health information system consistent with the reproductive cycle and other targeting strategies outlined in paras 2.7-2.11, and to institutionalizing the CIS community health risk assessment and monitoring system (para 2.9) in each health office. 2.25 Technical assistance would also be provided to improve the overall management information system, Including information for all six management sub-systems referred to above. To Improve the sharing of information within and among the DOH, city and municipal health departments, NGOs and the communities, the project would support the establishment of a metropolitan wide information network for communication and management linking all parties involved in the proposed project. The system would include the use of word processing, spreadsheet, data-based management, project management, CIS, - 24 - presentation and communication software. Where telephone modem links are inadequate, packet radio-computer networking would be used; this technology combines two-way radios and computers, allowing error-free exchange of printed data. The system would be capable of communicating field health risk and epidemiological surveillance data, health information system (HIS) and management information system (MIS) data, and financial management information, including budget, procurement and expenditure data. The network would permit horizontal communication and rapid aggregation and analysis of data. And it would help DOH. to communicate policy, research, technical, and educational information requiring frequent and timely dissemination. 2.26 The project would strengthen these information systems through the acquisition and installation of about 70 microcomputers, communication and networking equipment, software and supplies. These computers would be installed in the various city and municipal units and linked with the DOH HIS/MIS through the network system. Technical assistance would be provided in the initial years of implementation including customizing local systems, networking, production of manuals and HIS/MIS forms and staff training. 2.27 Plannin; and Evaluation. Each city and municipality included in the project would be required to develop an annual area-specific strategic plan for targeting services to the poor communities, following the area-based planning process developed prior to devolution and supported under the on- going Health Development Project. The project would provide technical assistance to the local governments in the development of the plans. To implement the planning process, a series of area specific planning seminars would be held using the GIS community risk assessment methodology. The project would provide microcomputers, software, technical assistance, training, staff and operating costs to carry out these activities. 2.28 The project would also support improvements in the local governments' and DOH's program evaluation capabilities. Technical assistance would be provided for the design and implementation of the proposed baseline surveys, mid-term review and end-of-project surveys (para 4.23). 2.29 TrainIng. The training sub-component would finance both the re- orientation and in-service training of health managers, staff and opinion leaders in the project area, and the introduction of new training technologies. With regard to the former, the following types of training would be supported by the project: (a) technical and implementation skills training for all levels of health workers and NGOs; (b) orientation training for political and local community leaders on their health and nutrition situation and the programs and approaches available under the project to address them; and (c) management training in planning, budgeting, logistics, personnel, financial and information management, and research, monitoring and evaluation systems. Details of the number of staff to be trained and the course types and numbers are given in Annex 11. 2.30 With regard to new training approaches, training would, over the span of the project, shift from traditional classroom settings to individual and local need-based training using modern information technologies. The project would finance the introduction of desk-top publishing in each health - 25 - office to produce better print materials and presentation graphics. The project would finance the expansion and improvement of video-based training through (a) expanding and standardizing video equipment and formats; (b) converting existing video and film to a standard format with duplication capability in different formats; and (c) acquiring off-the-shelf video training materials relevant to the Philippine situation. In addition, the project would support the organization and development of a DOH video production unit utilizing new low cost desktop video production techniques. 2.31 Over the life of the project, interactive multi-media technology would be introduced, and its cost-effectiveness for the training of health workers evaluated. The telephone and computer network capability described in para 2.25 would initially be used to allow trainers and trainees to interact through televriters and interactive computers. A second stage of experimentation would involve upgrading the installed base of IBM compatible PC computers to a multi-media PC and videodisc capability. This would allow the purchase and use of the rapidly increasing number of off-the-shelf health and medical training programs, scientific journals and bibliographic data bases available on computer disk and video disk. A later stage would be the experimental development and evaluation of an interactive compact or laser disk by the DOH and the introduction of self-instructional interactive training stations in the city and district health offices. 2.32 For the above purposes, the project would finance equipment and software, including desktop publishing, video cameras, editing and portable players, videodiscs, systems, desktop audiovisual production and editing units, upgrades and supplies. Technical assistance would be provided to help develop the prototype materials, and new staff would be added, including instructional and production designers, a layout artist, a desktop publishing technician, video specialists, feature writers, and a computer technician. Both the above staff and equipment would be multi-purpose, in that they would also be used for the design, production and dissemination of communications materials under the information, education and communication sub-component (see below). 2.33 Information. ducation and Communications (IEC). The aims of the IEC sub-component would be to: a) strengthen the role of the Public Information and Health Education Service (PIHES) of the DOH as manager of IEC activities of the DOH; b) develop and implement a strategic IEC plan supportive of project activities; and c) institutionalize regular qualitative monitoring and evaluation of IEC activities, to ensure that the IEC strategy is continuously updated to meet clients' needs. A social marketing approach would be followed, with special emphasis on qualitative research, segmentation of the client market, and coordination of IEC activities with those of service delivery. Institutionally, the aim would be to make best use of the comparative advantage of government, NGO and commercial private organizations to implement different parts of the IEC strategy, with PIKES acting as contractor as much as implementor of sub-component activities. Further details of the strategy to be followed are given in Annex 12. 2.34 To strengthen PIHES* capacity, the project would finance foreign and local technical assistance and training, equipment and software, including * 26 - equipment and software for the development of a multi-media IEC and training materials design and production center (see paras 2.31-32). To develop and implement a strategic IEC plan, the project would finance a review of existing IEC plans, skills, materials and production resources; formative research among project clients; workshops for strategy development; materials development for inter-personal and mass media activities; and workshops and training for health staff at central, regional and LGU levels and for opinion leaders in client communities. To develop a "learning process" approach to IEC strategy monitoring, evaluation and refinement, the project would finance qualitative research among different client market segments, and annual, midterm and final IEC strategy reviews as part of the planned overall project implementation reviews. 2.35 Administrative and Training Infrastructure. Based on the survey of facilities coverage and suitability carried out during project preparation, the project would finance construction, upgrading, renovation and maintenance of the following administrative and training facilities: a) construction of one Regional Health cum Training Office for the NCR, including residential accommodation for about 100 persons; and b) upgrading of eleven city and district health offices, which would include office space, training space, and storage space for equipment, medical and nutrition supplies. 2.36 Proect Management and Coordination. The project would finance project management and coordination activities. Office equipment and three microcomputers would be provided, as would two passenger vans and one sedan. Management skills in project coordination would be upgraded through the provision of technical assistance, and contract staff would be hired for the life of the project, including a project coordinator, a project monitor analyst, four project staff assistants, a project accountant and a project secretary (this staffing plan is subject to possible revision at negotiations (see para 4.7)). Details of project management arrangements are given in paras 4.8-4.11 and Annex 13. Comonent Three: Community Partnerships for Health (USS4.9m) 2.37 This component would support community mobilization and community- based service delivery activities aimed at improving the health and nutrition of the urban poor. The underlying objective would be to give urban slum communities more control over their health and nutrition status. Following the strategy described in paras 2.14-2.17, the component would finance five categories of activity, details of which are given in Annex 14. 2.38 First, the component would finance development of city or municipal institutional infrastructure for community mobilization, including a) recruitment and training of community health volunteers who would work in partnership with the publicly operated service delivery network; b) provision of grants for the institutional development of qualifying NGOs, to strengthen their capacity to mobilize communities and provide health and nutrition services in the slums; and c) the establishment and maintenance of consultative fora and information networks involving all groups, government and non-government, with an interest and involvement in the health of the urban poor. These fora would be used as vehicles for orientation, advocacy, - 27 - training and education of the groups collaborating in community development. In areas where the UNICEF Urban Basic Services Program has been implemented, the structures and processes necessary for community mobilization already exist, and the project will utilize these wherever possible. 2.39 Second, the component would finance small planning grants in support of an organized process of community assessment, sub-project identification and sub-project development focusing on urban health issues. The area-based health planning methodology currently used by the DON would be the basis of this assessment and planning process, and the approach would also build on the experience with planning grants under the on-going Health Development Project. Third, the component would finance the implementation of community health care initiatives by making grants to non-government organizations, people's organizations and private sector providers to implement sub-projects generated by the planning process. These initiatives would include expansion of the community trust group concept described in para 2.17. 2.40 Fourth, the component would finance implementation by interested LGUs, NGOs and communities of specified high priority interventions in the areas of environmental sanitation, growth promotion, food and nutrition supplementation, maternal and child health care, and child day care through local women's groups, in particularly disadvantaged slums. These technical packages would be developed and promoted by DON to organized groups in the community. 2.41 Finally, the component would finance assistance from the Central and Regional offices of DON for the above processes, including a) additional staff to coordinate the program; b) technical assistance in the development of process guidelines and in project design and preparation; c) monitoring of sub-project grant administration by the LOU; d) sub-project evaluation for health impact, community acceptance, and sustainability, including feedback into DO's and LOUs community mobilization policies and programs. Two additional staff would also be financed in each participating city and municipal health office to help coordinate all the above activities. Comonent Four: Policg Research and Evaluation (US84.0m) 2.42 This component would support policy and operational research studies related to the implementation of project objectives and the evaluation of project progress. The main focus would be on testing alternative service delivery models to find those which are most cost-effective in the urban slum environment. The component would finance the following specific studies identified at the time of appraisal; funds would also be left unallocated under the component to address research needs identified during the course of project implementation. 2.43 Baseline Surve and Annual and Kid-Term Evaluations. During the first six months of implementation, an initial base-line study of health and nutrition conditions in the targeted slum communities would be carried out. This study would be preceded by completion in all the IAUs of the ocular survey identifying the clusters of slum households to be targeted (paras 2.4- - 28 - 2.5). The base-line study would include a multi-variate health risk assessment of the client population covering: (a) the epidemiologic, environmental, nutrition, and fertility status and risks; (b) service coverage, availability and accessibility; and (c) land tenure, demographic. social and educational status, and community organization. The study would use both quantitative and qualitative methodologies. Annual evaluations would track progress in selected indicators surveyed in the baseline study. Midterm and end-of-project evaluations would review progress toward achieving all project targets. In all these reviews and evaluations a particular effort would be made to seek feedback from project beneficiaries. 2.44 Workload and Work Routines. Staffing arrangements for service delivery at the periphery were planned on the basis of one mid-wife per 5,000 alum population and one BMW per 50 households. It is unclear whether these ratios are the most cost-effective for delivering the enhanced package of services proposed under the project. Therefore a functional task analysis of workers' jobs and work routines would be carried out during the second year of the project to determine whether the division of tasks or the ratio of workers to clients or workers to supervisors should be altered. Additional operations research on this topic would be carried out for nutrition services (para 2.46). 2.45 Women's Health. Operational research on women's health issues is initially proposed in the following areas: a) how best to iJentify women who are newly pregnant or who have unmet demand for family planning, and hence are in need of services; b) how best to integrate the various women's health interventions in the field, especially integration of maternal care and family planning, and the management of obstetric referrals from the outreach to the fixed facility system; and c) determination of the prevalence of STDs including AIDS in the non-high risk female population, and how best to manage them. See Annex 15 for research issues. 2.46 Nutrition. Four research activities are initially proposed in this area. First, the most cost-effective operational procedures for preventing and treating protein-energy malnutrition among pregnant women and children (see also para 1.21) are uncertain. In particular, growth monitoring, counselling and supplementary feeding are time-consuming and difficult, and it is unclear whether volunteer workers will implement them effectively. Therefore, operations research would be carried out on two different approaches: a) through volunteer Barangay Health Workers, and b) through paid community workers; both would work with organized 'trust groups' of women providing day care for children in the program. 2.47 Second, operations research would also be carried out on amylaze enrichment of food supplements to increase the volume consumable by very young children, who otherwise may not be able to absorb enough nutrients to get out of malnutrition. Third, universal supplementation of infants with iron is extremely expensive. It may be more cost-effective to limit this to low birth weight infants, protecting other infants instead by supplementing pregnant women and getting them to feed their infants weaning foods rich in iron. The relative cost-effectiveness of the two approaches would be compared through operations research. Fourth, improving breast-feeding and weaning practices - 29 - through counselling will be a key project nutrition intervention. Qualitative research on alum women's beliefs and practices regarding infant feeding would be undertaken, so as to provide a better basis for designing IEC messages. 2.48 Details of each of these proposals, together with a summary of on- going nutrition operations research studies relevant to thA project, are given in Annex 16. 2.49 Communty Environment DvloMnt. This study would examine alternative approaches to implementing alum environmental heelth improvements. During preparation, technical interventions to improve community water, sewage, solid and toxic waste, drainage, food vending, and rodent control systems were identified (see Annex 17). Slum communities were classified into six types and, based on environmental surveys also conducted during preparation, 87 communities representing a complete range of environmental problems were selected to study alternative implementation approaches. The study would attempt to match appropriate mixes of technical interventions to particular community types and problems. The most promising approaches would be identified for replication on a larger scale after the project mid term review. III. PROJECT COSTS. FINANCING. PROCUREMENT AND DISBURSEMENTS A. Cost Estimates 3.1 Summary of Project Costs. The total cost of the project is estimated to be US$82.2 million equivalent, including contingencies and net of duties and taxes. Foreign exchange costs account for US$24.0 million, or 29% of project costs. A summary of costs by project component is given in Table 3.1 and by category of expenditure in Table 3.2. Cost breakdowns by component category of expenditure and project year are provided in Annex 18. 3.2 Contingey Allowancs. Project costs include a contingency allowance for unforeseen physical additions (US$1.9 million equivalent and for inflation US$5.4 million equivalent). Physical contingencies are estimated at 3% of base costs. Following IDA regional guidelines, price contingencies are based on the following inflation factors: for foreign costs, 3.1% for the project years 1994-1998, and for local costs, 71 for each of the five project years. Price contingencies are equal to 7% of base costs plus physical contingencies. 3.3 Foreign Exchan e Costs. Direct and indirect foreign exchange costs are estimated at US$24.0 million equivalent, or about 29% of total project costs, including contingencies. The estimated foreign exchange component for the various expenditure categories are as follows: 100% for foreign technical assistance, contraceptives and =icronutrients; 95% for vehicles; 90% for drugs and chemicals; 75% for equipment; 30% for civil works, materials and other operating costs; and 20% for local technical assistance. - 30 - 3.4 Incremental Recurrent Costs. Project cost estimates include a significant level of incremental recurrent costs, representing the greater numbers of technical staff and community volunteers, and medical and other supplies needed to achieve project goals. Specific incremental recurrent costs include: (a) contraceptives, drugs and chemicals needed for service delivery expansion; (b) food supplements and micronutrients to treat malnourished pregnant women and 6-24 month old children; (c) materials needed for health services delivery and institutional development; (d) salaries for regular and contract health staff; (e) travel costs for incremental staff, maintenance and other operating costs for refurbished buildings, equipment and vehicles; and (f) community volunteer contributions of time and labor. - 31- *saj g 's -9na ••- •• - - sn i- 'R-MR2 :' ; 2 1 'fb'' 11: §Relk i a gn *ER q4 9. n0 N q-% I sleg di g a W E* 080 " 00~0* 0 0 0lada- -32- &＀扼――。＼-,/- 33 - B. FLUML85 3.5 The total projects costs of US$82.2 million equivalent would be financed by: (a) an IDA credit of US$70.0 million equivalent, representing 85% of total project cost; (b) a cofivancing grant of US$3.1 million equivalent from the Goverment of Australia, representing 4% of total project cost; and (c) local financing of TJS$9.1 million, equivalent, representing 11% of total project cost. The local financing includes community volunteer contributions of US$0.4 million equivalent. Project financing would be In accordance with Table 3.3 below. TAUS 3.3: FINMING PLAN (Amounts In US$ million, including contingencies) Expenditure Category Local a/ Australia IDA Total Estimated Share of IDA financing Civil Works 9.5 9.5 100 Equipment 1.0 3.0 4.0 75 Furniture - 0.1 0.1 100 Vehicles 0.8 0.8 100 Training 0.3 2.0 2.3 87 Technical assistance 0.4 5.2 5.6 93 Grants b/ 7.2 7.2 100 Contraceptives 3.8 3.8 100 Food supplements - 8.3 8.3 l%0O Micronutrients - 2.5 2.5 100 Drugs and chemicals - 6.1 6.1 100 Materials - 1.0 6.0 7.0 86 Staff salaries 6.0 - 3.3 9.3 35 Contract salaries 2.7 - 3.2 5.9 54 Travel 1.1 1.1 100 Community volunteers 0.4 - 0.4 0 Maintenance - 3.8 3.8 100 Other operating cost 0.4 4.1 4.5 91 Total Project Cost 9.1 3.1 70.0 82.2 85 Government financing and local commmity contributions. Community development grants to NGO& and euviromental health grants to LGUs under Components III and IV would be made by the concerned local government. C. ProMment 3.6 The procurement responsibilities for the project would be carried out by the-pentral DOH, and by the 21 local goverment units included in the proj ect'-4 , I., th4,k procurement &ZraugMentS are outlined in Table 3.4. - 34 - Table 3.4: PROECT COSTS BY PROMEMENT ARANGEMERTS (US$ million) Total Cost Procurement Method (nhdino Expenditure Category ICB LCB OtherW N.I.F. contloomies) 1. woks - 9.5 - * 9.5 (9.5) (9.5) 2. 2godg 2.1 Drugs, Chemicals, 9.9 6.0 4.8 hI . 20.7 Contraceptives, food (9.9) (6.0) (4.8) (20.7) supplements and micronutrients 2.2 Equipment, furniture, 3.9 4.0 2.0 2.0 11.9 vehicles and materials (3.9) (4.0) (2.0) (9.9) 3. Grantal1 - - 7.2 - 7.2 (7.2) - (7.2) 4. nsltanLes/Service 4.1 Training and technical - - 7.29' 0.7 7.9 assistance (7.2) (7.2) 5. Miscellaneoua 5.1 Contract and staff salaries, * - 15.6 - 15.6 community volunteerst/ (6.5) (6.5) 5.2 Travel, maintenance and 9.0 9.4 other operating costs * * (9.0) 0.4 (9.0) Igtalm.L A5A 3 -/ (13.8) (19.5) (36.7) (70.0) N.I.F.: Not IDA financed. Figures in parentheses are the amounts to be financed by the IDA Credit. m/ Shopping, unless otherwise noted. h/ As estimated US*2.5 million would be procured through Limited International Bidding or direct procurement. g/ Community development grants to NGOs and environmental health grants to LOUs under Components III and IV would be made by the concerned local government units. 4/ Technical support for the implementation of management services, training and I.E.C. ./ Time and labor provided by community workers. I/ Co-financed by Australian Government on a parallel basis. - 35 - 3.7 Procurement methods for civil works, goods, grants, technical assistance, and incremental salaries and operating costs are described below. Annex 10 contains a more detailed list of items to be procured under each category. (a) CWikwnrks totalling about US$9.5 million equivalent. The new NCR Regional Training and Administrative building (estimated cost, $0.9 million) and the remaining civil works, consisting of about 112 primary-level health facilities and 12 combined administrative/service delivery facilities with an average contract value of about $50,000 each, would be grouped into about 50 contracts and procured through the use of local competitive bidding (LCB) procedures acceptable to IDA. Overall responsibility for procuring civil works would rest with the central DOH Health Infrastructure Service. Standard bid documents would be used by the Public Works staffs of the concerned cities and municipalities, according to specifications prepared by the Health Infrastructure staff. Bid evaluation and award would be carried out by the Public Works staffs of the concerned city or municipality, subject to the approval of the central DOR Health Infrastructure Service. (See para 4.6). About half of the civil works expenditure would be for renovation and/or upgrading of existing buildings. For the limited number of new buildings being constructed, the local government units provided proof of land ownership to the central DOH prior to appraisal. (b) Goods (drugs and chemicals. contraceptives. food supplements. micronutrients. _equinent. furniture. materials and vehicles) totalling about US$30.6 million equivalent will be procured with IDA funds. An additional US$2.0 million equivalent would be parallel cofinanced by the Government of Australia. Goods totalling about US$13.8 million equivalent woule be procured by ICB in accordance with the Bank Procurement Guidelf.es of May 1992. The 15% preference for local manufactured products would apply to ICB. Goods would be grouped to the extent practical to form bid packages estimated to cost US$200,000 or more. Contract packages financed by IDA and valued at less than US$200,000, up to a total of about US$10.0 million, would be awarded through LCB procedures acceptable to IDA. Limited international bidding or direct procurement (of proprietary items) would be authorized for the purchase of drugs, chemicals and contraceptives with single or limited suppliers under the IDA credit, and would total no more than about US$2.5 million. Contract packages valued at less than US$40,000, up to an aggregate limit of US$4.3 million, may be purchased through international or local shopping on the basis of a minimum of three competitive price quotations. (See Annex 10). (c) grnts totalling about US$7.2 million equivalent. These will be awarded through direct subgranting by local government units to local NGOs, in accordance with central DOH guidelines agreed upon with IDA. These guidelines reflect the lessons from a similar * 36 - activity under Component III of the existing Health Development Project (Loan 3099-PH). (4) Consultant services for technical assistance, IEC, and training activities totalling about US$7.2 million equivalent. Contracts would be awarded in accordance with Bank Guidelines for Use of Consultants. Under Component II (Institutional Development), there would be two separate technical asastance packages for (a) management services improvement and (b) IEC and a training materials development center. The consultancy contracts would include supply and installation of the necessary computer hardware and software for each of the 21 LUs, and for DOH central and regional offices. Consultant services of about US$0.7 million equivalent would be parallel cofinanced by the Goverment of Australia. (See Annex 10). (e) Contract and reaular staff salaries of about US$6.5 million equivalent of the total $16.2 million equivalent would be supported according to government administrative procedures acceptable to IDA on a declining basis. (f) Travel, maintenance and other oeratina costs of about US$9.0 million equivalent. These incremental activities and services would be obtained according to government administrative procedures acceptable to IDA. Other operating costs of about US$0.4 million equivalent would be parallel cofinanced by the Government of Australia. 3.8 Procurement review. The following procurement review procedures would apply: (a) By credit effectiveness, IDA will complete a prior review of (i) standard bid documents for civil works and goods contracts to be awarded under ICB and LCB procedures; (ii) letters of invitation for consultant services, to determine their conformity with Bank guidelines. These approved documents would be used as master documents for all future bidding. (b) Except for those in paragraph (c) below, all contracts valued at or over US$200,000 would be subject; to prior review by I"k, whereas contracts under US$200,000 in value would be subject to random post-review; (c) All TOR and contracts for consultants and studies would be subject to prior review by IDA; and (d) Training and workshops would be subject to random post-review by IDA. The authority to carry out local shopping would apply to the DOH central procurement unit and to the recipients of community health development grants as well. Procurement by the Government of Australia would be on a tied basis. - 37 - D. Diabursemes 3.9 The IDA credit of US$70.0 million equivalent would be disbursed over a period of seven years with disbursements to be completed by the closing date of December 31, 2000 (see Annex 19). The disbursement schedule is based on the implementation schedule and the disbursement profile for education projects in the Philippines; there is no separate PHU profile. The disbursement profile is three semesters shorter than the education profile; these estimates are considered feasible In view of the advanced state of project preparation. 3.10 Disbursements would be made against: (a) 1001 of total expenditures for civil works; (b) for drugs and chemicals, contraceptives, equipment, furniture, vehicles, materials, food supplements and micronutrients, 100% of foreign expenditures for directly imported goods, 1001 of local expenditures (ex-factory cost) for locally-manufactured goods, and 851 of local expenditures for other goods procured locally; (c) 100% of total expenditures for grants under the Commmmity Partnership for Health component; (d) 100% of total expenditures for consultancies and services, including foreign and local technical assistance and training; (e) a declining percentage for contract and regular staff salaries as follows - 801 of total expenditures incurred prior to December 31, 1994; 401 for expenditures incurred prior to December 31, 1996; and 20% for the years thereafter; and (f) 100% of total expenditures for travel, maintenance ad other operating costs. Disbursements to be made against the IDA credit are summarized in Table 3.5. Table 5DISMi CER EYpenditure Category Ammt Percentage (1) CIviI Vorks 9.0 100% of total expenditures; (2) Goods (a) Drus and chaicats/ 100X of foreign expenditures; contraceptives 9.0 I 100 of tocal expenditures (b) Equipant/fumiturst > (ex-factory cost); vehictes/asterilets .0 ISS of toca "pnditures (c) Food supptewfnts and I for other tocalLy-procured micromtriants 9.0 items (3) Consultant*s Services 6.5 100K of total expenditures (4) Incramental Operatie 6.0 80 of total expenditures Costs facurred prior to December 31, 1994; 40X of expenditures incurred prior to Deceaiber 31, 1996: and 20X thereafter (5) Commity Partnership 6.5 * 100% of total expenditures Services Rendered as Grants (6) Travet/aintenance and other operatfng costs 8.0 * (7) Unattocated 7.0 IAL t 3.11 Disbursements would be made against Statements of Expenditure for the following: training; community partnership for health planning, - 38 - institutional and project grants; and contracts costing US$200,000 equivalent or less each for equipment, materials, vehicles, drugs, chemicals and contraceptives, furniture, food supplements, staff salaries and contract salaries, travel, maintenance and other operating costs. 3.12 The Government of Australia grant would be made on a parallel basis and would be administered by the Government of Australia. IV. = = ONILM I&Q A. Status of Prolect PreWratio" 4.1 The process of project preparation was overseen by a Technical Committee formed for this purpose by the Secretary, DOR, and including representatives of the DOH technical services concerned with the project, participating LUs, and other central government agencies with a stake in the project. The Technical Committee was assisted by local consultants, financed under Japanese Grant No. 2270-0, who coordinated the details of project preparation. Since Implementation would be the responsibility of the LUs and not the DON, an important part of project preparation was a series of workshops which involved IWUs over an eighteen month period in detailed discussions on project content. The final content of the project is the product of negotiation between LOUs and the regional central offices of DON, and to which all parties appear committed. 4.2 For the first time in a Bank-financed health sector proje-t, Critical Path Management computer software was used during appraisal to identify and plan the timing of key start-up activities in each component and sub-component (see detailed implementation schedules in Annex 20). This joint activity between project managers and the appraisal team increased all parties' understanding of the project; helped to create a shared vision of the project between Bank and Borrower; and ensured that realistic lead-times were planned for start-up activities. Prior to effectiveness, a series of project launch workshops will be held with participating LUs in which the product of this critical path planning will be used to build local understanding of and commitment to the steps required for project start-up. 4.3 Project objectives, strategies and costs have been clearly defined. Sketch plans for civil works have been prepared. An outline procurement plan has been prepared, and a detailed procurement plan would be completed by negotiations, with bid documents for the initial rounds of procurement ready by the time of Board presentation. Draft Memoranda of Agreement (NOAs) between participating goverment agencies have been prepared; these will be a key project management tool (paras 4.12-4.13 and 4.21). (See Annex 21). A staffing plan has been prepared for the project coordination unit (para 4.9), and it is anticipated that additional staff for this unit will be in place by project effectiveness. - 39 - B. Organization. anagement. Financing and Sustainability 4.4 Following devolution of health program implementation responsibilities to local governments, the proposed project would be implemented in a new administrattve environment in which LGUs would play the lead project implementation role. Central government, as Borrower of the IDA credit, would exercise its overall responsibility for project management through its financial control of project grants to LGUs and through MOAs to be entered into by central and local governments and binding the signatories to implement the project as agreed. This section describes in turn the organization and management arrangements at the LGu level, and the organization, management and technical support arrangements for the central and regional levels of DOR; the proposed system of MOAs with LUs; the proposed equity-related criteria for determining financial allocations to the LGUs; plans for ensuring project sustainability; and the arrangements for managing the flow of project funds. 4.5 Local government level. While Implementation strategies would vary in different IGUs, project implementation responsibility at the local level would be centered on the City or Municipal Health Officer, working under the authority of the mayor and local council. He or she would be responsible for coordinating the inputs of central and local goverment departments and NGOs involved in implementation, such as local ublic works units for the implementation of construction (component one), training support from the DOH (component two), or NG0s implementing sub-projects under the proposed community health partnership arrangements (component three). 4.6 LUs would be supported by the DOH Infrastructure Service, who in turn would contract private consultants in accordance with World Bank guidelines to assist in the implementation of civil works activities. The consultants would be responsible for the preparation of contract documents, detailed architectural and engineering plans, technical specifications, estimates and bidding documents based on model plans, schematic plans and outline specifications prepared by the Department of Health. They would appraise the sites or existing facilities and assist the local authority in the bidding process. In addition, they would provide construction supervision including time and cost control. 4.7 Department of Health. Following the change in government in aid- 1992, the DOH underwent a reoganization whose results are shown in Annex 1. Responsibility for this project would be placed in the Office of Special Programs; this office reports to the Undersecretary and Chief of Staff. 4.8 Project management in the DOH would be vested in the Undersecretary of Health and Chief of Staff, who would also serve as Project Director. He would delegate the coordination of project activities to a Project Coordinator, who has already been informally designated, and who is also the chief of a newly created permanent DOR unit responsible for advising the Chief of Staff on urban health policy and for implementing urban health programs and projects. This dual responsibility would help to ensure that the lessons from project experience were fed into national policy. * 40 - 4.9 Day-to-day coordination of project activities would be the responsibility of a UHNP project coordination unit, which would be an expansion of the existing unit managing the on-going Health Development Project. Its staff would be contracted for the life of the project. During negotiations, the Government agreed: (a) to establish a Project Coordinating Unit (PCU-UHNP) within DOH on terms of reference satisfactory to IDA to be responsible for overall supervision and coordination of project implementation. Establishment of the PCU-UHNP and appointment of the Project Coordinator and qualified staff is a condition of effectiveness; and (b) to maintain the PCU-UHNP throughout project implementation. The project coordination unit would be responsible for consolidating project plans and budgets, monitoring project activities, handling project procurement and disbursements, and preparing project reports and documentation. 4.10 In addition, the chiefs of central DOH units responsible for various technical and functional disciplines would be asked to provide guidelines, training and technical assistance to LGUs, and to implement specific project activities related to their discipline. Annex 13 sets out the central units responsible for technical support to or for managing different components/activities. This technical support role would include assistance to the three regional field offices of DO involved in project implementation (see below). In addition, staff from the relevant central technical units would form a task force to initiate, oversee and sustain the changes required by the reproductive cycle targeting approach, since this method of planning and integrating maternal and child health and nutrition services would substantially alter the service delivery approaches of city and municipal health offices, and would have broader national implications. 4.11 The three regional offices of DOH in NCR, Region VII and Region X, together with the four District Health Offices in Metro-Manila, would be responsible for providing training and technical assistance to the LCUs in their regions under component two; and for interpreting project guidelines at LOU request and for interpreting LGU concerns to the Project Coordinator/Project Director. 4.12 Memoranda of Agreement with MUs. The key legal agreements governing project implementation would be a series of KOAs signed by DOH, the Department of Interior and Local Government (DILG) and the project LGUs, setting out the rights and duties of each signatory; a separate NOA would be drawn up for each participating LOU, based on a common format, a draft of which is attached as Annex 21. Key features of the N0A include a main text setting out the roles and undertakings of the signatories and indicating the financing shares to be contributed by GOP and LGU; and two attachments setting out a) the program interventions and strategies supported by the project which the LGU commits to undertaking over the whole project period; and b) a detailed operational plan and budget for implementing these interventions and strategies for the next financial year. GOP brought to negotiations a standard version NOA, based on the draft agreed at appraisal. It was agreed at negotiations that, following inter-agency consultations within the GOP, the draft MOAs, IAAs and Annexes would be finalized for review by IDA during its next scheduled mission. - 41 - 4.13 Prior to effectiveness, the DOH and the mayor of each participating LGU, with the concurrence of the local council, would negotiate the main text and annexes of their respective MOAs. A condition of credit effectiveness would be that at least 9 of the 21 DOH/LGU/DILG NOAs required under the project would have been entered into with the DOH and become effective. Prior to the DOH budget cycle each financial year, DON and each participating LOU would negotiate an operational plan and budget specific to that LOU and year, in time for incorporation of the plan's resource requirements into both LGU and central budgets. This operational plan, as part of the MOA, would become a binding commitment on the LGU. At negotiations, assurances were given that the Government would provide project funds to participating LGUs on a grant equivalent basis once each LGU had signed its respective MOA. It was also agreed that each MOA would be signed by the DON, DILG and corresponding LOU and that each MOA would include a cost-sharing arrangement acceptable to IDA. 4.14 EaRtv-related financial allocations to LGUs. The amount of assistance from the credit flowing to a given LOU would initially be determined based on an assessment of two considerations: the size and health status of its client population; and the resource base of the LGU in relation to the needs of its population. The groject budet for a given LOU would be based on the standard package of project inputs and the size and needs of the client population. The 1G0 share of that local project budget would depend on its ability to pay. Since the devolution of central health budget resources under the Local Government Code was not in proportion to client populationt., GOP would use credit funds to redress resulting inequities. Thus, for example, GOP would offer to finance a larger share of the local project budget in the case of poor municipalities with very fast growing slum populations than in the case of better off municipalities with slower rates of growth. 4.15 The cost-sharing criteria to be used under the project would be based on the following principles. The cities and municipalities included in the project would be divided into three or four categories depending on the percentage of their likely health budgets in the last year of the project which the incremental operating costs of the project would represent. Estimation of the likely LOU health budget at the end of the project would be based on a) the potential for growth in local revenues over the period; b) the potential for an increase in health's share of local revenues over the period; and c) the increase in non-project central contributions which the LOU can expect during the period under the Local Government Code. Depending on estimated ability to pay, DON would then propose a different cost-share, to be decided at negotiations, for each category of LOU over the life of the project. DOH would seek LGU agreement to this cost-sharing arrangement as part of the MOA negotiations which would take place between credit negotiations and credit effectiveness. However, flexibility would be retained during project Implementation to renegotiate this cost-sharing arrangement in the case of I.Us whose client population increased faster than expected, or where LGU revenues unavoidably grew slower than expected. 4.16 Sustainabilit. Three approaches would be followed to ensure project sustainability. First, the participative approach taken to project preparation (para 4.1) and the resulting commitment to project objectives and - 42 - interventions on the part of LGUs would help to ensure that LUs are interested to continue project services after the credit is disbursed. Second, beneficiary communities would be asked to contribute to project implementation in two ways. Volunteer BWs from slum communities would contribute labor estimated approximately in the project costs at US$0.4 million equivalent. And under the community health partnership component, communities would be involved in defining their health problems and risks and monitoring the success of efforts to respond to them. This increased community involvement and awareness would help to ensure popular demand for sustained budgetary commitments to slum health care on the part of LGUs after the end of the project. 4.17 Third, participating LGUs would be asked to absorb an increasing share of project costs during the life of the project. So as to minimize the difficulty of absorbing the full recurrent costs at the end of the project, each participating LGU would be expected to contribute toward the cost of the project for recurrent rather than capital costs; contributions would begin at a level below the agreed average contribution over the project life (para 4.15) and increase to a level above this average over the life of the project. In addition, some LGUs whose local revenue collections are below potential, or whose health budget share in local revenues is below average, would be expected to increase their local health budgets during the project at a rate faster than their revenues have historically grown. For each category of LGU (para. 4.15), the proposed percentage increase in cost share in each year of the project would be based on 'ability to pay' data; proposed increases in the growth of health budgets would also be decided on an annual basis. As with the total LU cost share, these increases would be agreed between DOH and participating LGUs as part of their MOA negotiations. It should be noted, however, that continuing central subventions for some smaller, poorer LUs with large slum populations are likely to be needed after the project. 4.18 Funds Flow. Because the project's health and nutrition interventions are in the areas of a) preventive primary care, b) curative primary care with high external benefits, and c) operations research, neither Bank nor GOP policy expects their costs to be recovered from project beneficiaries or local governments. Project funds would therefore be provided to the LUs in the form of central government grants, rather than loans. In the case of the environmental sanitation activities financed under the operations research component, a review would be made at midterm of which technologies to replicate on a large scale basis (para 2.49); a decision would be taken at that time, depending on the technologies chosen, whether it would be appropriate to seek cost recovery for these interventions. In the case of the water supply interventions under this component, cost recovery from project clients would be instituted at the outset following current GOP policies. 4.19 Project funds would flow through two administrative channels to CHOs/HOs or NGOs, and thence to project communities. These channels would be: a) the central or regional offices of DON procuring or providing goods or services (for example, items procured centrally and distributed to individual health units, or services procured and provided by the regions such as training; b) local government procuring or providing goods or services (for - 43 - example, hiring midwives, making grants to NGOs, renovating facilities). For each project component and activity, DOH project management would determine the most efficient channel for disbursing project resources, and DON guidelines in this respect would be the basis for preparation by LGUs of annual project operational plans and budgets for negotiation and incorporation into the LCU MOA. 4.20 The DOH Project Coordination Unit would consolidate the project plans and budgets of the individual LOUs, the regional DOH offices, and the central DOH offices assigned to implement various aspects of the project. This consolidated project budget would become a line item in the DOF's Municipal Development Fund budget. Once appropriated, funds would be released by the Department of Budget and Management (DBM) following two tracks. Project funds disbursed by DOH would be released via the established Advice of Allotment/Notice of Cash Allocation procedures. Project funds to be disbursed by local governments would be released without passing through DOH, via the Municipal Development Fund (MDF) administered by the Department of Finance through the Bureau of Treasury. The XDF has proved an effective mechanism for channeling project funds to 1Us under the three on-going Bank-assisted Municipal Development Projects. (See Annex 22). 4.21 An IAA would set out the relationship between the DOR, DOF, DBM, DILG and LGUs with regard to the project's financial management in general and the management of funds releases through the MDF in particular. A draft of this NOA agreed between the appraisal mission and representatives of the concerned agencies is at Annex 21. GOP brought to negotiations a final version of this MOA now being reviewed by all concerned government departments. Signature by the DOB, DOF, DBM, NEDA and DIL of the Inter Agency Agreement governing the release of Credit proceeds directly to each LGU, in accordance with the corresponding MOA, would be a condition of project effectiveness. C. Accounts. Auditing. Reportina and Suoervision 4.22 The DOH and LGU accounting systems are adequate to provide information on project finances and expenditures. The Government would cause DOH and participating LGUs to maintain separate accounts of project expenditures in accordance with sound accounting practices. Proposals from NGOs under the Community Health Partnership Component would include related audit and record-keeping requirements. Each LOU would have its project records and accounts audited no later than four months after the end of the government fiscal year. During negotiations, the Government agreed to provide assurances that audits of LGU and DOE project-related records and accounts would be undertaken in accordance with agreed accounting principles consistently applied, by independent auditors acceptable to IDA, and that audited accounts and financial statements, in a format agreed with the Bank, and including a separate audit of statements of expenditure, would be sent; to the Bank within nine months of the end of each Government fiscal year. The Government also agreed to provide assurances that it would submit semi-annual progress reports to the Bank and prepare, within six months of the Closing Date, a project completion report. Annex 23 provides a detailed description of the IDA Supervision Plan. - 44- D. Monitoring and Evaluation 4.23 The Project Coordination Unit would be responsible for monitoring project implementation and producing quarterly progress reports based on service statistics and other data. The Project Coordinator would be responsible for carrying out an annual review of project implementation progress, and to facilitate an annual progress review workshop. The results of the annual program reviews would form the basis for the annual operational plan and budget prepared by each LGU. During negotiations, the Government agreed to provide assurances that, beginning in fiscal year 1994, the DOH would review the individual LGU yearly NOA implementation programs, and progress achieved in executing project activities by July of each such year. These HOA programs, including a draft aggregated operational plan and related financial budgets, would be reviewed and finalized by October 30 of each of such year. The Government also agreed that not later than the end of each fiscal year, beginning in 1994, IDA and the DOH would review jointly the individual LOU yearly HOA implementation programs (including their respective operational plans and financial budgets), and these programs would take into account IDA comments; and thLz a baseline study of health and nutrition conditions in the targeted slum communities prepared under terms of reference satisfactory to IDA, would be carried out by December 31, 1994. In addition, two separate follow-up studies would be carried out also under terms of reference satisfactory to IDA, not later than December 31, 1996 and December 31, 1999, respectively. 4.24 Different objectives and methodologies would be adopted for performance, process and impact evaluation respectively. Performance evaluation would focus on the annual measurement of the DOH's program outputs with respect to physical accomplishments, financial performance and client satisfaction. It would include a longitudinal client-based analysis of the DOH's performance as well as a quantitative analysis of program indicators. Data for evaluation would be generated from the program HIS and MIS monitoring systems, from surveys, and from ongoing beneficiary analysis. This assessment would be undertaken to assess the overall accomplishments of the project, identify problems and issues, and recommend measures to accelerate activities or redirect efforts to facilitate goal achievement. Management and direction of the performance evaluation would be undertaken through a technical assistance contract with a local university-based or otherwise qualified research group. 4.25 grocess evaluation would examine the approacbes used in service delivery and for community participation, attempt to explain variations in levels of performance despite comparable project inputs, and derive suggestions for improved approaches. Structured interviewing, participant observation and focus group methodologies would be used, with technical assistance to carry them out. This type of evaluation would focus particularly on the reproductive cycle approach to service delivery and on project operations research activities, because of their innovative nature; and on the Community Health Partnership component, because of its participatory nature. Imact evaluation would focus on project impact in terms of morbidity and mortality reductions, improved efficiency of DOH systems, and improvements in equity of access to DOH services. - 45 - V. PROJECT. BENEFITS AND RISKS A. enefita 5.1 The institutional benefits of the proposed project would include a) development of operational models for health and nutrition service delivery and community empowerment in urban slum areas which are potentially replicable in urban areas outside the project; b) testing of innovative approaches to client targeting (especially the reproductive cycle targeting approach and the GIS-linked area targeting approach), to training and communication methodologies and to nutrition service delivery which have potential applications on a national scale; c) building DOB's capacity to fulfil its new role after devolution of providing support to rather than management of the health departments of local governments; d) testing approaches for managing the relationship between DOH and local governments which have potential applications on a national scale (especially the proposed system of MOAs, equity-oriented differential financing of I0Us, and center/local cost-sharing arrangements); and e) increasing the capacity of the 21 local governments in the project area to plan, manage, monitor and evaluate their health and nutrition programs. It would build local communities' awareness of their health, nutrition and environmental problems, and involve them in a pro-active way in seeking solutions to them. 5.2 The direct benefits to about 0.9 million households in the three target cities would include better access to health and nutrition services; reductions in infant and maternal mortality; an increase in the contraceptive prevalence rate and in the spacing of births; reductions in protein-energy malnutrition, anemia and goiter, and elimination of vitamin A deficiency; reductions in the incidence of pneumonias; and reductions in the prevalence of tuberculosis. fl. &like 5.3 The main risks foreseen are (i) whether LUs would be able to provide and sustain the financing required for the project; (ii) whether LUs with newly devolved responsibilities would have the capacity to manage the proposed project; (iii) whether implementation would be delayed through shortfalls in and slow release of project funds by the central government; and (iv) whether all 21 LUs would agree to participate in the project, as well as the likelihood that project outcomes would not be uniform in all LUs. With regard to the first risk, strong commitment to project goals was generated by the participative approach to project preparation (para 4.1). The commitment to implementation and counterpart financing would be formalized through the proposed central/local government M0As (para 4.12), which include provision for a rising LU counterpart contribution during the project life aimed at ensuring project sustainability. Community awareness and involvement in the project would also help to ensure sustained commitment to service provision on the part of I=Ua. - 46 - 5.4 With regard to the second risk, IWU managerial capacity would be considerably strengthened by project institution-building activities, with technical assistance and training being provided by central and local offices of DOH and by private consultants. In addition, the flexible approach to implementation which is proposed, based on annual performance reviews followed by adjustments to strategies, plans and budgets, would allow scope to deal with managerial problems as they arise. 5.5 Budget shortfalls and slow funds release from central government are a significant cause of delay in Bank-financed projects already under implementation in the Philippines. Three approaches would be taken to minaisme this third risk. First, GOP and the Bank are undertaking a project and program prioritizing and restructuring exercise which would help to ensure that central government funds are concentrated on fully funding a limited number of priority projects, including the proposed project. Second, the proposed system of releasing the majority of project funds through the MDF is likely to be faster than the normal system through DO, based on experience with the Bank-assisted Municipal Development Projects. An understanding would also be sought from GOP at negotiations to release project funds in six- monthly tranches into the MDF, thus helping to ensure an adequate cash flow. Finally, all 21 LUs participated in project preparation and project design includes financial incentives in grant form for communities to participate in the project. C. Impact on Women 5.6 The project would have a special focus on women clients of reproductive age, since these clients are at relatively high health risk. The project's specific benefits to women clients would include the provision of better access to women's health and family planning services for 1.2 million reproductive age women, and the provision of regular outreach services and a package of integrated care to more than 700,000 women within that reproductive age group who would be pregnant or have children under five during the project period. Also, the project would provide training in health service delivery and health education to about 3,700 volunteer women Barangay Health Workers, thus increasing both their skill levels and their status in their communities. D. Rnvironmental Aspects 5.7 No project-related risks to the environment are foreseen. The environmental health activities proposed under component four would improve the urban environment by providing safe water, sewage, solid and toxic waste disposal and insect and rodent control. - 47 - VI. REACMM AND R&ILhuLUM LUMEDN. 6.1 As project covenants, agreement was reached at negotiations with GOP that: (a) by December 31, 1994 a study on pro-school child development in the Philippines would have been carried out under terms of reference satisfactory to IDA (para 1.62); (b) a Project Coordinating Unit (PCU-UNNP) would be established within DON on terms of reference satisfactory to IDA to be responsible for overall supervision and coordination of project implementation. The Government agreed to maintain the PCU-UNP throughout project implementation, and to ensure that the PCU-UHNP is headed by a Project Coordinator and qualified personnel (para 4.9); (c) the GOP would provide project funds to participating LUs on a grant equivalent basis once each LU had signed its respective M0A. It was also agreed that each HOA would be signed by the DOH, DILQ and corresponding LOU. Each NOA would include a cost sharing arrangement acceptable to IDA (para. 4.13); (d) audits of LU and DOH project-related records and accounts would be undertaken in accordance with agreed accounting principles consistently applied, by independent auditors acceptable to IDA, and audited accounts and financial statements, in a format acceptable to IDA, and including a separate audit of statements of expenditure, would be sent to IDA within 9 months of the end of each GOP fiscal year (para 4.22); (e) the Government would submit semi-annual progress reports to IDA and prepare, within 6 months of the Closing Date, a Project Completion Report (para. 4.22); (f) beginning in fiscal year 1994, the DON would review the individual LOU yearly MOA implementation programs, and progress achieved in executing project activities by July of each such year. These MOA programs, including a draft aggregated operational plan and related financial budgets, would be reviewed and finalized by October 30 of each of such year (para. 4.23); (g) not later than the end of each fiscal year, beginning in 1994, IDA and the DOH would review jointly the individual LOU yearly HOA implementation programs (including their respective operational plans and finanrial budgets), and these programs would take into account IDA comments (para. 4.23); and (h) a baseline evaluation study of health and nutrition conditions in the targeted slum communities prepared, under TORs satisfactory to IDA, would be carried out by December 31, 1994. In addition, two * 48 - separate follow-up studies would be carried out, also under terms of reference satisfactory to IDA, not later than December 31, 1996 and December 31, 1999, respectively (para. 4.23). 6.2 As conditions of effectiveness, the GOP provided assurances that: (a) the DOH would have established the PCU-UHP and appointed its Project Coordinator and personnel (par&. 4.9); (b) at least 9 of the 21 DOH/LU/DIIO MOAs required under the project would have been entered into with the DOH and become effective (para 4.13); and (c) the DOH, DOF, DSM, DILS and NEDA would have signed the Inter Agency Agreement governing the release of Credit proceeds through the Municipal Development Fund directly to each project LU, in accordance with the corresponding MOA and that the Agreement will have become effective (4.21). 6.3 With the above conditions, the proposed project would constitute a suitable basis for an IDA credit of SDR 50.5 million (US$70.0 million equivalent) to the Republic of the Philippines, at standard IDA terms with 35 years maturity. 添―合〕 50 Annex i Page 2 of 7 PHUIPPIM ~= AM NUMMOB PRO31= Dmo~by of the Cides TöW Populaxice. UMå Rurmå DiMbutim. ud Intemmså 0~ Rue tycenuayon commug Y«r T~ U~ Inter Cefflå Rmrål later Cund Population Population 0~ Rate Population 0~ Retc (rer Gent) (per ~t) 1960 (POL 15) 27087685 1WO (MO 6) 366~ 11677820 25006666 1975 (KW 1) 42070665 14046527 2U 28024138 12.1 INO 1) 17943897 27.7 30154563 7.6 1990 614=80 26245568 4&3 35234612 W So~ Phil~* ~~ Y~book. 1990 De~by of the Cities ~atim of AD Citim Dmåty, and 0~ Rate byCensusYen CUS»Yew Population Dcasity Growth Rate (OW) (Petun^. Km-) (Poremt) 1990 12917 687 26.9 19W 10182 54M 14.8 1975 8= 464 16.5 1970 7610 404.6 W 1960 5370 285.6 47.4 1948 3644 1918 - Sm~ Philippinc &a~ Youbock. 1990 wV^wkI - 51 - Annex 1 age 3 of 7 PHILIPPINES URBAN flALTH AND NUTRTION PROJECT Demographyof the Citifs Estimated Urban Poor Population by City 1990 Regiol/Province Total Population Urban Poor Population (Estimated)* NCR 7,928,867 3,888606 Kalookan 761,011 266,354 Manla 1,598,918 559621 Pasay 366,623 183,312 Quezmf Cty 1,666,766 1,083,398 District1 805,229 402,615 District2 758,720 531,104 District3 823,980 288,393 District 4 1,147,620 573,810 Metro Cob 936,896 500,772 Cebu city 610,417 335,729 Lapulapu City 146,194 73,097 Mamdaue City 180,285 91,945 Cagayan De Oro City 339,598 101,879 Total Project CktfrfDiatricts 9,205,361 4,491,257 Percentage of Urban Poor Population to Total Population basd on UHNP AssessmtStudies city of ManDa 35% District 2 70% Que~on City 55% District 3 35% Pasay City 50% District 4 50% alookan city 65% Cbu City 55% District1 70% Cag de Oro 30% Percentag of Urban Poor Population to Total Population as providd by Heaith Office Madau city 51% Lapulapu City 50% The disep in totals are du to roundg - 52- Annex 1 Page 4 of7 y i ysam s h p p~ - 53 - Annex 1 Page 5 of 7 PIHLIPPINE URBAN HEALTH ANDNU'IRMIONPROJECT Tablo 1 Epidemiologyof Urban Aress Leading Causes of Death among the Urban Poor. Queon City. 1990 Caums of Death Per Cent A. Per Household Survey 1. Lung infecdon 22.1 2. Mels 17.6 3. Diarheas 14.7 4. 1-defnedsymptoms 8.8 5. Heart diseas 5.9 6. Accident 5.9 B. Per Death Regitry 1. Cardo-vacular dseases 21.7 2. Respiratory diseas 20.7 3. Disess of the central neroussystem 9.2 4. 'Thbeculosiba. &6 5. Traumatio injuris 7.5 6. Mal~gancles 7.4 7. Gatro-intstinal disass 6.9 & Sere viraIlbacteuialnf 4.9 9. Birth complications 2.4 10. Degenerat diseases 2.4 Tae 2 lading Causs of Morbidity amog the Urban or. Qusn city. 1990 Causes of linesu (Pr survey) Per cent 1. LUif.edon/tuberculosis 37.9 2. Non-specifcinfections 2&9 3. Diarrheas 13.6 4. D-defnedsymptoms & conditions5 5.Asthma 3.1 - 54 - Annex 1 Page 6 of 7 PHIIPPINES UfRAN HEALTH AND NUTR~TION PR~OBCr Table 3 lding~ Cau Charhy Wad ~ ~s 8,am Quom=at y,1990 Caus of Admison Per dest A. A ces 1. ChRdbIrth S2.9 2. Dhamesot the d~ies1e systm &1 3. D~seasesof the respiratory systm 1.3 4. Roa d~sass 5.5 5. Taumaticwejur~es 4.8 6. Bakelrl infections 3.8 7. Di~aOeftho ~~entralnevousystm 2.2 & C~ardo-vasculardisases 1.9 Gyeoloio~.conditions 1.9 9. S~wreviralinfo s 1.6 10. m.aIa ~ 1.4 Ophta~uineondh~os 1.4 I. Udr's 1. Upper "spiratorytract infocdons 29.2 2. Darheas 23 3. Spss 12.4 Montne. 12.4 4. Appendimi~s 3.5 Nutradosal dfcils 3.5 5. Acdents 2.7 TM 4 aicnc oftsusot Death Amog thkUba Poor,CebuCiy1990 Causos of Death (For Death RegIstry) Por east 1. RespratoyfPe d~oa ss 21.3 2. euutdisease 14 3. Crmmtas*dcular~disss 12.2 4. Cancers 7.8 7.5 6, Gastro-InetsstIuaIds= 6.4 7. Dig m~es sj~t.disass 4.5 & Gato-arnarytra~ inf~dons 4.1 9. Skin amas 2.7 10. HypOVOff~da 2.7 - 55 - Annex 1 Page 7 of 7 URBANHALTR AND NUTITIONPROEC' Taue 5 LeadingCause etMorbidilyla the rbanPior.Cab City. 1990 Camses et MorMidity (Per Dar. 111th Statue separt) Per esnat i Uppnsphatoy tract ~ t fmction 42A 2. Aute resatoylasio- 10.9 3. k ro~ 9.3 4. Diareas 8A 5. Broc~ti .1 6. Paratan 5.5 7. Infectedwounds 2 8. Anemdb 1.9 Gaaso-intesdanal disorders 1.9 9. Tuberculosia 1.5 10. Hypertensioa 1A •. TTabe t Major Causas .f liaeaia Kalota. TaguIg.& P.1991 ceas atnsas (pr a.~vey Pr oent 1. ~e and nu 2. EEiafede~ 3. An~s!. 4. uL idfcdo 5. Kidneyfgelladdoacisfcoa s. Xa ds~as inkales Notma Pereat aftduayadicated M*rCau~ eta HONhpt~latna Ex~eoaa.Tagi . Paui.m1991 Cassa oe.-pk*•dk- . (pW serv.y) Per esa L Cbldbit 16 2. Bla a 1 4. ThaId/H-f wr 74 5. Heart pea 6.4 . Mauh 5.7 7. Pams Iarepod.sthu utem i. 8. MAltm. 3. 9 Hasin 34 *1 i IIIjFi -57- Arnex 2 Page 2 of 6 MEGIONAL FELD HEALTH OFMCE Of &Cofh la~n A~ Re onalDire ctor T.o--Co~ Fawdh~ia _ _ _ _ _ _ _ _ ~ Md R~S~ TecludalSenee f iansing ••tana&120 Diiio egltinmieani so ennnkCo 1aa 24 'il'?aga 3 ofT 5li *1 59 - Åqgex 2 Page 4 of 6 Kalookan City HOMth Department DOH D4 0 cit (Setr) Mayor NCRO(Dir.) Asst CH0 Admi~s H~ l S~ traiveOper~o PE RTS Serices Division Divii~ Seri~ Diviio N4~iintingt- Cffinic P P 7rog Public NHeal. 12V12 HealthHeaat - 60 - 2 pag* 3 sof6 ORGAZAIONAJPERSONNEL CEART Tagi eathDeartuait DOa (secuwayar NCR OMM (NCRD~uctor) Disen M-nkcpal ovt Dhsicilkasta cacr. f l Omeer Mayor Office 3 3 MkUSOpyLylngla Phandg amt17 avate~ x~s Office ca=te Sankluyfukh Officer Office - 61 - Annex 2 Page 6 of 6 ORGANZATIONA1UPERSONNEL CHART Pas Municipul Hath Department Department of Health (Seay NCRD (NCKDirector) Micipal (Office of the Mayor) Heah Officer) (MOffow) __________________Administrative Staff pad Té~or Services Techncal Servce Health Pur- Speia Cultur Trainn Cener caner Servces Plans and Coordi- nation Statstcs and Recr lServces ý - 62 - URBM åEALT ~ AD RITITIM PROCT Table 1: Revnu= of Lab 1992 IRA Local Totat Local Revenu~ Population <1993) Rovenu Reveu Total Revmnu (1993> <1993) <1993) Catoocam 8m3477 289213591 22784739 517060330 0.441 Nnito 1751172 559150719 1266174751 18732570 0.694 PasMy 401534 1559a369 416564734 572528432 0.728 *An 1875480 5967693 11209216 1717912009 0.652 Ombu 668543 68125032 351592441 599717473 0.553 Lapu Lapu 160115 89883 37493469 127337332 0.294 Nandau 197452 95180974 52397057 14757801 0.355 Cagayan de Oro 371936 196478511 113028807 309507318 0.365 letro Umita Kiclpatities 375156 321303664 655445240 976748904 0.671 ØTE: The revme estlates for the Netro Kiantia oicipale ties ar understated. The IRA re presented is only for the astropolitan areas a provine , ad dom not include the indivdutal ~unicipet attocotions. Table 2: Currmt Healtth Ex~nditures of La 1992 1991 Totet health Per capita exeditur expenditure expmnditure health by LGIS by 0H expend iture CaLoocan NA 15373524 15373524 18.45 "amitla 121280524 30131166 151411490 86.46 Pasay 12212992 6332322 18545314 46.19 Que&on 80858028 30080925 110938953 60.77 Cbu 27657384 4093908 31751292 47.49 Lapu Lpu 3186890 851564 4038454 25.22 M ~andau 881219 1043048 1924267 9.75 Cagyan de Oro 8680632 367752 9048384 24.33 Netro maita micipalities N 12852426 142852426 37.74 UTE: Locl hasth expanditures of Catocan and the Metro mita mnicipaities mere tuvaltable. The 1991 xpenditures of 008 are also the stimtes of the cost of devolved functions to be absorbed by LWs. Tabt* 3: Health Ex~nditures and Locm Revenue mealtth Expmditure Local share of s of total revmms totat health ependiture Ca;oocan 3.01 NA Nanile 8.3% 80.1% Pasay 3.2 65.9% Ousfn 6.5% 72.9% Cebu 5.3 87.1% Lapu Lapu 3.2X 78.9% Nendau 1.3% 45.8 Cagy de Oro 2.9% 95.9% "*tro "Mita ~elicipolities 14.6% N - 63 - Annex 4 Page 1 of 3 PHILZIM URBAN HEALTH AND NOTRITION PROJECT Current Donor_Antivity in Urban aealth and Nutrition Urban Basic Services PrograM (MBSZ) This project, funded by UNICEF, is the most significant donor activity currently responding to the health and nutrition concerns of the urban poor in the Philippines. UBSP started as a demonstration project involving four cities in 1983 and expanded to 13 cities during the 1988-1993 program period. For 1994-1998, UBSP will further expand its coverage to include the 8 cities and the 13 municipalities targeted by the Urban Health and Nutrition Project, plus the cities of Bacolod, Iloilo, Davao, General Santos, Olongapo and Angeles. These cities and municipalities have a combined population of approximately 11.4 million, of which five million are children aged 0 to 17, representing 39 per cent of all urban children. Over the ten years of its implementation, UBSP has demonstrated that a basic services strategy, coupled with strong community participation, is an effective way of providing needed health and nutrition services to urban poor communities. The project focuses on empovering the poor to participate in their own development through support activities such as community organizing, training and capacity building, advocacy, social and resource mobilization and networking, research, monitoring and evaluation. For the 1994-1998 program period, UBSP will intensify efforts to address the needs and problems of children in expecially difficult circumstances, particularly street children, who are considered the most at-risk children of the urban poor. Preventive community-based initiatives to help street children such as organizing children and their families, provision of appropriate and viable work and income opportunities, alternative learning schemes, and the provision of appropriate health and nutrition services will be strengthened and accelerated. The major output objectives of UBSP are classified into direct services and support services objectives. The direct services objectives are further classified into child survival, child development and child protection objectives. Under the child survival service component, the project will support the following activities: a) expanded program for immunization; b) control of acute respiratory infections; c) control of diarrheal diseases; d) women's health and safe motherhood; e) promotion of breast feeding, weaning and growth monitoring; f) maternal nutrition and micronutrient supplementation; g) prevention and control of dengue fever; and h) community- based prevention and control of sexually transmitted diseases and HIV/AIDS. Water and sanitation activities, such as the promotion of appropriate technology for waste management and the introduction of home-based double-fit latrine, will also be supported under this component. - 64 - Page 2 of 3 The child development component will provide early child care and development services to preschool children, improve the elementary cohort survival rate, promote literacy among parents, and provide functional education on effective parenting and family life skills to adolescent girls. UBSP's child protection initiative will focus on the problems of street children. Activities to be supported under this component include efforts to remove children from exploitative and hazardous occupations, provide physical rehabilitation, protection and counseling services to children in conflict with the law, and reuniting street children with their families or providing them with alternative family care. To meet its support services objectives, the following project activities will be undertaken: a) strengthen the capacity of city/municipal governments to plan, implement, monitor and evaluate programs for child survival, development and protection; b) strengthen and sustain community participation through the formulation and subsequent implementation and monitoring of community action plans; c) sustain the basic services delivery mechanism at the city/municipality and barangay levels; and d) establish linkages with the private sector and other UN and international agencies for resource mobilization in support of the project's goals. To implement the 1994-1998 UBSP plan of operations, UNICEF will make available US$4,650,000. The Government wiL1 edntribute adequate counterpart funds. The project will provide block funds for community- initiated projects such as protection schemes and non-formal education programs for street children and out-of-school youth, improvement of water and sanitation facilities and credit schemes, and income and employment generation activities. Block funds for organizing and training related to self-help slums upgrading and land tenure will also be available under this project. The Urban Health and Nutrition Project (UHNP) has drawn largely from the lessons that have been learned and experienced in the course of implementing UBSP, and will be employing some of the strategies and approaches that have been proven to be effective. Having identical goals and objectives, UHNP will be an important complement to UBSP. UNICEF recognizes that UBSP's strengths in community organization, mobilization and participation, as well as its multi-agency and multi-sectoral approach to planning and programming services for the urban poor should be complemented by bigger and more systematic efforts to shape policies at city and national levels that will be effectively responsive to the needs and problems of the urban poor. Institutional Sunort to the Health Care Program in the NCR This project, funded with a grant from the Italian Government, is a continuation of an activity that was initiated in 1989. Its objeccive is to strengthen the delivcry of basic maternal and child health services in the National Capital region using the primary health care approach. For the 1993- 1994 implementation period, the project plans to cover the cities of Manila, Quezon and Kalookan. Two strategies will be pursued: increasing the capabilities of government institutions to expand and improving the delivery - 65 - Annex_4 Page 3 of 3 of maternal and child health services; and developing or Improving comunity initiatives in the provision of maternal and child care. Under the institution capability building strategy, the project will provide logistic and technical assistance to regional and city health offices to Improve managerial and supervision capacities. It will also train health personnel to improve the quality of maternal and child care, and foster collaboration between government and non-government organisations in the planning and delivery of health services. The strategies to promote commnity participation will include organization of primary health care committees, training of barangay health workers to sensitize them to health needs and effectively manage comunity development activities, and the adoption of primary health care approaches. The Italian Government will provide US$320,000 to fund the two-year Implementation of the project. The funds will be used to support training and ISC activities, procurement of vehicles, drugs and other medical commodities, office equipment and supplies, hiring of support staff, supervision, monitoring, and evaluation. - 66 - Annex 5 Page 1 of 4 URWA HEALTH AMD NUTRITION PROJECT Intervention Objective Whether Whether Process Measured by (P) or Service Impact Statistic (SS) (I) or Survey (SU) General Register 90% of pregnant P SS women by the end of the first trimester Pre-natal care 100% of registered pregnant P SS women receive three pre- natal exams/counselling sessions Anaemia 1002 of registered pregnant P SS women receive iron tablets for at least four months Reduction of anaemia by 25% 1 SU Tetanus 1002 of registered pregnant P SS/SU women receive 2 tetanus shots Goitre 1002 of pregnant women with P SS visible goitre get iodine capsule by end of fourth month PIK 100% of registered pregnant P SS women at high nutritional risk receive 6 months of calorie supplementation Reduction in low I SU birthweight by 25% STDs 1001 of health center P SU - 67 - Anu 5 . Page 2 of 4 PHILIPINES URB.HEALN A n =., TION PROJECT xammy 1~IONS NDOJMGE= Intervention Objective Whether Whether Process Measured by (P) or Service impact Statistic (SS) (I) or Survey (SU) facilities and staff in the project area equipped to diagnose and treat gonorrhea and chlamydia, and diagnose and counsel HIV cases Safe birth Timely referral of 100% of P SU pregnancies/deliveries with obstetrical complications Post partum 100% of registered post- P SS care delivery women receive five counselling sessions for themselves and their infants in the first 6 months Vitamin A 1001 of registered women P SS deficiency receive vitamin A mega-dose within 4 weeks of delivery 1001 elimination of I SU deficient and low serum retinol values Family Planning Each project area health P SS/SU facility has a three-month supply of contraceptives available Reduce by half the number 0 SU of deliveries within 2 years of the preceding one - 68 - Annex 5 Page 3 of 4 PHILIZUNES M&AN HAM AND MU=RTION MROECT Intervention Objective Whether Whether Process Measured by (P) or Service Impact Statistic (SS) (1) or Survey (SU) SU Increase the contraceptive 0 prevalence rate among project target vomen between 15 & 45 from 201 to 452 General Register 90% of 0-24 month P SS children through quarterly surveys PEN 1001 of registered 0-24 P SS month children receive at least 18 out of 24 monthly weighings 100% of qualifying children P SS are fed supplement Reduce the prevalence of I SS/SU underweight and stunting at age 24 months by 25% Vitamin A 100% of registered 0-24 P SS deficiency month children should have received 4 vitamin A mega- doses 100% elimination of I SU deficient and low serum retinol values - 69 - Page 4 of 4 PHILIPINS URBAN HEALTH AND NUTRITION PROJECT Intervention Objective Whether Whether Process Measured by (P) or Service Impact Statistic (SS) (I) or Survey (SU) Acute 25% reduction in the P SU respiratory incidence of pneumonia infections (lower respiratory infection) in 0-2 year old population Anaemia 100% of LBW are treated P SS with iron by six months of ase Reduce anaemia in 0-24 I SU month children by 25% TB Availability at health P SS centers of 6 months of SCC drugs for predicted sputum- positive cases over next 3 months 80% of sputum-positive cases should have completed P SU SCC course - 70 - Page 1 of 3 URBAN HUMLT AND NUTRUTION PROJECT A STUDY OF THE URBAN POOR IN OUB20N CITY: A Brief Summary of Methodology and Findings The Assessment Study of the Urban Poor In Queson City was commissioned by the Department of Health as part of the planning of the Urban Health and Nutrition Project (UHP). It is an integral part of a wider v Ady of selected urban poor areas, namely Kalookan City, Cagayan de Oro City, aDu City, Pasig, and Taguig. The general objectives of the study were: (i) to develop and test a methodology for identifying, classifying and locating the urban poor; (ii) to identify and classify urban poor areas and high risk population groups; (ILL) to determine the most widespread and serious health risks affecting the urban poor population; (iv) to assess the servioe capability of existing institutions providing health services for the urban poor; and (v) to recommend specific interventions to modify health risks and improve health and nutrition status of the urban poor. Quezon City was chosen as the pre-test study area because it is the largest and most populous city in the country, with a rapidly growing urban poor population. It had a population count of 1,666,766 in the 1990 census, with a population density of 10,030.1 persons per sq. kilometer. The average density, however, is misleading since it does not reflect the crowding usually observed in such areas with high concentration of urban poor dwellers as Barangay Capri, which had a population density of 117,164 persons per sq. kilometer in 1990. The city was divided into 4 administrative districts, each of which was administered by a district health office. The study was divided into 3 parts: part 1 focused on the beneficiary assessment, part 2 on epidemiologic analysis, and part 3 on institutional analysis. The beneficiary assessment study consisted of an ocular survey and mapping of urban poor communities, focus group discussion with purposively selected urban poor residents, and in-depth survey of randomly selected urban poor households. The epidemiologic analysis involved a detailed investigation of the major causes of death (per death certificate records) and hospital admissions in charity wards of government hospitals located in Q.C. in 1990. The institutional analysis focused on the service capacities of existing health centers, clinics, and hospitals in Quezon City, giving particular attention to - 71 - Annex 6 Page 2 of 3 the Q.C. Health Department as the major health service institution serving the urban poor in the city. Methodology and Ap=roaches The methodology and instruments for the rapid appraisal of urban poor communities in Q.C. was developed specifically for this study and used in identifying and classifying urban poor communities. Briefly, the methodology for the beneficiary assessment portion of the study called for: (i) the conceptual definition of the urban poor community, (11) the conduct of an ocular survey around the city to identify and locate those communities considered as urban poor, (iii) the compilation of pertinent information about the communities identified as urban poor using both secondary data and key informant interviews, (tv) the classification of urban poor communities Into typologies based on physical and socio-economic characteristics, (v) the mapping of identified urban poor communities indicating broadly their physical location, their typology, and socio-economic deprivation scores, (vi) the selection of sample communities in each typology for in-depth household interviews and focus group discussion, (vii) the conduct of focus group discussions among urban poor mothers with children under 5 years old, and (viU) the conduct of household interviews with randomly selected households in the sample urban poor communities. For purposes of the study, urban poor communities were identified as those with limited or no access to basic amenities such as water and power supply, sewerage, garbage and excreta disposal, and adequate housing. The basic unit of analysis was the colony or cluster of 20 or more households exhibiting the physical characteristics of an urban poor or seum community. Colonies were classified according to location and ranked according to degree of deprivation, using 13 basic indicators, namely: (I) distance of community to nearest health facility or practitioner; (ii) cost of transportation to above; (iii) population density; (iv) condition of children; (v) general environmental condition in the community; (vi) density of houses; (vii) predominant construction materials of walls of houses; (viii) predominant construction materials of roofs of houses; (ix) main source of income of labor force; (x) type of toilet facility; (xi) source of drinking water; (xii) means of garbage disposal; and (xili) type of lighting. The methodology for the epidemiological analysis segment of the study- consisted mainly of a records review of the death certificates and charity vard admissions in 4 hospitals in Q.C. The review of the death certificate records was aimed at determining the death profile and the major causes of death in Q.C. In 1990. Basic information such as name, age, residence, occupation, attendant at death, underlying, antecedent and immediate causes of death, and place of death were collected from 100 1 of all deaths of Q.C. residents registered in Q.C. in 1990. The review of hospital admission records, on the other hand, was aimed at determining the hospital admission profile and the major causes of hospitalization of Queson City urban poor residents in 1990. A 4 month (Jan, Apr, Jul and Oct) sample of charity ward admissions in 4 hospitals was selected. All charity admissions in the sample month were included in the study. Pertinent data such as name, age, residence, - 72- Annex Page 3 of 3 occupation, discharge diagnosis, hospital charges, and amount paid by patient, were collected. The methodology for the institutional assessment segment of the study consisted of a rapid appraisal of the facilities and manpower complement of the existing office and clinics of the Q.C. Health Department as well as of private clinics and medical facilities, including hospitals, of other government and non- government organizations operating In Q.C. Pertinent information such as location of clinics/hospitals, catchment area and population served, available health manpower, equipment and instruments used, services provided, performance targets and achievements, status of physical facilities, clinic schedules, and usual clinic loads were collected, processed, and analyzed. In-depth interviews with a sample of 8 clinics, all district health offices, and the Q.C. central office, was conducted to obtain information on the organizational and management dynamics of the City Health Department operations. All data and information gathered were processed and analyzed to draw up the general characteristics of the urban poor and to describe the major health and nutrition problems affecting them. From these, recommendations were made on the broad means of improving the health and nutrition status of the urban poor and how the UHNP could best respond to their most important public health problems. - 73 - Page I of 5 PHiILIPPIE URBAN HEALTH AND NUTRITION PROJECT The project would employ two distinct active outreach targeting strategies as well as strengthening facility based services provided on demand. Women of reproductive age and children under '5 years (the group most at risk) would be targeted for client-oriented services during critical high risk periods in their life or relroductive eycle. Specific geographical urban areas or communities which are known to harbor the highest incidence and prevalence of a number of health problems, including tuberculosis, would be targeted for area-based preventive and disease control interventions. The health services supported by the project requiring health facilities for delivery, and that are in addition to those already available at health centers, would be referred to in this project as facilitZ-based services. This approach departs from one dimensional area based targets and in so doing will achieve the main objective of public health services: reach those most in need of services; accurately measure the extent of need; avoid the provision of services to those not as needy and not at as great a risk. Life or Reproductive Cycle Based The birth-based services are designed to .-respond to the needs of women of reproductive age and children as they go through the critical reproductive life cycle stages covering the period from before pregnancy, pregnancy, childbirth, the Immediate post-natal period, and the first five formative years of child growth and development. This approach begins with a household level targeting strategy aimed at meeting the large unmet need for family planning among the estimated 1.5 million women of reproductive age living in the project's target slum communities. Through the outreach educational and promotional activities of midwives and barangay health workers (BW), attempts are made to identify all poor women of reproductive age who are at abnormal risk to pregnancy or desire family planning services. The identified women are registered and enrolled in a family planning service or method if they so choose. If the individual choice involves a method only provided at a health center, hospital or other health facility (IUD, sterilization etc.), the outreach workers facilitate the referral. Once the service is provided, they follow up the women in the home and provide advice and assure a successful patient outcome. (see facIlity base family planning services below) Through the same outreach approach, there would be an attempt to identify, register and track 100% of all women who become pregnant and to enroll them in a preventive pre-natal care service. The objective is to enroll the mother as early as possible in the pregnancy and provide her a minimum of three pre-natal visits during each normal pregnancy. Women identified, as a result of the outreach activities and pre-natal visits to be at high risk to delivery, (approximately 5%) are monitored separately to - 74 - Annex 7 Page 2 of 5 minimize risk and assure optimum attention at delivery. The project would support critical inputs during pregnancy such as tetanus immunizations, food, iron and other micro nutrient supplementation in order to reduce risk to both the mother and the new born. For another 10% of women who incur complications at birth, for which such complications cannot be detected ahead of delivery, the project would support referral and transport to an appropriate hospital as well as provide support for the management of obstetrical complications to the facility. (see facilIt bage below) All newborns will be registered and tracked monthly for the first two years of the child's life and quarterly until five years of age. The monthly visits to the health facilities will provide the opportunity to integrate a range of services for both the mother and the child. Through the combination of household outreach and the health facilities, services for children would include promotion of breast feeding, growth monitoring, proper weaning, immunization, food and micronutrient supplementation, prevention of pneumonia and dehydration, devorming and disease surveillance/consultation. For the mother, the immediate post delivery period would focus on the priorities of monitoring potential complications of delivery and counseling on the value and provision of family planning services. For the child, the goal would be to assure normal child growth and development during the first five years of life. The reproductive cycle approach puts special emphasis on monitoring the first two years of life when the child is most vulnerable. This approach enable early intervention as soon as the child s development deviates from a normal Aevelopment pattern. The cycle then repeats itself with the next birth to the mother. The first schematic diagram, which follows, illustrates the reproductive or life cycle approach as it applies to the project beneficiaries under the UHNP. Beginning on the left, there is an estimated urban population of 9.2 million people in the three urban areas covered by the project. Roughly one half or 4.6 million are living in slums; within this group, an estimated 1.5 million women are in the reproductive age group. Based on current fertility patterns, approximately 160,000 pregnancies would occur among these women in the first year of the project, increasing to 180,000 per year by the project's end. This strategy should be the most manageable and cost effective approach as it significantly reduces the scope and work load of the public health system as compared to more traditional total population based approaches. The second diagram illustrates the integrated services that would be provided during one of the reproductive cycle visits. The example chosen represents the protocol for the post-partum visit that occurs 24 hours after delivery. Under the reproductive cycle approach, integrated pro-,-ocols are defined for Agh type of visit. Ares Based The area-based services are designed specifically to target geographic areas and total populations identified as high risk for specific health problems. For example, due to the close corre&ation of tuberculosis - 75- . Page 3 of 5 prevalence to population density, the targeting of tuberculosis control efforts would be done on the basis of stratifying urban poor areas by population density. Under the project, initial active case-finding for tuberculosis would be launched, on a priority basis in the most dense slum areas. Geographic Information Systems (GIS) would be used to map the risk to various health problems by small areas or barangay (village) and assist in the uaagement of this area based targeting approach. Ia ity. Based Sanort The facility-based services to be promoted and strengthened under this project include the following: (i) fam Ty planning, requiring a health facility, (including voluntary surgical sterilization) either referred from the household outreach activities described above or on patient demand basis; (ii) control of sexually transmitted diseases and AIDS for women; and (iii) treatment of child pneumonia referred from the household outreach early ARI detection program or from direct patient demand. The facility-based services are designed to respond to the service demand of a variety of clients. For instance, the facility based family planning services are offered to all women on demand regardless of economic status, whereas, the focus of the family planning outreach educational and promotive activities would be to reach women living in the slum communities. Adolescent women are included because of their physiologic and economic vulnerability and would be a special target for the outreach and facility based family planning services. The proposed facility based services for the control of sexually transmitted diseases and AIDS are designed to respond to the needs of reproductive age women who may be exposed to STD risks as a result of their own, or their partner's, behavior. Currently STD services are not available to women at public health facilities except special clinics for commercial sex workers. The project would support the introduction of this new service. The facility based services for pneumonia treatment are targeted to children under 5 years old who are self referred or have been detected and referred to the facility by the outreach workers. The outreach workers would be trained using standard DOH policies and guidelines for the early household detection and treatment of acute respiratory infections including pneumonia (ARI) in infants and children. Particular attention is focused on this problem because, despite its relative ease of detection and treatment, pneumonia remains the most single most common cause of infant and child deaths in the Philippines. Slum children are particularly vulnerable. UHNP Reproductive Cycle (Life Cycle) 1.5 w~Family Planning 2.3K F 160,00 Prenatal Care Isd Yar Ist 29d 3d " NaCh Birth FP 4.6 M Pmu- post Part= 9.2 M. Tota 4.6 M.Nnoor 77, - Annex 7 Paee 5 of 5 URBAN HEALTH & NUTRION PROJECT Example of Immediate Post Partum Visit Protocol (24 Hours After Delivery) Routine Post Partun Care Assess Health Status 1) Within 24 Hour After Delivery - Check for atony/bleeding Umbilical Cord Care - General perineal care - BF initiation Iitiate Growth Monitoring 2) After 24 Hours to 1-2 Weeks - Check for signs of infection Endorse Breast Feeding Protocol Breast Feeding Set Visit Schedule - Exclusive if possible Health Education on - Family planning/birth spacing/ others - Care of the breast - Nutrition of mother & child - Child visit schedule - Child immunization schedule - TT Immunization (if required) Nutrition Supplementation - Iron Supplements (continuing) - Vitamine A Supplements (one mega dose) - Iodine Supplements (1 capsul if not already taken) Food Supplementation (per criteria) 78 - Annex 8 URBAN HEALTH AND NUTRITION PROJECT Staff Number of Staff Medical Doctors 98 Public Health Nurse 138 Mid-wives 467 Dentists 4 Nutritionists 58 Ned Techs 28 Sanitary Inspectors 39 COST OF SMA (Killion) Staff Peso (5 year) (US$) Medical Doctors 42.7 (1.7) Public Health Nurse 49.3 (1.97) Mid-wives 100.2 (4.0) Dentists 1.4 (0.6) Nutritionists 12.1 (0.48) Ned Techs 9.8 (0.39) Sanitary Inspectors 6.4 (0.26) Total Peso 221.9 $8.88 - 79 - Annex 9. Page 1 of 2 URBAN HEALTH AND NUTRITION PROJECT 1) FRISI 2E O There are four major phases in the development and implementation of facilities for repair/rehabilitation or for new construction . They are as follows: (a) Site Appraisal and Schematic/Design Development Phase (b) Contract Documents Phase (c) Bidding and Awards Phase (4) Construction Phase 2) Schematic/Design Develoment Phase All schematic/design development plans, outline specifications, and preliminary estimates to be used for the preparation of Contract Documents, shall be prepared by the DOH-Health Infrastructure Scrvice (INFRA), based on their earlier appraisal of existing conditions of sites, services and physical plants. 3) Contract Documents Phase (a) Each project/facility, whether for repair/rehabilitation or for new construction, shall have a corresponding set of Contract Documents to be used for construction purposes. These include Detailed Architecture and Engineering Plans, Technical Specifications, and Detailed Estimates. I (b) Consultants will be hired for the preparation of these Contract Documents. The procedures to be followed for the procurement of consultants will be in accordance with the NEDA Guidelines for Hiring of Consultants for government Infrastructure Projects (Attachment 1). (c) Based on the NEDA Guidelines, the Offices of the Provincial Governor for Cebu and Kisamis Oriental (for Cebu City and Cagayan de Oro City projects) and the Office of the Governor for Metro Manila (for Metro Manila projects which will not be implemented by the DOH) shall each organize a Prequalification, Evaluation and Awards Committee for Consultancy (PEVAC) which will be responsible for the conduct of prequalification of consultants, evaluation of proposals, selection, and recommending award of contracts for consultancy services. - 80 - Page 2 of 2 (d) The PEVAC of the DOH shall handle the hiring of consultants for projects to be Implemented by the DOH (see Annex 1). (e) Projects shall be clustered or packaged on the basis of geographic accessibility and establishment of a cost limit of approximately P per package. (f) The attached Terms of Reference (see Annex 2) will be used for the hiring of consultants. They indicate, among others, detailed scope of services, qualification standards, and fees. All consultancy contracts shall be subject to DOH and World Bank revi-w before award. 4) Bidding and Awards Phase (a) The projects by package shall be implemented by the Offices of the Concerned Governors and by the DOH (see Annex 1), using PD 1594 Guidelines (Attachment 2). (b) The Offices of the Concerned Governors, in compliance with PD 1594, shall organize a Prequalification, Bids and Awards Committee (PBAC) which will be responsible for the conduct of prequalification, bidding, evaluation of bids and recommending award of contracts for construction. This PBAC is separate from the PEVAC (for hiring of consultants). 5) Construction Phage (a) Based on the TOR, the construction supervision of the project packages will also be provided by the consultants. (b) As a special provision, all requests for variation orders, extra costings, advance and progress payments, work suspension, contract time extension, and contract price escalation shall be submitted first to the DOH for review and certification/approval. (c) The final acceptance of the project shall also be subject to review and certification/approval by the DOH. - 81 - Annex 10_. Page 1 of 14 URBAN HEALTH AND NUTRITION PROJECT LIST OF ITENSW TO BE PROCURED I. CLINIC EQUIPMENT/INSTRUMNENTS Copoonent 1: Service Deliv-era Women's and Child Health 1) FP Service Clinic Equipment Set Examining table w/stirrups 1 Sphygmomanometer 1 Stethoscope 1 Goose neck lamp 1 Sterilizer 1 Revolving stools 1 Kelly pads 2 Instrument tray v/cover (stainless) 1 Instrument tray w/o cover 1 Vaginal speculum (6 medium, 2 small) 8 Uterine sound 2 Tenaculum forceps 2 Uterine forceps 2 Mayo scissors 2 TUD hock 2 Sponge forceps 2 Urethral catheters (3 sizes) 2 2) Voluntary Sterilization Clinic Equipment Set Oty./Set Examining table 1 Sphygmomanometer w/stand 1 Ambo bag 1 Suction apparatus 1 Oxygen tank v/gauge 1 Halogen lasp 1 Surgical instrument table 1 Surgical instrument tray 1 3) Nutrition Equipment Scale, bar type Scale. platform type Calibrating weights (set) Calculator Weaning food equipment (set) Tuberculois Control 1) Microcoscope, Binocular 2) Microscope, Spare Parts - 82 - Annex1 Page 2 of 14 Services Unrading 1) STD Clinic Equipment Set Sterilizer 1 Kelly Pads 2 Instrument tray v/cover (stainless) 1 Instrument w/o cover 1 Mayo table 1 Vaginal speculum 6 Tenaculum forceps 2 Uterine forceps 2 Flushing tray (sedium) & pitcher set 1 2) CARI Equipment Set for Health Centers Oxygen tank v/gauge and flow meter 1 Oxygen refill 4 Nebulfser 1 One-minute timer 1 Otoscope 1 3) CARI Equipment Set for Referral Hospitals OIX./Set Nebulizer 1 One-minute timer 1 Otoscope 1 Pulse oximeter 1 4) Clinic Equipment Set for Existing Health Center Stethoscope Sphygmomanometer Nursing bag Delivery Kit 5) Clinic Equipment Set for New Main Health Centers and new Health Centers Oty./Siet Weighing scale, clinical-adult 1 Weighing scale, infant 1 Vaccine carrier, 1.5L 1 Refrigerator 1 Portable dental equipment (dental chair, accessories & instrument) 1 Examining table v/pad 2 Stove, 1p gas, one-burner 1 Microscope, binocular 1 Gooseneck lamp 1 Sterilizer 1 Light gas lantern 1 Hospital bed 1 ientrifuge, clinical, electric, 4 tube 1 Test tube holder, 10 test tube capacity 2 Lamp, alcohol, stainless I Test tube rack, 12 test tube capacity. 1 - 83 - Ae 10 Page 3 of 14 Hemoglobinometer 1 Forceps, ovum, 9-1/2*, stainless 1 Forceps, kelly, straight, stainless 2 Forceps, sponge, straight, stainless 1 Forceps, tenaculum, single prong, stainless 1 Forceps, mosquito, straight, stainless 4 Forceps, mosquito, curved, stainless 4 Forceps, thumb, stainless 2 Forceps, tissue, stainless 2 Needle holder. Mayo, 7-1/2, stainless 2 Scissors, bandage* stainless 2 Scissors, iris, stainless 1 Scissors, Mayo, stainless, curved 170 m 1 Surgical set, minor, with case 1 Speculum, vaginal, graves, 4-1/20, stainless 2 Speculum, vaginal, virginal, stainless 1 Uterine sound, 120 bulb end, stainless 1 Cervical dilator 3 Instrument tray, stainless, 8*x3"xl-l/20 v/cover 1 Catheter tray, 17"4 , stainless, cover 1 Tastrument tray, enamel, 8"x100, cover 1 Kidney basin, 100, stainless 1 Kidney basin, 10', enamel, cover 1 Wash basin v/stand, stainless 1 Enema can, 2 qt capacity, v/tubing & tip 1 Nursing instrument set, w/bag 1 Auxilliary Midwife kit v/vinyl bag 1 Sanitary inspector's kit, v/accessories 1 Medicine glass, graduated 30cc 4 Stethoscope, bell type 3 Head mirror, 3-1/2" diameter 1 Percussion hammer 1 Kelly pad 1 Eye test chart 1 Opthalmoscope 1 Otoscope set 1 Magnifying lens, 4' diameter I Sphygmomanometer, mercurial, desk type 2 Graduated cylinder, 250 at 1 6) Clinic Equipment Set for New Bgy. Health Stations (BNS) Osy./Set Weighing scale, clinical-adult 1 Weighing scale, infant 1 Examining table v/pad 1 Stove, lp gas, one-burner 1 Sterilizer 1 Forceps, uterine, dressing, stainless 1 Scissors, bandage, stainless 1 Sphygmomanometer, mercurial, desk type 1 Stethoscope, bell type 1 Thermometer, oral 1 Thermometer, rectal 1 - 84 - Annex 10 Page 4 of 14 7) Clinic Equipment set for New Lying-in-Clinics Halogen lamp 2 Delivery table 2 Resuscitator/suction apparatus 1 Weighing scale - infant 2 Bassinet 3 Beds 10 Oxygen tank w/gauge 1 Sphygmomanometer/Stethoscope 3 incubator/Oven 1 Weighing scale - adult 1 Foot stool I Aluminum pail 2 Mayo table 2 Stretcher 1 Wheel chair 1 Kelly pads 4 Delivery set 10 Kidney basin 1 Long straight forcep 3 Cervical Mayo scissors 1 Syringe & needle 2 Suturing needles Round 2 Cutting 2 Umbilical cord clamp 1 Needle holder (forcep) 2 Gloves 2 Urinalysis set 1 Test tube 1 Burner 1 Test tube holder 1 ggnant2: Institutional DevelopM Facilities Ubgradin 1) Clinic Equipent Set for CHOs/DHOs Autoclave Refrigerator, electric 6 cu. ft. Refrigerator, kerosene, 6 cu. ft. Diagnostic set component_A: Research and Evaluation ZnrmmenalHeallh 1) Equipment Set for CHOs/DHOs Comparator Kit (Residual Chlorine) Fogging machine Lightmeter Sprayer (stainless steel) Water container, pvc w/cover (20 liters) - 85 - Anx10 . Page 5 of 14 1) Equipment for City Laboratories Mandaue CitX Laboratgr Lapu-Lanu City Laboratory Bunsen burner Bunsen burner Centrifuge Centrifuge Hemacytometer set Hemacytometer set Hemoglobinometer set (sahli type) Hemoglobinometer set (sahli type) Hematocrit centrifuge Hematocrit centrifuge Microscope Microscope Urinometer Urinometer Refrigerator Refrigerator Sarofuge Serofuge Spectrophotometer Spectrophotometer Water bath Water bath Oven/dryer Differential counter Caravan do Oro City LAorator Cebu Cit Laboratory Bunsen burner Immunoassay analyzer w/ Centrifuge centrifuge & accessories Hemacytometer set Henoglobinometer set (sahli type) Hex-atocrit centrifuge Microscope Urinometer Refrigerator Serofuge Spectrophotometer Water bath 2) Laboratory Equipment for Referral Hospitals Osnital ng Kakati Pasgy City Gen. Hospital Spectrophotometer Elisa equipment Microscope Spectrophotometer Eliza equipment Water bath Aerobic incubator Clinical centrifuge Flame photometer Refrigerator Automated tissue processor Aerobic incubator Coplin jar Coplin jar Staining dish Staining dish Automatic Voltage Regulator Refrigerator Las Pas Dist. Hoso2tal Ospital ng Kalookan Eliza equipment Elisa equipment Automatic Voltage Regulator Automatic Voltage Regulator Refrigerator Refrigerator Staining dish Staining dish Coplin jar Coplin jar Incubator/oven Incubator/oven Spectrophotometer Spectrophotometer - 86 - Ane 10... Page 6 of 14 Manila Public Health Lboratory E. Rodriuez Dist. Hos2ital Refrigerator Eliza equipment Airconditioner Chemistry analyzer Automatic voltage regulator Refrigerator Eliza equipment Automatic voltage regulator Bilogical safety cabinet East Avenue Medical Center Equipment set for water analysis Eliza equipment Bacteriological Testing Set Flame photometer Incubator-Aerobic Microscope Binocular microscope Blood gas analyzer Bunsen burner w/tank Aerobic incubator Refrigerator (10 cu. ft.) Biological safety cabinet Chemical/Physical Testing Set Automatic Voltage regulator PH meter Uninterrupted Power Supply Oven, sterilizing Refrigerator Candle turbidimeter Pipette washer Duezon City Gen. Hospital Spectrophotometer Chemistry analyzer Magnetic stirrer Eliza equipment Waterbath Aerobic incubator Refrigerator (10 cu. ft.) Refrigerator Gas chromatography Vacuum pump v/filter Valenzuela. Dit.-Hospital Biological Testing Set Refrigerator Water sampler Coplin jar Inverted microscope Staining dish Compound microscope Spectrophotometer Risal Medical Center Eliza equipment Refrigerator III. OF QW Services U2radin Filing cabinet Stand fan Information._Bducation and fgmmuication Desktop Video Production: High-powered PC SVGA monitor Editing box (video mixer-3-input-l-output mixer) Video monitor VCR Desktop publishing: Personal computer w/ battery, 4 megabyte memory, 386 DK 120 megabyte storage in a fixed or 0hard" drive, one other drive for reading diskette, one monitor (screen), one pointing device (mouse) Printer for manuscript drafts Laser typesetter for final pages (600 DPI, 4 megabyte memory) - 87 - Anx10 Page 7 of 14 Electronic scanner for copying illustrations and integrating with typeset pages AVR with surge protector Word processing software for windows, desktop publishing aoftware and various materials (diskettes, tone, paper, etc.) Colored photocopying machine Computer. lap-top VCR and TV set Megaphone CPM software Windows software Trainina and Human Resource Develoment CHO/DHO Training set Electronic whiteboard Ordinary whiteboard Carousel set Copier w/ sorter and transparency Mimeographing machine, convertible Karaoke system Leroy set Slide projector screen Handy camera onitor RHO Training set Video cameta VHS player*recorder, 4 heads TV set, 200 color Electric generator Central Office Training Set Still camera, 35 am, autofocus Video editing machine m nawement Systems Imorovement 486 PC (LAN server) 386 PC w/ printer Modem Network card peripherals VHF base and antenna VHF handset Fax machine Calculator LCD panel CiS Facilities Uparadin. Equipment for RHO/RTC: Generator, portable PABX system (10 stations) Copier Overhead projector - 88 - hAe10 Page 8 of 14 Whiteboard Projector screen Vacuum cleaner (heavy duty) Floor polisher (heavy duty) Karaoke system Refrigerator, electric Filing cabinet Equipment for CHO/DHO: Generator, portable Pump, pressure Pump, deep well Aircon, 2HP Video projector Project Management and Coordination Computer system, AT 486 (Server) Computer system, AT 386 Fax machine Refrigerator, electric, 10 cu. ft. Filing cabinet w/safe Generator WS player-recorder TV set, 20' colored Stand fan VHF, base unit and antennae VHF, handheld unit Modem Network and peripherals Airconditioner LCD panel - 89 - Annex 10 Page 9 of 14 URBAN HEALTH AND NUTRITION PROJECT SUPPLIES AND iPHET. FOR FIRST ROUND OFTHE MHIV SRIUANCE YSM (Estimated reautrement for 1.400 individuals. Gooe for 6 months) 25T. Serodia PA 100 t/k 25 kits LIATEK HIV 1+2, Organon Teknika 2 kits Western Blot H1V-1 1ST 1 kit Microtiter plates, U-bottom, rigid type, FASTEC 67 pcs Gloves, medium (100 pcs/bx) 34 boxes Micropipettor, with tip ejector 0-200 ul variable/ continuously adjustable 7 pcs. Disposable tips in racks, 0-200ul, 6 pcs/rack 20 racks Disposable tips, 100-1000ul, 100 pcs./rack 10 racks Microdroppers, 25ul Fujirebio 1 box Vacutainer tubers with hemoguard, 5.0 a. plain (red top) 30 boxes Multisample needle, 021 x 1 30 boxes Syringe with needle, 5.0 ml G21 x 1 1 box Torniquet, 1" x 24" Becton Dickinson 18 pcs Test tube rack, 60 tube cap 15 pcs Biohazard pouch (200 pes./pk) 2 pks Collection bag 9 Pcs Cryogenic vials 1.8 ail, self-standing, Sarstedt or Corning 3,300 pes Cryogenic boxes, 9x9 array, cardboard 89 pes Disposable tips in packs, 0-200ul 1,000 pes/cs 8 cs Pasteur pipet, 5 3/4* 250 pes/bx 8 boxes Diluters 0.025 ml. 6 pes/box 3 boxes Western blot tray 1 pC Cryobox, 9x9 array, cardboard 5 boxes Coveralip No. 1, 24 x 60 mm 10 oz Hg Lamp OSRAN 100w/2 1 PC - 90 -Anex 10 Page 10 of 14 JUAN HALTH AND N YgTITION PROJRCT Womeans Health and Pamily Plannin 1) Cotton rolls 2) Gauze pads 3) Lubricants 4) Pregnancy test kit 5) Vaginal antiseptics 6) Linens 7) Phantom dolls 8) HBMR 9) Family folder 10) Referral forms 11) VHW record book 1) Kitchen utensils 2) Recipe book 3) Nutrition forms 4) Growth chart 5) Dietary slips TubercUlosIs Control 1) Syringe, disposable (5ce) 2) Treatment cards 3) Sputum microscopy supplies a) Sputum cup b) Glass slide c) Reagents , Basio fuchain Ethyl alcohol Phenol crystal Methylene blue Sulfuric acid Cedar wood oil Xylene Area-Based Planning 1) ABP training materials Trainin and Human Resource Develoment 1) Training manuals 2) INK materials 3) Newsletter 4) CD-ROK database NagatementJlWa&mlanKomnt 1) FSIS manual 2) Pis manual 3) FIS manual 4) Payroll manual 5) LTs manual 6) Document management manual 7) cIS manual 8) Service networking manual - 91 - Anne 10_ Page 11 of 14 MWBA HATM AND N=TTON PROJECT Women's Health and baih Plannina 1) Contracetives Pills IUD Condom Injectables* Norplant* Other contraceptives* 2) Lxing-in-Clinic Drugs Oxytoxin (injectable) Oxytoxin (tablet) Analgesic/antipyretics (tablet) Antibiotics (Amoxycillin) Anaesthesia (local) Adrenalin/Ephenephrine (ampule) Magnesium sulfate (ampule) Tranquilizer (ampule) 3) Micronutrint Vitamin A Ferrous sulfate Iodine capsule Child Health 1) Anthelaintics 2) Control of Acute Respiratory Infection D:fus Cotriaoxazole Salbutamol Benzyl penicillin Gentamycin Chloramphenicol 3) Micronutrients Vitamin A Ferrous Sulfate Tuberculoais Control 1) Type I Blister Pack 2) Type II Blister Pack 3) INH 300 MG 4) Streptomycin 5) Ethambutol 400 ag * Inclusion to National FP Program still to be decided on. - 92 - Anne 10 Page 12 of 14 1) Chlorine (60-75%) 2) Orthotolidine Solution 3) Insecticide (wettable powder), 100 ml 4) Fogging solution (emulsified concentrate) 8W 1) Norfioxacin 2) Bensathin Penicillin 3) Minoxycillin 4) Metronidazole 5) Aoyolovir 6) Lindane (1% solution) 7) Miconazole Nitrate * Suggested STD drugs to be used in Operations Research - 93 - Annex 10 Page 13 of 14 PHILIPPINES URBAN HEALTH AND NUTRITION PROJECT L=1S OF TECHNICAL ASSISTANCE Comenentg1: Service Delivery Service Ungradina 1) Civil Works Management Instintional Develooment Area-Based Planning 1) Consultancy Services on: a) Revision of ABP Guidelines b) bevelopment of ABP cum Training Curriculum c) Development of Training Materials 2) Plan Formulation 3) Plan Presentation to LGUs 4) Annual Plan Review Information. .Education and Communication 1) Evaluative Research 2) Foreign (to be provided in kind by AIDAB Canberra) Training and Human Resource Develonment 1) Consultancy Services on: a) Job and Needs Assessment b) Development of Data Bank and Career Plan c) Development of Training Program d) Development of Recruitment, Selection, 2romotion & Deployment System 2) Course Development 3) Training Evaluation & Planning 4) Impact Evaluation of Training Plan 5) Foreign a) Consultancy services on Interactive Multi-Media Technology Management Systems Improvement 1) Consultancy Services on Organizational Systems Review 2) Information System Planning 3) Systems Development & Implementation a) Geographic Information System b) Personnel Information System c) Services Networking Information System d) Logistics Information System 4) Systems Installation Facilities Voarading 1) Civil Works Management Project Management and Coordtnation 1) National Annual Program Review 2) National Work & Financial Programming 3) Management Consultant Services - 94 - Annex 10 Page 14 of 14 QCmmnL Partnershi Planning Grants 1) Program/Project Planning and Management 2) Project Evaluation Institutional Grants 1) Consultancy services on: a) Project Development b) Project Evaluation c) Project Monitoring d) Community Organizing for Health Project Grants 1) Consultancy services on: a) Project Management b) Project Evaluation Research and Evaluation BaselLrn and Evaluation Surveys 1) Baseline and Evaluation Survey 2) Mid-term Evaluation 3) Impact Evaluation 4) Rapid Appraisal 5) Evaluation of Birth-Based Approach 6) Overall Process Evaluation 7) Overall Impact Evaluation EvLronmental Health Develo2mn 1) Consultancy services on: a) Survey of Project Areas b) Project Evaluation c) Program Preparation Women's Health/Family Planning 1) Consultancy Services on: a) Conduct of Research b) Community organizing for Women c) Research Documentation d) Research Utilization Nutrition DevelgiNU 1) Consultancy Services on: a) Development of Marketing 6 Distribution Scheme of Food Packs b) Conduct of Research c) Process Evaluation Schemes Operations Research 1) Consultancy Services on: a) Conduct of Research b) Research Utilization -95 - Page I of 2 !liILIPRIlM URBAM HEALTH AND NUTRITIONERORCT 1. Strategy for Training in UHNP 1.1 Support operation of a center for developing training courses - capacity to design and specify training course - ability to contract course development and course material production - ability to evaluate courses delivered 1.2 Buy services from available sources of training course delivery - regional offices of DOH - selected academic institutions - NGOs with training capacity 1.3 Develop training course coordinators in LGUs with capacity to organize, schedule, procure and evaluate training courses 1.4 Flexible scheduling and selection of batches of trainees from LGUs. 2. UHNP will develop a new midwife course using the birth-based approach, a new set of program managers and supervisors courses based on devolution and a new set of planning/budgeting/monitoring courses based on urban poor focus and devolution. 3. UHNP will upgrade existing training course the content of which need not be radically altered. Upgrading will be towards multi-media or interactive video disk. 4. UHNP will support delivery of upgraded and new courses. 5. Major concern is to speed up course development, course updating and course upgrading from about 2 years to 6 months. 6. One concept is to design a turn-key contract for a pilot course development center. The contract will include: - hardware and software needed; * roster of materials design/graphic design specialist; - pool of funds for training materia'.s development activities (pre- testing/prototype production, etc.). !" P1iU"1 11 " 11 11 iffllf1ll"jiff'r"' 1110 re s ra r a ra , p ii i i iiiiiiiii 111 '44 [ . . . 1 . . . 1 . st i ssaf. . . . . .. . . . * . . .. . .. . . . . . . . . . . . . .3 .0 a P9 Pi2 . 9 :; ^ 9 9 - d ä h , 1 - - 97 - Anne 12 Page 1 of 9 URBAN HEALTH A M MI* 9Ai* CgnDonent 2; Insttujtionzal..DevelgpnMDL Subcom2onent 2: Strengthening Information. Education and Communications (IEC) 1. Obiectives and Target The primary objective is to promote health consciousness and stimulate positive health seeking behavior amongst the urban slum populations, particularly those identified as priority beneficiaries of the services provided under Component One. Specifically the project shall seek to achieve the rollowing: (a) to develop and implement a strategic IEC plan for the project; (b) to improve the effectiveness of the face-to-face communications at the point of service at the outreach, BHS, health center and lying- in clinic level; (c) to develop multimedia center within the DOB to support IEC and training activities of the DOH especially in the context of the UMIP; (d) to develop and implement IEC activities in the following areas, segmented appropriately for the audiences noted below: Audienes urban slum populations and individuals, especially women health personnel at barangay, health center and lying-in clinic levels local health authorities and LOU officials Areas family planning antenatal care delivery postnatal care breastfeeding reproductive tract infections maternal nutrition childhood nutrition weaning childhood development including growth monitoring - 98 - Annex 12 Page 2 of 9 Immunization acute respiratory tract infections childhood diarrheal diseases tuberculosis sanitation water usage use of various levels of health facilities health worker support materials for client-based materials health worker updates and newsletters the concept of UHNP support for health, nutrition, safe motherhood and family planning activities (e) to strangthen the capacity of the DOR to manage IEC a3tivities - development and implementation; and (f) to strengthen linkages and working relationships between services and IEC, and LGU staff and IRC. 2. Basic strateg3 and a=aroach The current system of IEC activities within the DON has been beset by problQms of inconsistency, mis-timing and delays and poor dissemination. Messages ranging from information to motivation are usually delivered using print media. The volume of information which needs to be communicated is enormous and messages are sometimes inconsistent and conflicting. Despite high levels of awareness, often retention of information by the clients is poor and patchy. Moreover, resources for social marketing are not sufficient to communicate corporate policies and enables the campaigns to be effective. Strengthening the communications efforts in the light of the implementation of the local government code is deemed necessary. The vision is to enhance the capability of the national, regional and city/municipal levels in undertaking face-to-face communicatidn supported by appropriate teaching and learning aids and broader awareness raising messages. All health personnel particularly those at the primary health care and first referral levels have and require interpersonal communication skills, and to be familiar with the key messages. At the same tirLe, some of these staff are identified and trained as dedicated health educators and are mandated to provide specific TEC activities within the catchment p-Pulations. IEC support for the UHNP shall Initially focus upon developing a project specific IEC strategic plan. This plan shall include identification of key messages, audience segmentation, message and materials development strategies, dissemination strategies and monitoring and evaluative activities. It would be based upon reviews of existing materials, skills levels, production resources in the public and private sector as well as in-house. It would be developed through a networking process with these agencies and the various services and UNP management. - 99 - Annex 12 Page 3 of 9 In order to improve comsunications and social marketing capabilities at the central, regional and city/municipality levels, support shall be provided for the acquisition of skills and equipment for developing and reproducing IEC materials through the development of a supporting multimedia center. In addition, after a careful initial phasing of the introduction of TV/video capacities at the lying-in clinics, an expansion of this will occur, if favorable reviews, to all the 43 existing and 6 new LICs in the project areas. The DON will receive support through training, foreign assistance and equipment and software to be managers of IEC activities. This will include critical path mapping of individual as well as project wide activities within the strategic plan, interfacing with the critical paths of the various services and LGU activities of the UHNP. and integration with the DON Global and IEC Plan for the five years. Support shall be provided for regular IEC activity specific and annual/mid-term reviews of the IEC sub-component, and to review the following years strategic and annual implementation pland. Ongoing monitoring of the IEC activities will be undertaken. In addition, the sub-component will be involved in the design of and the pre- and post-project evaluation activities. The key messages developed shall focus upon the following: (a) promoting comprehensive approach to maternal and child health through the reproductive cycle/birth based approach; (b) generating awareness of and increasing appropriate behaviors regarding the prevention, recognition and management of tuberculosis, acute respiratory infections, and other infectious diseases during childhood and of the reproductive tract; (c) increasing the appropriate use of public health facilities and services within the UHNP; (4) promoting awareness of and increasing the appropriate behaviors regarding environmental health; (a) promoting and supporting the use of family planning methods; and (f) promoting and supporting the use of mtaternal health services. 3. IM tation strategy The Public Information and Health Education Services (PINES) of the Department of Health (DOH) shall be responsible for the operational management of the IEC activities of the UHNP, including the overseeing of contractual arrangements for the plan. It shall coordinate the development, revision and production of IEC materials, social marketing and other IEC activities for the project at all levels. - 100 - Annex 12. Page 4 of 9 The PINES. in coordination with the Health Manpower Development and Training Service (HNDTS) shall facilitate the development and Implementation of consistent messages for IEC and training an4 similat arrangements shall be developed for the PINES and other DOH services, PINES and IAUs and PINES and the UHNP management team. 4. Resources to be grovided Need to note here somehow that although not included in the UHNP documentation and cost schedules, through the parallel co-financing mechanism being used to disburse the Australian grant support to the UHNP, PINES will receive two years of resident foreign technical assistance in operations management specific for XEC programs, as well as a vehicle after the completion of the Resident Advisor's term. - 101 - Annx 12 Page 5 of 9 URBAN HEALTH AND NUTRITION PROJECT Information. Education and Communication Item Number Unit Cost Cost Inestment Costs A. Equipment Color photocopying machine- 150,000 150,000* Desk top publishing- 530,000 530,000* Desktop video- 360,000 360,000* Computers (laptop)- 4 60,000 240,000* TV/VCR- 48 15,000 720,000* Megaphone" 259 2,500 647,500 Cpm software- 1 27,000 27,000 Windows software- 1 27,000 27,000 Subtotal 2,701,500 B. Training Desktop publishing" 6 28,034 168,2001/ Feature writing" 6 142,034 852,200 Evaluative research" 30 1,303 39,100 Workshop on social marketing" 2 39,100 78,200 Subtotal 1,137,700 C. Technical Assistance Foreign2l Local evaluative research* 2 pm 30,000 60,000 Subtotal 60,000 Total Investment Costs 3,899,200 - 102- Annext 12. Page 6 of 9 Recurrent Costs A. Materials4/ Reproduction of existing IEC materials* 15,000,000 Development of new activities/ materials* 30,000,000 Subtotal 45,000,000 B. Travel Monitoring 400,000 C. Distribution costs" 400,000 D. Maintenance 10% equipment total* 200,0003/ B. Other operating costs Supplies etc.* 7,500,000/ Total Recurrent Costs 53,500,000 Total Baseline Costs $7399,200 Physical Contingencies (5% as *) 100,000 Price Contingencies - foreign (2% p.a.) (as -) 41,080 - local (7% p.a.) (as #) 7,674,590 Total Project Costs 65,214,870 Taxes ------ Foreign Exchange 20.540,000 Nates: 1/ Contract for procurement of desk top publisting equipment should try to obtain a maintenance and training component to the actual hardware and software procurement. 2/ Foreign TA covered through the Managing Agent contract that will be obtained by AIDAB Canberra. 3/ On a declining basis over the five years, reduced to 50% by the fifth year. 4/ Includes all cost of the development of these materials - formative research, field testing, message and materials development, dissemination by whatever means of production - e.g., contract, in-house. - 103 - Annex 12_ Page 7 of 9 (A) Desktop Publishing Training For 6 persons, 2 weeks of training, conducted by a contracted trainer held in Manila: Daily allowances 250P/day for 14 days for 6 persons 21,000 50P lumpsum incidental allowance for 6 persons 300 Travel 4 persons from Nan @ P100 each 400 1 person from RHO, Cebu @ P2,800 2,800 1 person from RHO, Cagayan de Oro @ P3700 3,700 Tainer 1 trainer @ P70,000/week for 2 weeks 140,000 Tnal 168,200 (B) Feature FWing For three regional and three headquarters staff, residential in Manila, for one month"s apprenticeship conducted under contract with a company to produce modules and curriculum, place temporarily in local company, and train. Outputs during this apprenticeship will be useful for the PINES e.g., in- house newsletter, feature for radio/newspaper/TV feeds. Held in two batches. Dail. allowances 6 persons @. P250/day for 30 days 45,000 6 persons @ P50 incidental allowance 300 4 persons from Man @ P100 each 400 1 person from RHO, Cebu @ P2,800 2,800 1 person from RHO, Cagayan de Oro @ P3700 3,700 Contract for 4 weeks @ P100,000/week for 2 sessions * 800,000 Zotal 852,200 - 104 - Annex 12. Page 8 of 9 (C) WorkAsho - Social Marketing For 2 days in Manila, attended by up to 30 participants - from HQ services (including UiNP (10), PINES (5), Regional (3), and CHO HEPO (12)). To be facilitated by staff of PIHES, RA PIRES and Services Experts for technical assistance. Daily allowance 30 persons @ P250/day for 2 days 15,000 Incidentals allowances P50/person 1,500 Venue Fees P1,000/day for 2 days 2,000 Travel allowance P100 for Manila/NCR for 20 persons 2,000 P2,800 for 4 persons Cebu 11,200 P3,700 for 2 persons Cagayan de Oro 7,400 Total 39,100 - 105 - Annex 12 Page 9 of 9 LIST OL EUIPMNT FOR DESKTOP PIBLISHING Item Number Unit Cost Cost Personal computer, with battery, 1 100,000 100,000 4 megabyte memory 386DK, 120 megabyte storage on fixed *hardO drive, one other drive for reading 1 monitor and 1 mouse Printer for manuscript drafts 1 100,000 100,000 Laser typesetter for final pages 600 DPI 4 megabyte memory 1 200,000 200,000 Electronic scanner for copy illustrations and integrating with typesetting 1 70,000 70,000 AVR with surge protector 1 20,000 20,000 Word processing software for windows, desk top publishing software, diskettes, toner, paper, etc. 1 40,000 40,000 Total 530,000 List of EauLment for Desktop Video Production High powered PC SVGA color monitor 1 100,000 100,000 Editing box (video mixer, 3 input- output mixer) 1 150,000 150,000 Video monitor 2 35,000 70,000 VCR 2 20,000 40,000 Total 360,000 - 106 - Annex 13 Page 1 of 13 RB& HFALTH AND NUTRITION PROJECT ORGAMZ&7=O AMD RVVAEMMN OF ORU PROJECT Organizational Structure of the UNNP 1. The DOH Organization for UNP The DOH provides overall direction of project Implementation as well as undertakes direct implementation of nation-wide or region-wide activities. The UHNP is headed by the Project Director, a DOH Undersecretary and Chief of Staff reporting to the Secretary of Health, supported by a Project Coordinating Unit for UHNP, and supervising four groups of DON managers. Group one consists of the units of the Office for Management Services, headid by an Undersecretary. These units prepare all finance, budget and accounting documentation for action by the Project Director. This group prepares the communications sent by the Project Director to the Municipal Development Fund, Bureau of Local Government Finance, Department of Finance regarding releases of funds to DON implementing units as well as local government units implementing the project. Group two consists of program managers for TB, ARI, Family Planning, Women's Health, Nutrition and Environmental Health which generate implementation guidelines to be followed by LOU's implementing the project and undertake technical supervision through the regional field health offices. Group three consists of the managers for the functions of infrastructure, procurement and logistics, IEC, training and 0anagement systems and evaluation studies which generate implementation guidelines to be followed by participating LOU's as well as undertake actual implementation activities. Group four consists of regional directors for NCR, VII and X, who provide field assistance to participating LUs, adapt the project guidelines to the regional conditions, and undertake implementation of region-wide activities like training, IEC campaigns, supplies distribution, etc. These managers perform their functions for UHNP using their respective staff units within the regular structure of the DOH. For purposes of UHNP activities, however, they relate to the UHNP Director. - 107 - Annex 13 Page 2 of 13 The PCU-UHNP is a staff unit providing the functions described in Annex 1. It is headed by a Project Coordinator who is a regular official of the DOB (Assistant Secretary or Director level). The staff consists of 23 positions: 3 of whom shall be assigned to the OMS to assist in budget and accounting transactions; 2 of whom shall be assigned to the MDF, BLGF, Department of Finance to assist in the funds flow transactions; 18 of whom shall be directly supervised by the Project Coordinator. Based on the breakdown in Annex 2, seven positions of the PCU-UHNP would be regular DOH positions, and the rest of the 16 positions would be contracted positions funded from the project. The DO authorizes the release of funds for project activities by DO units (central and regional offices) and by LU's via the action of the Project Director issuing the appropriate instructions to the Municipal Development Fund, Bureau of Local Government Finance, Department of Health. Contents of draft order on project management attached as Annex 3. 2. The MDF of BISF. and at the Department of Finance A unit handling the UHNP account in the MDF shall be set up by BLF. It shall be responsible for releasing funds to DOH and LU on the basis of the request and authorization of the UHNP Project Director. The documentary requirements for authorizing these. releases shall be prepared by DOH, specifically the PCU-UNP and the OHS. 3. The LU Orsanization Each of the 21 LU shall establish their respective UHNP implementation organization. It will typically feature the city or municipal health officer serving as the UHNP implementation officer, reporting to the mayor, and supported by other city or municipal officer as necessary. In actual staffing of the contractual positions of PCU-UHNP, persons coming from the PCU-PHDP would be utilized in order to maximize the use of experienced and trained personnel. A plan for shifting the PCU-PHDP personnel into the PCU-UHNP positions would be made to respond to the growing activities of UHNP and the corresponding decline in activities of PHDP. - 108 - Anmex 13 Pae 3 of 13 UHNP Orgaizational Structure Secr Gf yam DOF PCU fDrUP P~- Staff Tro~o 'naining, WH,me ManaeetS«m OthRegionamDOdctors (VI, X, NCR offim Lv~ LZEæciyHffZJic -IIIl 1 l D A R T U T O F l iIP T ~ _______92622* 53948 ?__3083 9 28 00 _____ n_________________ __r_____ 36986$ ~_ig 2mø00 Tos. 233 - •8 -Ul. 4 ØM 263m - - 110 - Annex 13 Page 5 of 13 Task to be Undertaken by PCU-UHN 1. Preparing the Annual Project Budget Proposal 1.1 Formulate guidelines to estimate annual project ceiling: a. Determine projected annual expenditure based on SAR; b. Provide initial indications of amounts to managers of project components; and c. Assemble an initial indicative annual project budget. 1.2 Propose annual project budget. 1.3 Assist Project Director in negotiating final annual project appropriation during the budget preparation and authorization phases. 1.4 Upon approval of project budget ceiling, proceed to prepare annual work and financial plan. 2. Preparing the Annual Work and Financial Plan 2.1 Assemble the inputs necessary for managers of project components to draft a plan and budget for their respective components: a. set initial ceilings per component and per expense category based on supporting papers of proposed budget; b. determine status of obligations per component, based on inputs of ONS; and c. identify activities/items/components that are likely to be re-planned based on implementation experience. 2.2 Design procedures and forms to be used in the preparation of component plans and budgets. 2.3 Draft, obtain Project Director approval and disseminate guidelines on the preparation of component plans and budgets. 2.4 Assist managers of project components in preparing their respective plans and budgets. 2.5 Design procedures, mechanisms and guidelines for the review and integration of component plans and budgets: a. propose a committee to conduct review (for approval of Project Director); b. propose criteria and guidelines for conduct of review (for the approval of the Project Director); c. assist in conduct of review proceedings; d. document comments, recommendations and results of review proceedings; e. summarize the results of review for approval by Project Director; and - 111 - Page 6 of 13 f. prepare and facilitate issuance of final decisions on the outcome of the review for the information of all concerned. 2.6 Assist managers of project componelts in revising their respective plans and budgets in accordance with the outcome of the review. 2.7 Coordinate with OHS in transcription of the component plans and budgets into the required forms prescribed by DBM for work and financial plan. 2.8 Assist OMS in the preparation, submission and follow-up of the Work and Financial Plans with DBM. 2.9 Assist ONS in the revision or provision of additional documentation as required by DBN for approval of the Work and Financial Plans and subsequent release of budget. 2.10 Work with OHS and MDF in the budgetary release and dissemination of copies of release documents to the managers of project components. 3. Providing the Funds to Defray Project Activities 3.1 In coordination with OMS and MDF, prepare guidelines for initial funds release via one or all of the following: a. use of available LOU funds td be reimbursed by DHNP funds through the MDF; b. use of available DOH funds to be reimbursed by UMNP funds through the NDF; and c. use of other available COP funds by DOH or LUs to be reimbursed by MltNP funds through the MDF. 3.2 In coordination with OHS and MDF, process disbursement transactions: a. assist LOU's and DOH units in generating proper statements of expenditures for project activities; b. collect and consolidate these SOE's; c. prepare summary of 80E's for submission to Bureau of Treasury; d. prepare application forms for withdrawal of IDA credits; e. document applications versus replenishment; and f. liaise with CB, PNB, BT, and WB on the replenishment 3.3 In coordination with OS and 1DF, process reimbursements of disbursements: 4. prepare instructions for MDF.-to pay project expenditures of DOH and LU's; b. monitor releases of XDF to project components; and - 112 - Arnex 13 Page 7 of 13 c. assist LUs and DOH units in sustaining the flow of activities, funds and documentation. 4. Implementing the Technical Assistance Activities 4.1 Prepare a consolidated technical assistance plan for the year: a. collect all technical assistance requirements in the component plan; b. consolidate/package technical assistance requirements into possible contracting modules;, and c. prepare a schedule of technical assistance contracting and implementation. 4.2 Assist managers of project components in the development of Terms of Reference and Scope of Work for required technical assistance. 4.3 Propose contracting approach based on VB-IDA guidelines as applied to specific requirements/circumstances (for approval by Project Director). 4.4 Assist managers of project components in undertaking the contracting for technical assistance (request for proposal, review of proposal, preparing contract documents). 4.5 Coordinate with all DOH units involved in contracting (lAgal, OHS, COA, others as needed). 4.6 Assist managers of project components in monitoring contractor performance, submission of outputs and documentation of satisfactory performance. 4.7 Coordinate with OS and MDF in facilitating the release of payments to contractors based on adthorization of component managers and Project Director. 4.8 Monitor all technical assistance contracts and facilitate termination, amendment, extension or addition according to recommendations of the managers of project components with approval of Project Director. 5. Preparing Guidelines for LU Implementation 5.1 Prepare draft NO& and specific negotiation issues for each LU involved in UHNP. 5.2 Plan procedure and schedule of negotiations for Project Director approval. - 113 - Annex 13 Page 8 of 13 5.3 Assist Project Director, program managers, functional managers and regional directors in identifying and preparing essential guidelines for LGU implementation of USNP. 5.4 Assist Project Director and Regional Directors in undertaking negotiations for MOA signing by LGUs. 5.5 Document all negotiations between DOH and LGU. 5.6 Assist LGU in preparing initial project plan and budget proposal. 5.7 Through the regional field health offices, maintain communication with LGU regarding status of project implementation. 6. Coordinating Central Procurement 6.1 Request managers of project components to prepare initiating documents for procurement (e.g., RIVs). 6.2 Review request against budgetary authorities and restrictions. 6.3 Assist PLS in managing the procurement: a. assist in organizing technical committee to write specifications and undertake review of offers; b. participate in bid administration (issuing bid documents, conduct of bidding, awards); c. monitor the review, evaluation and award; and d. keep managers of project components informed on status of procurement. 6.4 Assist managers of project components in preparing plan for utilizing procured items: a. preparing the distribution list for approval by Project Director; b. arranging the distribution; and c. documenting the receipt and use of items. 6.5 Ensure that procurement documents are reviewed and approved by concerned agencies (man&,ers of prdjact components, PLS, World Bank, all other authorized units or offices). 6.6 Facilitate resolution of procurement issues (complaints of losing bidders, extension of delivery dates, non-acceptance of deliveries, non-release of contract documents from Legal or COA, obtaining approval of various units) by monitoring, coordination, reporting to Project Director, and recommending action by concerned officials. - 114 - Annex 13 Page 9 of 13 7. Monitoring and Troubleshooting of Project Implementation 7.1 Prepare quarterly physical accompltshment reports: a. collect information on day-to-day implementation from all implementing units; b. conduct quarterly consultative meetings or implementation; and c. summarise reports and recommendations for Project Director's information and action. 7.2 Prepare inputs for preparation of monthly and quarterly financial reports of OMS and MDF: a. collect monthly obligations and disbursement by all project implementing units; and b. consolidate reports according to project formats. 7.3 Prepare reports required by WB-IDA and other GOP oversight agencies: a. submit quarterly reports to NEDA, CCPAP and WB; and b. submit annual reports to NEDA, CCPAP and WB. 7.4 Serve as secretariat of WB monitoring/supervision missions. 7.5 Respond to all queries and complaints relative to UNP Implementation (delayed releases, disputes in implementation, confusion about guidelines, etc.). 7.6 Follow-up action by concerned officials necessary for project implementation. 7.7 Report to Project Director all issues, developments and concerns regarding project implementation requiring decision and action. 7.8 Undertake the implementation of any project component or activity which the Project Director decides should be managed directly by the PCU-UHNP. - 115 - Page 10 of 13 Contents of the Deartment Order on UNNP Imolementation 1. Project Director: Undersec. and Chief of Staff, Jaime Galvez-Tan. 2. Project Coordinator and Head of PCU-UHNP: Director Felicitas Ureta. 3. PCU-UHNP organized with - regular DOH Staff assigned to it, and contractual staff funded from project funds (functions). 4. Central office managers responsible for overseeing the guidance of implementation of the following project components: 4.1 Women's Health (Family Planning, Maternal Care, Women's Career Screening); 4.2 Child's Health (ARI, Nutrition, Nutrition OR); 4.3 Facility Upgrading (service delivery facilities, administrative facilities); 4.4 Service Delivery Organization of LGU's (Project Coordinator Ureta); 4,5 Area-based Planning; 4.6 IEC (PIHES Director); 4.7 Training and Human Resource Development (HNDTS Director); 4.8 Nanagement Systems (personnel, budget and finance, facilities and equipment, logistics and procurement, HIS/MIS); 4.9 Community Partnerships (Director Bonoan); 4.10 Baseline and Evaluation Studies (ASEC Dayrit); 4.11 Environmental Health Development (Director Environmental Health Service); and 4.12 Operations Research. 5. Central office managers responsible for ho general support of project implementation (OS/Legal). 6. Regional Directors in NCR, VII and X (field support to LOU). 7. Funds release via MDF of DOF according to KOA. 8. Field Implementation by 21 cities and municipalities according to KOA. 9. Set project cycle with schedule for first year implementation. - 116- An 13 Page 11 of 13 General Roles In Inlementation 1. DQB 1.1 Project Director - decides on project implementation strategies, plans, budgets and activities. 1.2 Project Coordinator * supervises PCU-UHNP. 1.3 PCU-UHNP - performs all the staff functions necessary to support project implementation. 1.4 OHS - performs all budget, accounting and financial management functions necessary for project implementation, in accordance with MDF and DOF. 1.5 Designated Managers of Project Components - prepare all technical guidelines on the implementation of the component by LGU's; and - implements project activities assigned (see typical tasks of Program Managers). 1.6 Regional Directors (NCR, VII and X) * assist LGUs in organizing project implementation in the locality; - interprets project guidelines at LGU request; - provides technical and administrative assistance to LOU in project implementation; and - interprets LGU concerns on project implementation to Project Director/Project Coordinator. 2. MDRD - provides ceiling for UHNP in its annual appropriation; - requests release of UHNP funds basid on DOH work and financial plans; - provides UHNP funds to all implementing units based on work plans; - disburses UHNP funds based on DOH authorization; - prepares financial reports for DOH transmittal to WB-IDA; and - receives releases of project proceeds. 3. mgg 3.1 Mayor - signs MOA on UHNP participation; - establishes UHNP implementing organization; - 117 - Annex 13. Page 12 of 13 * designates UHNP implementing officer; * approves annual work and fLancial plan on UHNP implementation; - approves all disbursements of UHNP funds; and - delegates project Lmplementation authorities to appropriate officials. 3.2 City/Municipal Health Officer * serves as UHNP implementing officer; * directs implementation of UHNP activities in the LOU; * prepares plans and budgets; and - approves implementation actions. - 118 - Anx13 Page 13 of 13 TVDical Program Manager Tasks 1. Technical design of prototype service delivery packages (environmental health package, birth-based mother package, birth-based child package, etc.). 2. Design of training for implementation of .service delivery packages. 3. Conduct of trainers training 4. Design and execution of monitoring and evaluation of service delivery package. 5. Technical review of LU policies and provisions for implementing service delivery packages. 6. Preparation of findings about service performance, service utilization and management and operations. 7. Sharing findings with LGU's and other groups with interest on issues. 8. Staff support in facilitating provision of inputs for LU Implementation (training, IEC, logistic, information). - 119 - awn 1A Page 1 of 6 ZHILIMNEE M&WA HEN=T MN NMTITION MROECT Community Partnership for Nealth and Ntrition in Urban Areas This component operationalizes the mobilization of community participation by adapting the partnership approach utilized by the on-going Philippine Health Development Project (PNDP), and building on the institutional infrastructure and operating experience created by the UNICEF Urban Basic Services Program (UBSP). Described below Are the critical details of this component. 1. Basic AIproach The component provides grants that create and sustain community- level organized actions of a partnership among the local government health authorities, the non-government organizations operating in the localities, and the people themselves in the urban poor areas. The grants cover planning (local level consultations, area-based planning with NGO's, creation of area- wide committees, identification of sub-projects, preparation of sub-project proposals, and partnership organization); implementation of approved sub- projects; and strengthening of operating capacities of existing non-government organizations. These three groups of activities correspond to the three types of grants, namely: planning, project and institutional grants. These activities would be undertaken in each of the 21 cities and municipalities of the UHNP. The DON, through the central Community Health Services and the regional field health offices, would provide the technical guidelines and the administrative support for LOU-level implementation. The funds for the grant would flow through the Municipal Development fund route provided for the whole UNNP. Planning Grants The planning grants would support the following activities and outputs: (a) preparation and adoption of localized and specific city/municipal policies on recruitment, training and utilization of community health volunteers linked to the public health service delivery network; (b) organization and institutionalization of a consultative decision- making structure involving all groups and organizations active in local health and nutrition action for the urban poor; (c) development of procedures and methods for adapting the area-based health planning process to community partnership approach; - 120 - Annex 14 Page 2 of 6 preparing sub-project proposals, reviewing them, and generating local consensus on supporting them; (4) providing dedicated administrative support to sub-project development and implementation in the context of partnership approach. (Specifically, supporting component coordinators at central, regional and local levels.) In localities where these preparatory activities have been undertaken by the UNICEF UBSP, and where the structures and processes for a local partnership are already in place and operating, the component would use these structures and processes to generate sub-project proposals. The USP-created inter-agency committees and project preparation and review procedures could be authorized by the local chief executive as the same mechanisms for implementing the component's project grants. The planning grants will create, or whenever appropriate expand, the existing mechanism for participatory and collaborative planning, community targeting, project identification, project preparation, project review and approval, and monitoring and evaluation of projects. The NGO's in the partnership would be required to be legally registered; with a track record of project implementation, financial accountability and administrative responsiveness; with experience in community-level operations; accredited by the local government; with existing operations able to provide some counterpart resources. The steps in the planning process after the initiation by the LGU are as follows: Activities Outputs Negotiations for participation Agreements to participate of identified groups signed between LOU and NC0s Collaborative planning, Community inputs to area prioritizing of areas and interventions based health plan Identification and preparation of project Proposed project for review proposal (a) Local review and . Endorsement of inter-agency recommendation committee to health officer (b) Regional/Central DOH review Recommendation by DOH of technical aspects of regional director to health proposal officer (c) City/Municipal health Endorsement to mayor by office review health officer based on (a), (b), and (c) Final review and action Approval of project by the mayor Contracting formalities Contract for grant At the end of this process, a project proposal is ready for impleasatation. - 121 - Annex 14 Page 3 of 6 Protect grants The implementation of project grants would be at the IAl-level. The decision-making infrastructure of the partnership established by the planning grants would identify the projects and the project sites, prepare the project proposals and review their project proposals. Based on the consensus of the participating groups, and the independent technical review by the central and regional DOH, the health officer as a key officer of this partnership would recommend projects for approval by the local chief executive. The component plans to support at least 480 project grants on general community health priorities, 216 water/sanitation grants, 108 food and nutrition grants. Based on the assessment of the urban area, the following guidelines would be used to review and approve of project grants: (a) Projects should involve community participation processes in preparing and planning the project proposal specifications. (b) Project should assist communities to obtain some security in access to basic necessities that are essential to long term health and nutrition improvements such as: - development, supply, promotion and distribution of adequate weaning foods through women's groups - setting up schemes for assuring supply of affordable essential drugs - implementing sound environmental health technology packages - utilizing day care and child minding centers for child survival and development activities in health and nutrition - utilizing women's trust groups for health promotion and generating demand for primary health care. (c) Projects should address priority problems of the urban poor with direct or indirect impact on health and nutrition, such as: - provision and maintenance of safe water supply - provision and maintenance of sanitary excreta disposal facilities - organization of cooperative health financing schemes, revolving drugs funds and similar mechanisms for making health care affordable to the urban poor * testing of community mobilization measures in support of TB control, family planning, women's health and child health - use of community cultural events and mass media for targeting health and nutrition IEC to urban poor - organization and training of street food vendors for healthier and more nutritious food. - 122 - Annex 14 Page 4 of 6 (d) projects would have an individual P100,00 per year ceiling; eligibility for 3 years of support upon satisfactory evaluation; with no mere than 20% of costs allocated and spent for overhead. (e) Projects may support an existing activity evaluated and considered to merit continuation, expansion or enhancement. (f) While most projects would be generated from proponents, a group of projects would be focused on promotion of environmental sanitation technical packages and food and nutrition technical packages would be promoted. These technical packages are designed and developed by the central DOB for propagation and implementation by NGO' s or communities themselves. (g) Project would support technical training of iaplementors on the specially designed packages and the more popular types of projects being proposed. In addition, general training on project management, proposal preparation, monitoring and evaluation would be provided. Institutional Grants Institutional grants would support the operations improvement of accredited NGO's with a track record of project implementation. Activities included in the grants based on NGO proposals may be as follows: - training on project development, proposal writing and project documentation - technical assistance on health and nutrition operations and service delivery - manualisation of community organizing experience - developing project monitoring methods - visitation and information sharing with model NGO's - specific training needs of key NGO officers (accountant, operations officer, manager, etc.). A total of 24 grants not exceeding P50,000 per grant is planned. The proposals for institutional grants would be generated as part of the planning and organizing process, when NGO capabilities may need to be developed ahead of any project grant proposal. Training and technical inputs to be supported by institutional grants would be obtained from DON, other government agencies, other NGO's and academic institutions. 2. Sds Flow The component would be executed in discrete pieces called grants. Once a grant is made and the proceeds released, it will be considered a project expenditure. - 123 - Amne 14 Page 5 of 6 The funds flow mechanism would consist of the following elements: (a) A proposed annual plan for planning, project and institutional grants would be prepared by each LOU. This will be included as a part of the LOU' s proposed UHNP annual plan. (b) The central DOH (specifically the CHS with the PCU) will consolidate and review the proposed plans. A recommended allocation of component resources by city/municipality would be prepared for the approval of the project director. (c) Upon approval and release of the UHNP budget, the final allocation of each city and municipality would be provided by the DOH. (d) The IWUs would proceed to process and approve grants based on DOH guidelines and review proposals. The LUs use their own funds to support the initial funding requirements of duly approved proposals. (e) IGUs present expenditures on grants, together with all required documentation, to the DOH via the regional offices. (f) Upon satisfactory review of expenditures, the DOH, through the Project Director, informs the Municipal Development Fund at the DOF that the presented LU expenditures are proper and may therefore be reimbursed by UHNP funds. (g) LU withdraws UHNP funds for grant expenditures and continues the cycle of disbursement and reimbursement. 3. DON Soort to Comaonent lJlementation The DON will support LOU implementation of this component via the central Community Health Services (CHS) and thd regional field health offices. The CHS performs the following support functions: (a) initiates the activation of the component in each LOU by preparing and processing the initial planning grants until the city/municipal decision-making structures are in place and operating. (b) consolidates annual implementation plans and recommends fund allocation for the component activities in each LOU. (use GIS inputs may be important here) (c) prepares the technical and administrative guidelines to be followed by each LOU when implementing the component in the locality. - 124 - Aug 14 Page 6 of 6 (d) receives, reviews and recommends to PCU for Project Director action on expenditure claims of LUs for the component. (e) coordinates the development of model or prototype technical packages for project grants using outside consultants or in house DOH specialists as appropriate. (f) establishes mechanisms for inter-city/inter-municipality/inter- regional exchanges, networking and information sharing among participants in the local partnerships (visitations, dissemination of reports, sharing of manuals, etc.) (g) creates opportunities for technical documentation and promotion of component implementation approaches and experiences (such as issue- focused conferences, policy seminars, case study presentations) (h) undertakes evaluation of project grants from a process as well as an impact standpoint, and disseminate results of evaluation for the benefit of learning by local partnerships. The regional DOH units support the LU implementation by serving as a host and a conduit of CHS activities in the region and by generating reviews of LU implementation for the benefit of central DOH as well as the other regions. The above functions would allow CHS and the regional DOH to facilitate sharing of information and experience from PHDP and UHNP. - 125 - Annex 15. Page 1 of 6 URBAN HEALTH AND NUTRITION PROJECT WOMN'S HEALT AND I= PLANNING Intervention Present Strategy Issues to Consider Family Planning Household Level -- curretitly no Out-patient services and Service Delivery family planning delivered at proactive facility-based household level counselling (high-risk GYN patients, STD Area Based Level - presently clients) missed opportunity to reach groups on dialect, religious etc. grounds Facility Based - services available only on demand, and not in all DOH facilities Limited access for men to family How to include men in planning services and client groups information Protocols Limited availability of family Increasing knowledge by planning manual service providers of updated protocols System for updating protocols Contraceptive Nix Choice limited to: 1 generic Introduction strategy for oral pill, 1 IUD, condoms, new methods, including surgical sterilization, natural injectables, progestin- family planning only pill, Norplant, trials for new contraceptive technologies Logistics Lack of contraceptive supplies Long-term strategy for in urban slum outlets (and in institutio- household distribution). UHNP nalizing logistics rough estimate of 2.2 million management in DON years of contraceptive protection needed over project period - 126 - Annex 15 Page 2 of 6 URBAN. MEALTh AND NUTRITION PROJECT VMGN#8s UWn AND EUM PINM@ Intervention Present Strategy Issues to Consider Medium strategy of utilising Integrating family CARE for accelerated delivery of planning supplies with contraceptives nationwide other birth-based supplies Uncertain supply needs for supporting natural family planning IEC IEC Master Plan regarding IEC Has plan been development incorporating implemented? Does it audience segmentation, message address roles and content etc. exists responsibilities of various agencies? How will birth-based approach be incorporated into Master Plan? How will rumors and misinformation regarding family planning be handled? Need for materials to inform clients and potential clients about type, location etc. of specific services How will information be provided to males? Training Method-based training expanded Training needs in project areas - levels of personnel, skills and functions - 127 - Annex 15 Page 3 of 6 URBAN HEALTH AND NUTRITION PROECT WOMN*08 HEALTH AND PAILY PLANNING Intervention Present Strategy Issues to Consider HoW Will training activities incorporate birth-based approach? How will program training activities enhance NGO and private practitioner service delivery? Monitoring and Breakdown of previous family How to identify women Evaluation planning monitoring system with unset need? Need to agree on performance indicators to reflect birth-based approach How to monitor program quality? How to monitor and evaluate IEC effectiveness? Quality assessment systems have How to develop a focused on certification carried provided-based approach out on facilities rather than to assessment? individuals Organization and Incomplete integration of family Can birth-based approach Management planning and maternal and child facilitate this structure health integration? Unclear support functions for Better definition of other DOH units (e.g., PIHES, support functions HNDT) - 128 - Page 4 of 6 URWA HRALTH AND NUTRTION PROJECT vIMv's WUM~ u A ZM= LANNMN Intervention Present Strategy Issues to Consider Ineffective interagency policy How should the functions committees of these best be carried out? Uncertainty regarding health How to facilitate sector management structure in adoption of birth-based light of devolution approach (including family planning) by LGUs? Operations Establishing women's Research knowledge and preferences regarding reproductive health Design OR to determine needs for STD services to break the cycle of STD infections for women Client satisfaction with birth-based approach - 129 - Annx 15. Page 5 of 6 PHILIPPINES URAN HEALTH AND NUTRITION PROJECT SMMOARF O ISSUES AND RECOMMENDATIONS RE FP COMPONENT O UNP UMP Appraisal Seasion No. 2. 12 January 1993. DO-0QS Conference Room Issues Recommendations Target group to include all For birth-based approach, target group is WRA or all married WRA or the cohort pregnant women cohort pregnant women For facility-based, target groups are: a) 15-45 years old WRA for FP services b) 10-45 years old WRA for FP-IEC Pill dispensation Ideally, physical/pelvic exam recommended prior to initial pill dispensation. However, checklist may be used in lieu of physical exam. One month initial supply of pills, however, more than one month supply may be allowed depending on certain conditions, e.g., distance of residence of acceptor from service facility. Six months supply thereafter. Clients should be advised to come back for check-up after one month of initial pill use then clinic check-up and re-supply every 6 months thereafter. Protocol for physical and Recommend that any new FP acceptor have a pelvic exam physical and pelvic exam within a year after acceptance of a method. Annual check-up of acceptor thereafter. For IUD acceptor, physical and pelvic exam should be an integral part of the IUD insertion procedure. Contraceptive method mix FP National Program provides for wider choice of contraceptives. Policy on method ix to be prepared by Clinical Standards of OCS. This mix should include the introduction of injectable and Norplant. - 130 - Page 6 of 6 URBAN HEAL1R. AND NUTRITION PROJECT SUMARY OF .IUBS ANILRBCONOENDATIONS RE P COMPONENT OF UHNP MUWP Apraisal Session No. 2. 12 January 1993. D-OC Conference Room Issues Recommendations UHNP to provide supplemental funds for contraceptives and training on new methods if these are met by other funding, the UHNP budgeted amount may be reprogrammed for other activities. UMNP to include OR and other research on: 1) FP method choice or preferences of urban poor women and 2) on the introduction of Norplant. Contraceptive Prevalence Rates Dr. Corazon Raymundo of UPPI agreed to provide a provisional CPR for the low socio-economic groups of Metro Manila. Monitoring and Evaluation Performance indicators should complement Indicators with existing indicators of the National Program. These performance indicators should include: - availability - quality - utilization - client satisfaction These indicators should be based on qualitative as well as quantitative measures. Further support may be required to develop specific indicators. The standard National Program indicators and standards for facilities and services shall be prepared by the Committee on Clinic Services. - 131 - Page 1 of 3 URBAN HEALTH AND NUTRITION PROJECT OPERATIM SU O110 3NUTIR Three pieces of operations research are proposed under the project, and two are on-going, as follows. Oerations Research Proosed Under The Project OrSanization of Lrowth promotion. All three of the main elements of growth promotion--growth monitoring, counselling and food supplementation-- are time-consuming and difficult. In other projects, experience has shown that it takes two days a month for a worker to growth monitor the under two children of a client population of 1,000; and at least an hour and a half a day six days a week to organize food supplementation. This is on the assumption of on-site rather than take-home feeding; to avoid food supplements being shared with other family members, the former is more cost-effective. It is unclear what in the Philippines context are the best methods for organizing growth promotion. The current government policy of relying on volunteer workers has potential advantages. It would maximize community participation, hence increasing potential sustainability; and it would minimize the burden on volunteer workers, since each SW would be responsible for only 50 families (or about nine pregnant women and about 18 under twos), and the workers would be assisted by mothers' groups. On the other hand, good growth monitoring and counselling require considerable skill, and hence regular in-service training and supervision; preventing leakages of food also requires close supervision. With an average of 17 Mas per aid-wife, and the many other tasks for which aid-wives are responsible, will aid-wives be able to provide this? And will unpaid BHWs be prepared to give up the equivalent of several days a month to help run a nutrition program In addition to their other duties? OR would therefore be carried out during the first two project years on alternative methods of organizing growth promotion, with the idea that the most promising approach would be expanded project-wide during the last four years of the project. First, a desk review would be carried out on alternative approaches. Then two alternatives would be explored in the project area: (1) BWs (and BNS where available) would carry out growth n-)nitoring and counselling; local mothers' 'trust groups' would be responsible for preparing supplements and organizing feeditig on an on-site, group basis at one of the group's homes; (ii) feeding would be organized in the same manner, but the quality of grcvth monitoring, counselling and feeding supervision would be strengthened by creating one part time paid community worker, receiving ? P400 a month, per 1,500 client population and responsible only for these activities. - 132 - AnMexld6 Page 2 of 3 In view of the importance of this research for the design of nutrition programs in the Philippines, it would be carried out at several sites to ensure validity of the findings: the two alternatives would be compared in two areas of Manila (a very poor and a less poor slum); one site in Cebu; and one site in each of two municipalities--a total of 10 test sites. Sites would be chosen where the ratio of mid-wives to clients would be about 1:5,000. The scale of experimentation in each case would be one Health Center area, or about 30,000 client population, since it is important to try out organizational changes over at least one organizational unit. The outcome measures to be tracked would include: percentage of children regularly monitored/counselled; participation rates in feeding; quality of monitoring, counselling and feeding; and anthropometric measures of impact. The implementing agency for this research would be the DOH Nutrition Service. Food supplement content. The food supplements proposed for initial use under the project have been carefully designed with reference to palatability, cultural acceptability, variety and shelf life; and designed around a base of bulgur wheat and peas, since these are the supplementary foods which are most readily available in the Philippines through the PL480 program. It is not clear, however, if this supplement is the most cost- effective approach if there were no need to accept bulgur wheat and peas as the base. Therefore, during the first year of project implementation, research would be carried out to develop alternative recipes which appear likely to be cost-effective, and in the second year of the project the most promising ones would tested in the field to determine their acceptability, and their effects on malnutrition. Both Asian and African countries have had some success with the amylaze enrichment of food supplements; this rqduces the viscosity of the supplement, enabling children being supplemented to consume more at a sitting. This is of particular benefit for very young children, whose appetite is limited, and who may have difficulty consuming much solid food; and for severely malnourished children, who are often anorexic. Simultaneously with the above research, operations research would be carried out on the cost- effectiveness of amylaze enrichment of chosen supplements. The implementing agency for this research would be the DOH Nutrition Service in partnership with the Food and Nutrition Research Institute. Iron supplementation for infants. The 50 days of iron supplementation proposed for infants will be very costly. At the same time, it may be that other interventions proposed under the project will have a substantial effect on infant and child anaemia--notably iron supplementation of pregnant women, and IEC encouraging women to eat and to feed children more iron-rich foods; in this event, direct iron supplementation of infants may be unnecessary, or not cost-effective. OR would therefore be carried out to test the effect of direct supplementation versus other approaches to reducing infant and child anaemia. This research would be carried out during the second year of the project. The implementing agency would be the Food and Nutrition Research Institute. - 133 - Anx16. Page 3 of 3 On-Goin Operations Research Arm circumference as a.screening tool. A study is being carried out in Jose Favella maternity hospital to assess the relationship between arm circumference and birth weight for a population of a thousand women. This would enable DOH to decide whether arm circumference is a satisfactory screening criterion for selecting pregnant women for supplementation under the project. A prospective study, which would be time-consuming and costly, is not required, because arm circumference changes very little during pregnancy. Goiter. The project currently proposes to, supplement with iodine only women with visible goiter. It is unclear at present whether Iodine deficiency in women with non-visible goiter in the urban areas is sufficient to warrant broader supplementation. A survey of T4 and TSH in blood in a thousand women is on-going also in Jose Favella hospital, and the results will be analyzed to address this question. - 134 - Anx17 Page 1 of 8 ZHILIJPINES URBAN HEALTH AND-NUTRITION PROJECT BASIC SERVICES TO BB PROVIDED AND TECHNOLOGY OPTIONS FMR ENV2RONMNL HEWnT IN URUAN POOR-9OIAMMITIES Pilot project sites in the cities and districts of Metro Manila, Metro Cebu and Cagayan de Oro have been identified, taking into account the diversity of the physical and environmental characteristics of urban poor settlements. A variety of technology packages for water supply, excreta disposal, solid waste management, drainage, vermin control, and food sanitation shall be introduced based on available technical options with appropriate modifications to suit land space conditions, water resources available, drainage conditions and access to services from utility companies in the selected urban poor areas. There will be 12 pilot project areas in the initial year of the project with 8 in Metro Manila, 3 in Metro Cebu and one in Cagayan de Oro City. From the second to the fourth year of the project, demonstration projects will be implemented in 36 urban poor areas, i.e., 24 in Metro Manila, 9 in Metro Cebu and 3 in Cagayan de Oro City. The environmental health service package will consist of the following: - construction of water supply, toilets and drainage facilities, and food stalls; - provision of materials and equipment for the pilot projects including collection carts for the solid waste management project, and for insect and rodent control; - institutional development in the form of technical assistance and support for community organization to be provLded by NGOs; - technical assistance to LGUs and participating government agencies in project planning and management; - training of project implementors and beneficiaries; and - project support in terms of logistic support for travel, meetings, seminar-workshops, report preparation, documentation and communication. The technical and technology options to be pilot tested, initially in 12 urban poor settlement areas (1 per city/district), are briefly described below: - 135 - Annex 17 Page 2 of 8 1) Water su9glX_technology outions For water supply, those urban poor areas which are within the service coverage of the MWSS in Metro Manila and the Cebu Water District for Metro Cebu and the Cagayan de Oro Water District for Cagayan de Oro City may be connected to the water utilities as a single consumer, with water distributed and sold through public standposts as Level II service. In areas where the water mains of the water utilities are far and the supply not adequate to serve the community, several deepwells may be drilled to serve each community. Alternatively, rainwater catchment tanks may be set up. It is unlikely that spring sources will be available in the middle of cities where most slums are located for development as water supply sources. Technology options for water supply are discussed in more detail in the implementation volume. 2) Excreta disposal technology options The overcrowding and lack of space in many urban poor communities poses a severe constraint in improving toilet facilities, whether individual or public. Land space availability will determine whether individual or public toilets will be used and whether on-site or off-site treatment will be prescribed. Furthermore, availability of adequate water supply will also determine the type of toilet with regards to flushed or sanitary latrine type. These options are discussed in the implementation volume. 3) Solid waste management options Options for solid waste disposal is also limited in terms of known and used practices. It is common to see piles of garbage around the cities when garbage collection by city authorities are not efficient. This results in uncollected garbage, not only near slums and squatter areas, but also near markets and even the affluent sections of the city. This explains why those near rivers and creeks commonly throw their garbage into these bodies of water and other drainage canals. Clogging of drainage pipes and canals often results in local flooding which also affect these communities. The strategy adopted is to reduce the volume of garbage to be disposed through recycling of materials like bottles, plastics, metal, and paper. Sorting and community collection will also be adopted in pilot communities. Technology options for solid waste management are discussed further in the implementation volume. 4) Draina&e Drainage is the responsibility of the Department of Public Works and Highways. However, in the slum areas, internal drainage within household lots is the responsibility of the residents. The unplanned nature of most slum and squatter settlements prevent the digging of drainage canals leading to the drainage mains along most streets in the cities. The construction of internal drainage to take away sullage and effluent from septic tanks will require community action and cooperation. Simple concrete canals with adequate covers that can be removed for regular cleaning, de-clogging and maintenance can be - 136 - Annex 17. Page 3 of 8 designed and constructed. Drainage options are discussed further in the implementation volume. 5) Food sanitation and street food trade For food sanitation, training of food operators, food handlers and mothers is the basic intervention. However, minimum standards of food sanitation will be developed to apply primarily to the ambulant street food trade. This will legitimize their existence and at the same time enable the City Health Offices and District Health Offices to monitor their activities. Moreover, technical and material assistance shall be extended to these vendors to enable them to comply with basic sanitation requirements. The project also envisions the setting up of pilot street food and trade areas in Quezon City for Metro Manila, District II in Cebu City and in Cagayan de Oro City. This will require the cooperation and support of the concerned city governments in terms of site selection and provision of land. Facilities to be set up in the area such as stalls and public toilets will be provided by the project. To make this component viable, fees for the use of the facilities will be collected. For the management of the pilot street food and trade area, a vendor's cooperative is envisioned. Please refer to the implementation volume for information on the pilot street food trade area concept. 6) Insect and rodent control Strategies for dealing with the problems brought about by insects and rodents are mainly health education and control measures. The health education aspect of the project will deal with the promotion of good sanitation practices in the household and in the community. Control measures include: a) environmental and physical control; b) biological control; and c) chemical control. The first is covered by the improvements to be brought about by the preceding package of environmental improvement. Fogging and spraying will be the main technology options to deal with mosquitoes, houseflies, cockroaches and rats while environmental and physical improvements are being implemented in the communities. Insect and rodent control are discussed in Annex 7. The pilot projects will be monitored and evaluated throughout the entire project cycle to determine feasibility and acceptability of the technology options to both implementors and beneficiaries. Successful pilot project technologies and approaches will be replicated in 36 other areas through demonstration projects towards the latter years of the project. It is expected that the pilot project phase will take about 1-2 years allowing the remaining years of the project for the demonstration project phase. While the feasibility and acceptability of the projects are determined during the planning, construction, operation and maintenance of the sub- - 137 - Amnex 17__ Page 4 of 8 projects, the projects will also be evaluated for their institutional, financial, sociological and technical implications. STRATEGIES TO EACH THE URBAN POOR Because of the relative uncertainty of effectiveness of the approaches used, and the large magnitude of need for environmental health intervention in the urban poor areas, it is deemed more practical for the project to focus on the development and testing of alternative technology packages that may be applicable in various types of urban poor communities. The sites for the pilot-test and demonstration projects were selected based on their being representative of the various types of urban poor community. The types of urban poor settlement are described more fully in Annex 6. Once appropriate technologies have been successfully field tested and demonstrated, other urban poor areas may benefit through expansion programs that may be adopted by various local rnd national institutions concerned about the welfare of the urban poor. The accessful technologies shall be disseminated and shared with other organizations and communities for possible replication. Under Component 3 of this project, other communities will use these technologies for specific priority environmental sanitation problems to be funded through project grants to NGOs. The Environmental Health component requires the introduction of technology, institutional setup, financial arrangements and procedures that may not be familiar to the implementors and the beneficiaries alike. It will be necessary to train project personnel and organize beneficiaries so that a cohesive team of institutional workers and beneficiary groups will work together for the successful implementation of the project activities. The training and community organization activities are deemed to be inherent part of the technology packages to be tested. The DOH Environmental Sanitation Unit (DOH/ESU) will be responsible for providing technical assistance to the personnel of implementing agencies at the local level. These include staff of local government units, city and district health offices, water utilities as well as accredited NGOs. DOH/ESU will be assisted by local consultants in training, planning, design, implementation, monitoring and evaluation of projects. Local government units will be assisted in the coordination of project activities since the project involves different agencies and organization. In line with the decentralization policy of government as embodied in the Local Government Code, the project will take the opportunity to train local level agencies in the nuances of planning and programming of water supply, sanitation, drainage, solid waste and food handling. The project will also provide opportunities for NGOs to be trained in water supply development, sanitation planning, drainage and solid waste - 138 - Amnex 17 Page 5 of 8 management. Many NGOs working in communities miss the opportunity to provide assistance in ;hese fields due to lack of technical knowledge and experience in such projects. The pilot projects will adopt the strategy of providing an integrated package of interventions to improve the environment in slums and squatter settlements. The inclusion of drainage and solid waste management as part of sanitation, which traditionally was limited to excreta disposal, will help prevent the spread of diseases attributed to a dirty environment in the pilot project areas. The size of the pilot projects were chosen such that the resources required to implement an integrated package of interventions will allow for a number of projects to be implemented, monitored and evaluated. Funding limitation may not allow the whole integrated package of interventions for other communities. For other communities covered by UNP, NG0s will be provided with environmental sanitation project grants under component 4 to address specific water supply, excreta disposal, solid waste disposal or drainage problems. While the government sanitation interventions are to be implemented as a pilot and demonstration project package, these will be closely linked to the other components of UNP. This will be true in planning and selection of sites for priority but only to the extent that project costs will allow. It should be noted that the environmental sanitation components are really infrastructure projects that are relatively costly compared to other health and nutrition interventions. It is for this reason that resources may not allow the environmental sanitation component to cover the entire area targeted by UHNP for its health and nutrition components. Role of NOGs and Community Organizations Considering the low priority accorded to slums and squatter settlements by most government agencies, it is expected that development in these areas will happen only if the initiatives come from the slum dwellers themselves. The distribution of water either from the city water utility or from deepwells will require some form of organization to manage collection, operation, repair and maintenance. Maintenance of drainage systems and public toilets will also require organized effort. Collection of sorted garbage and their disposal will likewise need an organization to manage and maintain the system. The same organization that will manage the different projects once completed will be needed in the various phases of project development to its completion. The active participation of the community is critical particularly in the planning stages of the different projects. The fact that these are pilot projects means that a lot of new concepts will be tried which make consultation with the users a must. Once they are in place, the projects will require close monitoring in order to see how they can be made to function properly and how people can be motivated to use and maintain them properly. - 139 - Anne 17 Page 6 of 8 It ir recognized that NGOs who spend more time in the communities are better situated to handle the community organization aspects of the sub- projects. In many urban poor communities, NGOs are helping communities in livelihood, health and nutrition projects for which the communities are trained and organized to undertake the improvements themselves. The project will need the help of these NG0s in working with the communities to improve the environmental sanitation situation in the pilot areas. On the other hand, the project will help NGOs develop their capabilities to plan and implement water supply, sanitation, drainage and solid waste projects. LGU-NGO Collaboration With local government units providing the inter-agency coordination for the planning, implementation, monitoring and evaluation of the different environmental health packages, the project will also promote collaboration between the government agencies and NGOs at the community level. For most LGUs and most of the newly elected local executives, the project will provide the opportunity to implement development projects within their areas. Successful collaboration can only be attained with the participation of the inter-agency group in all aspects of the projects from planning to maintenance of the projects. It will be crucial during planning that the roles and responsibilities of each member of the group are defined and their commitment made. MONITORING AND EVALUATION The experimental nature of the environmental health project package and the application of technologies not familiar to the implementors and beneficiaries will necessitate constant monitoring and close supervision during implementation. Adjustments will be made as feedbacks are provided by field implementors and beneficiaries. Demonstration projects will consider changes made on the original design of the pilot projects of the first year. Evaluation will be made at the mid-year of the second and fourth years. The first evaluation will be used to improve the pilot project models. The second will be used as inputs to the preparation of the environmental sanitation program for urban poor communities. ARRANHMEFORTLIPLVARTION The Office of the Environmental Health Service (EHS) will be responsible for overseeing the implementation of the environmental health component of UHNP. They will provide technical assistance in planning, introduction of appropriate technologies, training, and management support to the field implementing units composed of the city and district health personnel, local government units and NGO staff in the implementation of projects within their areas of responsibility. The DOH will organize a project management team within EHS to oversee the day-to-day project activities in collaboration with the field implementing units. - 140 - Anx17 Page 7 of 8 The beneficiaries in each project site will be organized into Barangay Waterworks and Sanitation Associations (BWSAs) as provided under R.A. 6717 dated March 17, 1989. The responsibilities of the BWSAs will be modified to enable them to undertake wastewater disposal, solid waste management and rodent/vector control in addition to their mandated water supply and sanitation activities. Each BWSA will have one committee each for water supply, sanitation (excreta disposal) and drainage, solid waste management and food sanitation. These committees will be responsible for the operation and maintenance of the facilities to be turned-over to them by the UHNP. Anoroach to Immlementation The project will strengthen the decentralization policy of the government and provide the opportunity to exercise the provisions of the Local Government Code. While the DOH Central Office is responsible for the implementation of the project, planning and implementation will be the responsibility of the CHO/DHOs, LGUs and NGOs. The role of ERS is mainly to provide assistance to the local units through the Project Management Team. Technologies will be introduced through the CHO/DHOs. Institutional development support, particularly, on community organization and participation will be provided by NGO partners, and local government units will be involved in coordination and monitoring of projects. These groups who will be the main Implementors of the projects will be provided with technical training to develop their capabilities to implement the project. NG0s will be provided with technical support and training to help them implement environmental sanitation projects under component 4 in addition to providing community organization support to this component. Members of the communities selected by the BVSAs will be included in the training to motivate them to provide community inputs to the project. Beneficiaries and users of the facilities will be trained on proper use and maintenance of facilities to attain maximum health benefits from the project. Imolementation Schedule The projects are to be implemented over a five-year period from 1994 to 1998. The 12 pilot projects will be implemented in 1994 to early 1995. The 36 demonstration projects will be implemented from late 1995 to 1997. The final year (1998) will be used to evaluate the project and to prepare a long- term environmental sanitation program for urban poor communities. The detailed project implementation schedule is shown in the implementation volume. Consulting Services The services of local consultants will be procured for the duration of the project. The consultants will provide technical advisory services to the project management team at EHS, the CHO/DHOs, NGOs and the local government units in the following areas: - 141 - Annex 17 Page 8 of 8 - project implementation - institutional support - technology options - monitoring and evaluation - project documentation, and - preparation of long-term environmental sanitation program for the urban poor. Consulting services will be for a total of 24 man-months (m-m) with 6 a- a each during the initial (1994) and final (1998) years, and 4 m-m for each year from 1995-1997. Provision of Block Grants There are 5 components for each project that will require civil works. Each of these components will be designed to suit the situation in a particular area based on actual surveys and consultation with the beneficiaries. Materials would be better procured locally to offset the difficulties of transportation to project sites if procured centrally. Furthermore, adjustments may require changes in initially prncured materials considering the experimental nature of the projects. It is, therefore, recommended that in lieu of centralized procurement, block grants be provided to the projects through the implementing NGOs for flexibility in disbursement of funds. However, disbursements will have to be approved by the field implementing committee composed of the CHO/DHO representative, the LGU representative and the NGO representative. The total cost of the proposed environmental health component is P43,600,640. The project cost estimates are based on engineering designs prepared by the Environmental Health Service officials of DOH with the assistance of local consultants. It should be noted that the average cost of providing water supply, sanitation and drainage facilities were based on an assumed mix of technology options. Technical surveys and detailed design of these facilities will determine the actual costs for each project site. Annual financial requirements will, therefore, be based on the design which are prepared before the preparation of annual work and financial plan for each project area. A detailed breakdown of the estimated cost of the proposed p-oject is shown in the implementation volume. Civil works in the form of facilities construction comprise 60.4 per cent of the total cost, technical assistance, 8.1. per cent, training, 7.1 per cent, logistics support, 13.8 per cent and the remaining 10.6 per cent for equipment, materials, supplies and chemicals. omM. m an mtil7m PR~JEC 1994 1991 1996 1997 199 totel. eam.n's Realth 1,199,111 1,034,669 2.303,134 2,$1,469 2,494.863 18043,087 Childr.s Health 1423.1 484,670.6 2,1.1,11 321f,436 3,414,431 9,331,11 . Control 1,351.t9 1,.101986 1.1.24 1,4i1m1 8. 1,.4 .15.2,u0 .U...,,rg ,60,04. 1..14.11 1. .03 1.s.3 1. ,.3 1.. Suboal tweice 0et very . 9~0st9tiona Devaolement Ama Dased Plaming 245,19.4 50,943.4 10,943.1 1048.8 10,983.4 640,970,9 Inforwation, Uueatltna $ cm tnom ?",m11.8 61,'s9.# 1,202,01 61,509.4 61,509.l 2,114,040 Training £ sm Resouce Dev~ oRemnt 81,50.2 340.651.9 157650.8 30 930.9 19,396.2 188.004 Management System I.pøovement 1,183076 - - - - ,133,016 M..i..,.oli,ty,,,.86.9 ,.0.,m - 3. 7.3 346.31.2 9.27.3 1,...3? c. Commety Partnørgbip for ieulth flemala4 asts 201#282.6 1.W? 24736 30101 2818? 10813_ .titut.n.l r..t. .14.2 ... 1,2.. 1.26.2 ,...4 ..0 trojeck Brast 24463".1R.JA II .Rffla ~ubotøl ca~ty Prtt~bip for -løfflø IIøsul -IIL76 1MSØM ,0177 UIV 0. S e a eh 6 svaluati o5 Daseline aaation iurveys 1,113.3 1,113.2 6,113.2 6,113 6,113.2 30,16.60 Uuwironmel Health Developmet 76833.8 612,273.2 601,889.1 601,489.1 11,160.4 2,64,244 ..trie......Iq ant m0.m.,4 1..... - - - *0. .. Inflation Local 593,867.7 768,913.1 1,969,041 2,684,163 3,314,434 .9,3,020 Foreign 149,491.2 10JO. lles033,2 353s2 $ 0 ,‡,9 Subtotal Inflation -41.349.0 ø99,4.2 2,219,074 3,052969 3,929,743 10,61,69 Døvaluation -331,036.4 -432,576.9 -1,123,088.0 -1,6,103.8 -1,978,711.1 -1,419,164.1 sbtota #ic Contlfngncis Taxes . - - - I 1 Forølgn "xcheng» 9,72.918 2,909,328 3,397,603 3.600.974 4,322.679 23,968.490 0 l嗡 I綱 010 吋喝 闕I 劉為 黝之 ，一臼寥，視斗•神．耗，.t,．弱．州饞必．必吋•館e寥．唱討．粤亂蓄．權潤，．。t••．寥參也．唱，．必也，.OU館唱．,,,．你•開‘t•煙．必韶細叫綱唱婦鉀”d ，•－-－一，•”一•開朋甚 樂為嬝斤瞧劉離寡縫蚣鯽中必潺戴灑釁L總臨州默－L以么變榭j州他．劉選董〔“•醒L•蝕亡L“獲皇配邊L也饞劃血里糾鬨。斗細劇闖．,．劉 ：•訌：．計，：一：：亡，仕廈－－二豐一聖三一門！‘三竺。變．,．•，二，.．•，,&,，•，二，..，一餌審二二，鴉一膠奮甲”一，開’弓藝弓闢寫馴馴開閑蓄雙騙訪二I呂‘ 豐三塑雙。＿tl號豐曉巒豐＿___._r響侈．’唱，’萬，.．廈••，’祕i勺痲．’痲弱嚇一祈j婦吃弱痲．弱痲．i聶．，州騙騙騙日不弱必騙 挪．&r寥磷〝，、”〝t.，衛化．&,1…”,’二以．.,．細，&.．細必兩唱露痲e祕、必吃痲啄祈祈i.h•一’一痲泌，面泌耐瀾斤J 強折史擊→－&‘豐豐黠粚叫F寧工！藝”叮〔干賽干興，叩丈興，〔寧速〔、，織飄勰罵？.:&& ,~．•，~-－二“一，，一‘&&‘一亡＿._,,‘一‘••一，．•’．馴”闖•，寥馴’& :．一一＿－一：___＿。＿＿亡＿___&_＿亡＿。＿_，一“,&”••．一＿一”••”華•絮鵝夠奮•開••訪，t 巒一豐三淤－－一‘一，，一•．,’欄”‘•一‘“▼•，‘•，’觀，&&t二，“州蟀•·訪“騙”認 巒”&,.．一••一”亡＿.___.＿•”,,．•，．·•“叮”,&．刁馴唱’. 亡一•，:__.__＿。＿•，”一弓唱•一豐＿____-－一勵叮磚華浮．神二 仕－－一，•‘一”一t”•．•，一，&’寥巒＿,_＿•K,.1,.，•t•！鈴，．鱸’• 兀亡一•一•一•．&“•，劇結奮夠：,,t:t寥．‘昤化“,”戶”。．“細閱，. &-－一•－--．一，開州牌亡，，•馴縫，寥弘•妒•神夢••細唱 ------．一”一颼，一t,&－二，．一C鸛，．•朋州•讓劍紹馴論召”. ,．•。－-．一•－－一么‘.&&．。－-.--－一•州口．一‘•～一。血‘ 閱才－一一，,,,.-,．••＇•．．•，二一， 胛磚口蒲網O寥闢陽寫勵閱唱．t寫 ,．劉亡戲1－劉亡匹〕L註觔國中么總亡選佳•丈韭虻當甦．－變」觔朧二－--－一煙騷〕韭〕－必豳焜也L配區》醒－觀取洶〔L•獨，閑悶•••l，嶼 ，•－一，••－一，一口軍歸細．&. 繃齋臘荔－獸挪騙斗騙魷貍山斗〔驢訌縫－髡口離·一二－--－二－－一L團亡口必二－---－·二一一－一－--．馴”,”馴悶，&，悶網唱，，畸，喝 ．•，.，•．-．•‘-．巒透仕。巒雙：___＿一＿．•，&．•一寥一•寥口一屆唱藝，一•朋調叮嗡闕磚調寫劇增電開I網調唱 ，•馴開•劇牌二州，&．·……‘和細•－州繭神神中紹 ·…”二，&.,’二。·。：····．-，哺嚼翠魚：: 環汰繡：〕各一t&:j.,,...，〕一i撇；.-,,.:i..,c一i.．一麋！ •電“唱寥綢•馴“&．露．露 壟壟戴叢屬莽壟置 一抑”•馴叮胛攔開•神．蒲．。縣土一爾奮頃矚一→贊醴輛「 ·兀闕細寥電閱馴磚‘“唱．．•“戲奮唱．．•鬨•開 卹州關唱 座仕變么一一賺間開買→一―一－ 仰顯州觴荔編跚細 乃馴霄飲頂口爾蔆口頂閉零網劉 織縱韌m爾 a- civil *9 9.750.1å# 10.0 m sn-o g 3,559,612 39.9 m,ocm c: Stege tioffl.i 0. Tomeloa, m^.9 8. redning 1.691.40 91. Tochnicel #mojetonco 1~681 ANNUtanco. ftcotgn ?~igel Motat*~# smhtoM Tochmeal Aug~ 6. Ck«to Totd Invootenot coets 419,43 M -45.24x4 376se.w bl: ft 13 -511.1703 1 w -T.I 1.340.491 e tt. Recursomt couta a. omt~iv« D. rad 9~ 6~ 9 lat, 932. 1 C- ld-~ rimtg 2,349,1n ~ a ~ cal 51111#292 19.8 snoln-I Meglab 40459439% r. natt klar? 6.652.ftå contrect solcry 601*434.9 5.249*224 Iranol 24,111.0 ».111.; 5.434.8 tolös.o 1,103~ a. C, I at? völmtoorg 9240129.3 30. Mint~ 198.188.; 2,030211 111. Mur ~ rating cont Lut. total kocortont. cooto =:Eld X-50-i MåsMöj ~ DURLM CONTS 20454#246 nyfticel omtift~ tele* Cent& leo Allard fokom rna~ 0~ ni. I 0,1p1 Foreign cm~ sn.m.-o 0 ca 11b 壟 視t之〞”楓’題·t•已．露•寥．鷗弱•勿弱’t寥魷唱〞啊t,t。驢參．露鵝，t飩，＇各勵•’：驢0．口驢．寥一，·亂鵬．t電•藝寫‘,.to．驪弘t化輯’t斗一馳電’唱“•電唱闕自＇C必．’露露屆，神名 瓖界不寥二棗審寥奎縱鈇L辭卻分寥二州荊鈴路森于拱糅進·露二抑生江興亡止縱坏訐丰二饑錢予併調半，勰黑弟瀾中，r& •朧化1:.t一•t亂．亂鰓，t一t．•館．勵粤。t．弱．&t露t.-.，一t籐忿．tt•．露一邸寥寥．鷓二露。．，劇闕•調t州’開 響·t電囉，．開·奮·ttt．個騙·矓．鉤t.t亂•t·闢t，•鳥···二t·•寥唱．t騙藝。t·t認唱．奮寥藝，”馴”•負電觔寫勵奮，，網哺，‘禺 t討．粤t•t一電磚〞召•審．籐一t&t絲．•t一t”權魷．•縴－·－一。6必•．t•！•！一釭•．醒•1&t·t…鵝’. t輪．龍參．奮·t99．鰓，勿一寥．，言•．開•一露．,t•’唱：•－···一，露寥．••寥，t·•t露，•鰓’t·盧二！．寫勵，二•州唱‘• 已發奮＇．舛．•一t華•，•弱，t .t&t參t〞寡啄亂一審．t•勵．寥•t---－一tl二討•．t ot珍●．網口．•。名。．電吋J邵．韋籐‘婦 寥••．嗚勵唱．參．奮9審一黝徊，t tg已一t．。，蓄審，歸t，鉤審一t電寥奮．•t電t，訪•，唱參痲一，。一闢t,“珍，f。亂tt，讓認t．騷6華•，必t必．露．1．•”勵聯’忽 嗚寫韋〞•tt&，一。二•個寫，馳，.t•鳥．t t．露闢•”擊一•．&t•，t弓電．弱露．露露倡寥．唱寥‘.t辟。6•觀騙．討t．弱個‘唱亂t露‘露．切寥．t．言．倡扯勿寥，“奮．••必．•1.，胛馴。，‘加攤．口 弱t．如，．認一。鯽露化鵝勿，.&t，言t露－一，．挪t．寥寥審－-－一關么騙珍啄，t－一•t必．6輯〞t•寧”寫•馴開”J，州，) •騙．”•．•一•騙．唱夠．•一•．開鳥．必t.－二魷‘．必t•－·－－一t寥t．•鰓．亂一鰓電．0奪．也。．調馴開奮劍闢戶”由·t 曦”‘二，.．啄··寥餐，．幼．電常’“寫勿It··t&&，二It···二電二t,,,t·二t二‘,,&t州1祠．,．。，州。， 儲才•讓“審加••，•。．鑰”t寫 們吋 ·耀磯爭日－－鍛簽手娶。選么饑將辭于一霎磚鴃終興也L輿回江＋－賽也池響則也•州鄒訐于一•珊襬仔興回‘‘絢彎荔灣．l’與 珊機干日－■邵審卜驗！辭卜蘇驪篠－-．鬍概雜件薑嗡尖卜＋一一于一•＋－一→－，一珊鄒卜→一州磚許洗網于勰閑梁禺習訕叢婪r 奮．闢籐〞暱t珍－.t．閱露．啄啄曆露·闐唱．，。。露·卹嗚．曾。－－一t．•討．鰓珍－一電，•寥，．轉．婦1.&J．•馴”每．t“響t”審叫”名 •，••，.t劇悶，”騙闕”名‘. 闕‘憚個必．寥一煙麗，.0．言唱”，寥露’開露．嬸露t’魷一，．閱唱‘J必‘tCt.t·－·一幼•．露卯．言－．亂露．也館．！醒．t弱．t•細唱。零“名•• t”寥鶴一調口，寥．鰓•．t•9．•純，魷•騰，必•勵．tt一I’名鈴•．仰•，寥露－-－一•．啊露•馳•。•．關t．露t•一唱露I•勰口”權，寥寧購唱 唱．!t寥一開t一言．蓄奮寥唱魷一必．唱弱．審一唱t唱飼，寥一9．弱t.t一，．弱寥’t一也．初．.1●。t．唱弱，t6.”闕鉀”d’才 也糰．•開，t-.’粤，．飼唱：．開6化，&t開．弘－.’細，.．口t’餌，&:．自鉤倘闢。•’弱名嗡．’闢e館露觀，勺朋，’一1．中開化開神rt幼，’神”dl哺個’• 個馳，劇磚，6t一觀r飩，化亂開，魷rt你．”口．&t一t．唱tt勿tt唱·唱！唱．唱t二電規．唱幼一t.ttt．電驢鬍．神鳥．鵝寥魷亂．號鳥．6 .ttt.tt•．,ttt．亂開．t網楓目t釁．語‘彎 •勻劇繙妒州啊鉤豳啊，& 妒祕攤劇磁•一蒲系祇可一，爭祠，誠啊一啊擊蘊－州審論颼－杯”司鬥籵戶細，乍q一〕鋒了－下緬蘇－下滿楓『閑編『唁勾織一神擊蘊，•憤賬萬－】綢網r-’華可弋司 ,’電劍叩，”鉀矚，,’奮馴唱韋，，廈馴唱】 一一一渠果h霸騙『一―一雜么綢騙『一一一一州羲轟勰鳥闖一一－一－一’攤勿鬍辭一一一一 萬編騙不面兩斤飾可 騙祠不啼爾鄴痲甲軍編爾 騙申狗爾 - 146 - A=CX 19 PHIUffiNES URB AN HE" AND UIMMON MOJ D~ s~um ~rso~ D~ Onmil % Cuplu~ Disbumement IDA Remt Y~ Some~ cunwt~ Amount PmM for Philippines some~ (Us$ MMM) Diebumed M Educ~ Pn~ M Jan.-Jun., 94 0.2 0.2 0 0 EM Jul.-Dec., 94 1.4 1.6 2 3 Jan.-Jun., 95 3.5 5.1 7 3 E= Jut.-Doe., 95 4.2 0.3 13 6 Jan.-Jun., 96 6.3 15.6 22 14 wz Juf.-DOC., 98 7.0 22.0 32 22 Jan.-jun., 97 7.7 30.3 43 26 Jut.-Dec., 97 8.4 38.7 55 30 Jan.-Jun., 98 7.7 46.4 w 34 am JUL-Doc., 98 7.0 53.4 76 42 Jan.-Jun., 99 8.3 69.7 85 54 am Jut.-Dec.. eg 3.5 03.2 90 70 Jan.-Jun., 00 3.5 00.7 96 78 EM Juf.-Dec., 00 3.3 70.0 100 oe Jan.-Jun., 01 94 Jut.-Dec., 01 96 Jan.-Jun., 02 100 ~147- Anex 20 3ju a mu me lu 11 k till f l IIIII M Klil Ilili KI1 -148 - Annex 21 Page 1 of 9 DRAFT MEMORANDUM OF AGREEMENT (1MOA1*) THE DEPARTMENT OF HEALTH AND THE LOCAL GOVERNMENT UNIT AND THE DEPARTMENT OF INTERIOR AND LOCAL GOVERNMENT 1. Parties to the MOA This Agreement is entered into this - day of _ 1993, by and between the following parties: 1.1 The Department of Health, a national government agency established and existing under the laws and regulations of the Republic of the Philippines, with offices at San Lazaro Hospital Compound, Sta. Cruz, Monila represented herein by Secretary .,(hereinafter referred to as the "DOH"); 1.2 The [city government] [municipal government of 1, a local government established and existing under the laws and regulations of the Republic of the Philippines, with offices at represented herein by its Mayor (hereinafter referred to as the "LOUN); and 13 The Department of Interior and Local Government, a national government agency established and existing under the laws and regulations of the Republic of the Philippines, with offices at represented herein by the Secretary (hereinafter referred to as the "DILG"). 1.4 Each of the DOH, LGU and DILG are collectively referred to herein as the "Parties". 2. Premises 2.1 Whereas the Government of the Republic of the Philippines (hereinafter referred to as the "Government") as a party to that certain Development Credit Agreement dated . 1993, (hereinafter referred to as the HDCAN) has obtained from the International Development Association (hereinafter referred to as the "IDAN) a credit in the amount of million dollars equivalent (hereinafter referred to as the "Credit") to assist in the financing of a national Urban Health and Nutrition Project (hereinafter referred to as the "UNHP"), which UNHP is described in Schedule 2 of the DCA and covers, j=tct Aia& the area and - 149 - Annex 21 Page 2 of 9 population under the jurisdiction of the LOU; 2.2 Whereas pursuant to the provisions of Article of the DCA the DOH is designated as the lead national agency charged with the implementation of the UHNP; 23 Whereas pursuant to the provisions of Article of RA 7160 (1991) of the Republic of the Philippines (hereinafter referred to as the "Local Government Code of 1991") the DIM Is the national agency primarily responsible for assisting the President of the Philippines in exercising general supervision over local government units, including the LOU; 2.4 Whereas the effective planning and implementation ofUHNP activities require the participation of agencies of the local government by virtue of the Local Government Code of 1991 as well as other pertinent legilation and implementing regulations; 2.5 Whereas pursuant to an Inter-Agency Memorandum of Agreement entered into between the DOH and the Department of Finance, the Department of Interior and Local Government, the Department of Budget and Management and the National Economic and Development Authority of the Republic of the Philippines dated 1993 (hereinafter referred to as the Inter-Agency Agreemeat"), part of the proceeds of the IDA Credit shall be made available to the LU on a grant basis (hereinafter referred to as the "Grant") for the purpose of assisting in financing the implementation of the UHNP within the territorial jurisdiction of the LOU; and 2.6 Whereas the DOH and the LOU expressly recognize and acknowledge the desirability of implementing the UHNP with due diligence and efficiency and the necessity of specifying their respective duties and obligations in that regard so as to ensure the complete success of the UHNP. NOW THEREFORE, the Parties hereto hereby agree and covenant as follows hereinafter: 3. General Provisions 3.1 This Agreement sets forth the terms and conditions for the implementation of the UHNP within the territorial jurisdiction of the LOU. - 150 - Annex 21 Page 3 of 9 3.2 This Agroement defines the respedve authorities, dutles and obfgations of each of the DOH, DIW and JGU in undertaking the vadous actvies necessary for the iplementationof the U QNPwlthin the territorial jurisdicon of the LGU, which UHNP is a project pardaly funded from the IDA Credit which costituts a foreign ource financing within the meaning of the provisons of Ardcle 26, Rule V on Exceptions to Devoludon, of the Rules and Regulations Implementing the Local Government Code of 1991. 3.3 le Parties hereto sha~ at all times tak a acdon necessary to cooperate with e otbr aud perform their respecdve dutles and obligadons in order to, jat &li: (a) Achieve the objecaves of the UHNP as they are set out in Schedule 2 of the DCA, which objectives iclude namely each of the fo(owing:(I) mproving the health and nutridon status of slum dwelers in the LOU; (i) buding capacty of the LGU to plan, finance, and implement cost-effecve slm health and nutition programs, in partnership with loea cmanmide, NGOs, and the DOH (iii) assisting slum communities within the LGU in identifying ther own health, nutridon, and envfronmental problems and pardcipat in planning, implemendng, and monitoring appropdate iterventions;- amisting the DOH develop appropate polcies and strategies for improving the outreach and cost-effecdveness of health and delivery systems in urban areas; and (lv)implementing the man strategies and related policies of the UHNP. (b) Carry out promptly all UHNP acties and related duties and obligations falling within the territorial jurisdicton of the LGU, as such activides, duties and obligaons are described in this Agreement and in the DCA, on the basis of an overa f"ve-year Implementation Program which shall have been previously approved by IDA. Saild ImplementationProgram shaR be executed ana tyinaccordancewith a yearly Operadonal Plan, atisacory to IDA, wbich plan sha~ be prepared by the Pardes not later than December 31 in each calendar year, beginning with the calendar year 1993. Sild Operational Plan shal include theprdcipal indicatorsad terms and conditons set forth in Annex I which is attacbedhereto. (c) Not later than October 31 in each calendar year, beginnig with the calendar year 1994, meet with representatives of IDA for the purpose of reviewing the progress achieved in executing the Im&plmentadon Program during the year under review and, taking into considration IDA's comments and recommendatin, adjust accordingly the -151 - Annex 21 Page 4 of 9 Operational Plan for the immediately following year. 4. Designation of the LGU as Implementing Agency 4.1 Upon the effectiveness of this Agreement in accordance with its terms, the LU shall be designated by the DOH as an implementing agency for the UHNP within the territorial jurisdiction of the LU. 4.2 The LOU hereby declares its commitment to the objectives of the UHNP as set forth in sub-paragraph 33 (a) of this Agreement, and, to this end, shall () carry out the UHNP within its territorial jurisdiction with due diligence and effiiency and in conformity with appropriate administrative, financial, and health practices; and (ii) provide promptly as needed, the funds, facilities, services and other resources required for the UHNP within its territorial jurisdiction. S. Duties and Obligations of the IGU 5.1 The LU shall perform with due diligence and efficiency the following duties and obligations in implementing the UHNP within its territorial jurisdiction, all In accordance with the overall UHNP implementation guidelines and the provisions of this Agreement: (a) designating and assigning all local officials to be responsible for UHNP activities within its territorial jurisdiction (b) appointing all UHNP-supported contractual personnel to be placed under the supervision and control of local officials; (c) Initiating and preparing the annual UHNP Operational Plans for executing the Implementation Program in its the locality; (d) issuing instructions on the manner of executing UHNP activities in its locality; (e) approving the location and sites for specific UHNP activities in its locality; (t) approving all procutement contracts to be financed by proceeds of the Grant and otherwise all Grant funds released within its locality; (g) approving all grants made to non-government organizations to be paid from UHNP funds released to its locality; - 152 - Annex 21 Page 5 of 9 (h) approving the attendance and participation of all local personnel in UHNP activities such as meetings, conferences, workshops, training sessions, and field visits. 5.2 In order to implement the UfNP, the LGU, by executive action of the Mayor and, whenever required with the concurrence of its Council, shall: (a) establish, authorize and maintain a local organization that can carry out or cause to carry out necessary tasks for the timely, proper and effective implementation of UHNP activities in its locality; (b) adopt and comply with the technical and administrative guidelines issued by the DOH governing UHNP activities, including guidelines required by IDA; (c) promptly prepare, authorize, and execute as required by applicable laws and regulations a local annual governent budget which provides for the following costs associated with UHNP Implementadon, in accordance with the financing guidelines of the yearly Operational Plan described in Annex '. hereto: (i) cost of all local operations which UHNP is designed to augment or expand; (ii) the LOU*s local goverment share in the Government's counterpart cost funding for UHNP implementation; (iii) the costs of progressively absorbing in the local government those UHNP-financed activities which need to be sustained beyond the life of UHNP. 6. Duties and functions of the DOH 6.1 As the lead implementation agency for overall UHNP implementation, the DOH shall perform the following duties and obligations with due diligence and efficiency: (a) preparing and issuing guidelines governing the execution of UHNP activities, including the requirements of source of financing; (b) starting up the UHNP activities in each LOU locality; (c) preparing, consolidadng and finalizing national annual UHNP Operational Plans and related budgets based on the submission of the local UHNP implementation plans of the LOU; (d) implementing activities involving several or all LOU localities which can be more efficiently executed regionally or nationally; - 153 - Annex 21 Page 6 of 9 (e) initiating the authorization of funds availability, the approval of disbursements and the release of Credit proceeds for UHNP expenditures; (f) maintaining the flow of communication between the Government and IDA relative to UHNP, between DOH and the participating LOUs' between the implementation agencies and the other national agencies such as DOF, DILG, DBM, and the Commission on Audits; (g) monitoring and evaluating UHNPimplementation undertaken by other local governments; (h) organizing quarterly, semi-annual, and annual UHNP implementation progress reviews with the participation of the LOUs; (i) providing for regular consultations with LOUs on UHNP Implementation namely NCR, Region VII and Region X 6.2 In order to perform the above, and support the LGUs Implementing the project4 the DOH, by action of its designated ofiials, shall: (a) establish, authorize and maintain a national and regional organization to perform the tasks and duties if lead UHNP implementation agency; (b) prepare, propose, and execute a departmental budget that satisfies the DOH obligations for supporting the financing arrangements provided for in Annex I hereto; (c) provide or arrange to provide technical, administrative and material assistance to local government in support of their implementation of UHNP. 7. Arrangements 7.1 Proceeds of the IDA Credit will be made available to the DOH central and regional agencies, as well as to the LOU through the Municipal Development Fund established under PD. 1914 (hereinafter referred to as the "MDF"). The specific rules and regulations governing the availability and use of the proceeds of the Credit through the MDF are provided therefor under the Inter-Agency Agreement which is attached as Annex I hereto. While the Credit is a national government loan, the proceeds of the Credit herender are being made available to the LU on the basis of the Grant. - 154 - Annex 21 Page 7 of 9 7.2 The LOU shall utilize the Grant and such other funds, facilities and other resources allocated and made available to it for the purposes of carrying out the activities planned and programmed for the territory under its jurisdiction, in accordance with the provisions of this Agreement, including the Implementation Program, and also the technical and administrative guidelines of the DOH as the agency responsible for the overall management and supervision of the UHNP. 7.3 (a) The LOU shall maintain separate records and accounts adequate to reflect in accordance with sound accounting practices the operations, resources and expenditures in respect of the UHNP within its territorial jurisdiction (including, without limitation, its costs and the benefits to be derived therefrom) or any part thereot (b) The LOU shall (i) have the records and accounts referred to in paragraph (a) of this paragraph for each fiscal year audited, in accordance with appropriate auditing principles consistently applied, by independent auditors acceptable to IDA; (i) furnish to the DOH as soon as available, but in any case not later than four (4) months after the end of each such year, the report of such audit by said auditors, of such scope and in such detail as IDA shall have reasonably requested; and (fll) furnish to the DOH and such other information concerning said records and accounts and the audit thereof as the DOH or IDA shall from time to time reasonably request. & Eligibility of Disbursements 8.1 All disbursements of the Grant made under the UHNP shall be for expenditures in respect of the reasonable cost of goods and services required for carrying out the UHNP within the territorial jurisdiction of the LDU and to be financed out of the proceeds of the Grant. Said disbursements shall also be at all times in compliance with UHNP guidelines as set out in the DCA in order to be eligible for financing under the IDA Credit. The DOH, in consultation with IDA, shall determine the eligibility for UHNP financing of any disbursement made by the LOU. Any item of expenditure or transaction deemed ineligible for UHNP financing by the DOH shall be the liability of the LOU concerned. 9. EfrectIveness of and Amendments to this Agreement 9.1 This Agreement shall become effective once signed by the Parties and shall continue to be effective for the duration of the UHNP In accordance with the provisions of the DCA. The provisions of the - 155 - Annex 21 Page 8 of 9 yearly Operational Plans as further specified in Annex I hereto shall be negotiated and agreed upon annually. 92 This Agreement may be terminated by any of the Parties upon three months's advance written notice. Any amendments to any provision of this Agreement may be made only in writing and upon formal execution by the Parties. 10. Procurement of Goods and Works and Reuitment of Consultants 10.1 Except as IDA shall otherwise agree in writing, all procurement of the goods and works required for the UHNP, and to be financed out of the proceeds of the Grant, shall be governed by the provisions of the "Guidelines for Procurement under IRD Loans and IDA Credits" published by the World Bank in May 1992. 10.2 In order to assist the LU in carrying out the UHNP within its territorial jurisdiction, the LU shall employ consultants whose qualifications, experience and terms and conditions of employment shall be satisfactory to IDA. Such consultants shall be selected in accordance with principles and procedures satisfactory to IDA on the basis of the "Guidelines for the Use of Consultants by World Bank Borrowers and by the World Bank as Executing Agency" published by the World Bank in August 1981. 11. Representatives and Addresses of the Partles The following representatives and corresponding addresses are specified for the purposes of this Agreement* For the DOH: For the LOU: For the DILG: IN WITNESS WHEREOF, the Parties hereto, acting through their duly authorized representatives, have caused this Agreement to be signed in their -156 - Anne 21 Page 9 of 9 respeed~e nmes in Manil, Republic of the Philippins, as of the day and yar Erst above written. [LGU] DOH Authorzed Representative Authorized Representative DILG Authorized Representative - 157 - Anex 22 MDF Funds Flow (Loan Process) Foreign Lend'n Institution Issues Remittance Advice CBP Issues Credit Advice BTR Issues Certificate of Availability of Funds - CAF Requests A/A BLGF and NCA A--A Informs CPO that Issues A/A Funds are Available and NCA DBM Approves request/ Transmit to BLGF Issues/Credits Advices LBP T NCA to Release CPO the Funds to I euds t Infonns LGUs that U LOUs Funds are Available Request for Release of Funds L. -4 LGUs - 158 - Anne 23 Page 1 of 2 URBAN HEALTH AND NUTRITION PROJECT IDA SUPERVISION PLAN 1. IDA Supervision Input. The staff input indicated in the table below is in addition to regular supervision needs for the review of progress reports, procurement actions, supervision report preparation and correspondence (estimated for this project to require six staff-weeks per year throughout project implementation). 2. Borrower's-Contrib-ution To SgRervisio. 'ca) Annual work programs, to be prepared by each participating local government unit (LGU), would be reviewed by the Project Coordinator and appropriate central DOH technical and financial staff, and the content, plan and budget for each work program would be negotiated and agreed between DOH and the LOU. These plans would be aggregated into an overall project annual plan to be agreed by the DOH Project Director and Chief of Staff. (b) Six-monthly progress reports to be prepared by the Project Coordination Unit (PCU) would use a simple, tabular format, agreed with IDA during or before the project launch supervision mission, to compare achievement against agreed plans. The initial progress report would be due on June 30, 1994. (c) Annual project performance reports, to be prepared by the PCU, would include the progress report for the two preceding six month periods, and a concise, narrative section describing major project achievements and problems encountered. Annual progress reports would be due on June 30 of each year. (d) Project monitoring and reporting of implementation progress in accordance with the approved annual work program would be the responsibility of the PCU, with inputs from the DOH technical services and regional field offices as required. (e) The PCU would be responsible for coordinating arrangements for Bank and other donor supervision missions, and for providing information required by missions. Mission briefings on arrival and wrap-up meetings would be presided over by the Project Director and Chief of Staff. (f) The Government's contribution to a Project Completion Report would be prepared by the PCU and submitted to IDA within six months of the closing date. - 159 - Annex 23 Page 2 of 2 3. eld AInervision Plan Approximate Staff Input Dates Activity (staff-weeks) 01/94 Project launch mission 4 07/94 Initial supervision mission 6 12/94 Annual plan review mission 4 07/95 Annual progress review mission 6 12/95 Annual plan review mission 4 07/96 Annual progress review mission 6 12/96 Mid term review mission 8 07/97 Annual progress review mission 6 12/97 Annual plan review mission 4 07/98 Annual progress review mission 6 12/98 Annual plan review mission 4 07/99 Annual progress review mission 6 12/99 Final supervision/PCR mission 8 (a) Annual progress reports would be reviewed by an IDA supervision mission in July of each year. Lessons from this review of progress would then be fed by DOH and LGUs into the annual plans to be drawn up by IGUs. (b) These consolidated annial plans would be reviewed by an IDA supervision mission in December of each project year. (c) A comprehensive aid term review would be held in December, 1996 to determine the need for modifications to the design and implementation targets of all project components. (d) Each IDA supervision mission would: (i) require at least two weeks in the field; (ii) require the services of specialists in health and management on a regular basis, and of specialists in procurement, geographic information systems, computerized management software and Civil Vorks as needed; and (iii) revie" progress of procurement and civil works, financial statements and disbursements, credit covenants, and the Implementation of technical assistance and training activities. Specialized skill requirements would be added to the missions according to needs identified by previous supervision missions, and would include among others the following areas: women's health and family planning, nutrition, information technology, architecture, and community participation. PHILIPPINES IIAM lEAL,U Ae .TReim MiojecT Natidnal Capita] Region Population Change by Municipaflity, 1980-1990 -jam Increase Nationwide: 26.1% Avg. Increase in NCR: 33.8% Range of Change in NCR: -2.6% to 117.5% Percent Change - 1111Noetiv. Growth 30 > te IUIUMIHAL1U A- MWRIrT PROJC? National Capital Region Population Detisity by Municipality, 1990 Avg. Density in NCR: 13357.6 Persons Per Sq. Km. Range of Density in NCR: 6290.3 to 40133.3 Persons Per Sq. Km. Persons/KM []M 1500 - 25000 - 162 - Anne 25 RBIAN HEALTH AND NUTRITION PROJECT SELECTED DOCUMENTS AVAILABLE IN WE ZROJCT PIE 1) A Study of the Urban Poor in Cagavan De Oro City. August 24, 1992. 2) A Study of the Urban Poor in Ouezon City. Department of Health, October 1992. 3) Poor and Healthy? (The Health Situation of the Urban Poor in Cebu City in.19901. Office of Population Studies, University of San Carlos, Cebu City, 1991. 4) Comonent 1: Service Delivery Component 2: Institutional Development Department of Health, December 1992 5) Component 3: Community Partnerghip Co=onent 4: gesearch and Ryal-tas Department of Health, December 1992 6) Assessing the InstitutionaLl 2mnnents of the Service Delivery System of the DOB Health Care Program in Selected NCR Depressed Communities. College of Public Administration, University of the Philippines, March 1992. 7) Urban Poor Health. Nutrition and Family Planning: 1991 Netro Manila KAP Su=r. Population Institute, University of the Philippines, June 1992. 8) Hkalth and Nutrition Status and Health Seeking Behavior amon Families in Hish Risk Urban Communities. Social Development Research Center, College of Liberal Arts, De La Salle University, October 1992. 9) Rid AaraLsal of High Risk Commuities: The Case of bsis. Taggig and Kalooluan City. Social Development Research Center, College of Liberal Arts, De La Salle University, June 1992. 10) A Study of the Urban Poor in Queson City: A Brief Summary of Methodolony and Findings. Department of Health. 11) Poverty. Health and Nutrition in Cagyan de Oro CitS. Xavier Universitv, Cagayan de Oro City, October 1991. 12) Report bNF.C. Bowman (Consultant) on HW. Pre-Apraisal Mission (November 15-28. 1992). December 1992.