Strengthening Local Governance for Health (HealthGov) Project

First Quarterly Report, Year 2 October 1 to December 31, 2007

Cooperative Agreement No. 492-A-00-06-00037 31 January 2008

Prepared for Ms. Maria Paz de Sagun, CTO United States Agency for International Development/Manila

Prepared by RTI International 3040 Cornwallis Road Post Office Box 12194 Research Triangle Park, NC 27709-2194

This report was produced for review by the United States Agency for International Development/Manila

The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government. Table of Contents Page

List of Acronyms iii 1. Introduction 1 2. Summary of Major Activities and Accomplishments During the Report Period 3 3. Issues and Concerns Encountered During the Report Period 5 4. Major Project Activities Planned for the Next Period (Second Quarter Year 2) 5 5. Detailed Description of Activities Conducted During the Report Period 6 Project Management 6 Organization and Team Development 6 Corporate Management and Technical Support Visit 8 Revision of Year 2 Work Plan 8 Collaboration and coordination with Other CAs and National and Regional 9 Stakeholders 5.2 Project Implementation Activities 10 IR 1.1 Strengthening Key LGU Management Systems to Sustain Delivery of 10 Selected Health Services IR 1.2 Improving and Expanding LGU Financing for Health 16 IR 1.3 Improving Service Provider Performance 18 IR 1.4 Increasing Advocacy on Service Delivery and Financing 34 6. Monitoring and Evaluation (M&E) 40 7. Financial Report for the Quarter 41

HealthGov Project—First Quarterly Report Year 2 (October – December 2007) ii List of Acronyms

AI avian influenza AIDS acquired immunedeficiency syndrome AIP annual investment plan AO administrative order ARMM Autonomous Region in Muslim Mindanao BCC behavior change communication BEmONC basic emergency obstetric and newborn care BHS barangay (village) health station BHW barangay health worker BLHD Bureau of Local Health Development CA cooperating agency CDLMIS Commodity Distribution and Logistics Management Information System CEDPA Centre for Development and Population Activities CEmONC comprehensive emergency obstetric and newborn care CHD Center for Health Development CHLSS Community Health and Living Standards Survey CHO City Health Office/Officer CSO civil society organization CSR contraceptive self-reliance CTO Cognizant Technical Officer DA Department of Agriculture DILG Department of the Interior and Local Government DOH Department of Health DOH Rep Department of Health representative EC European Commission EPDM evidence-based participatory decision-making EPI Expanded Program on Immunization F1 FOURmula ONE for Health FHSIS Field Health Services Information System FP family planning FSW female sex worker HealthGov Strengthening Local Governance for Health Project HealthPRO Health Promotion and Communications Project HIV/AIDS human immunodeficiency virus/acquired immunedeficiency syndrome HPDP Health Policy Development Project HSR health sector reform ICV informed choice and voluntarism ID identification IHBSS integrated HIV/AIDS behavioral and serological surveillance

HealthGov Project—First Quarterly Report Year 2 (October – December 2007) iii ILHZ inter-local health zone IR intermediate result IT information technology IUD intrauterine device LAC local AIDS council LCE local chief executive LFC Local Finance Committee LGU local government unit LHA Local Health Accounts LHAD Local Health and Development LICT Local Implementation and Coordination Team LSI living standard indicators LSS local services standards M&E monitoring and evaluation MARP most-at-risk population MCH maternal and child health MHO Municipal Health Officer/Officer MIPH municipal investment plan for health MIS management information system MLGU municipal local government unit MNCHN maternal, neonatal, and child health and nutrition MOP manual of procedures MSM men who have sex with men NCDPC National Center for Disease Prevention and Control NCR National Capital Region NEC National Epidemiology Center NGO non-government organization OFW overseas Filipino worker OH Office of Health OP operational plan OPD outpatient department PAR participatory action research PC Provincial Coordinator PFMP public finance management plan PHIC Philippine Health Insurance Corporation PhilHealth Philippine Health Insurance Corporation PHN Public Health Nurse PHO Provincial Health Office/Officer PHTL Provincial Health Team Leader PIPH Province-wide Investment Plan for Health PIR program implementation review PLGU provincial local government unit PMG Project Management Group PMIS performance management information system PNGOC Philippine Non-governmental Organization Council for

HealthGov Project—First Quarterly Report Year 2 (October – December 2007) iv Population, Health and Welfare, Inc. PO people’s organization POPCOM Commission on Population PPA program, project, activity PPDO Provincial Planning and Development Office PRISM Private Sector Mobilization for Family Health Project PSEP Public Service Excellence Program PTAP provincial technical assistance plan RH reproductive health RHM Rural Health Midwife RHU rural health unit RPM Responsible Parenting Movement RPM-NFP Responsible Parenting Movement – Natural Family Planning RTI Research Triangle Institute SA situational analysis SBM-R Standards-based Management and Recognition SB Sangguniang Bayan (municipal legislative council) SDExH Service Delivery Excellence for Health SDIR Service Delivery Implementation Review SHIELD-ARMM Sustainable Health Initiatives through Empowerment and Local Development Project – Autonomous Region in Muslim Mindanao SIP service implementation plan SO3 Strategic Objective 3 SOAg Strategic Objective Agreement SP Sangguniang Panlalawigan (provincial legislative council) SS Sentrong Sigla (center of excellence) STI sexually transmitted infection TA technical assistance TAP technical assistance provider TB tuberculosis TBA traditional birth attendant TB-DOTS tuberculosis directly observed treatment, short course TB LINC Linking Initiatives and Networking to Control Tuberculosis Project TMIS Training Management Information System ToT training of trainers TWG Technical Working Group UNAIDS Joint United Nations Programme on HIV/AIDS UNICEF United Nations Children’s Fund USAID United States Agency for International Development USG United States Government VCT voluntary counseling and testing VSC voluntary surgical contraception WHO World Health Organization

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1. Introduction RTI International and its partners are pleased to submit this first quarterly report for the second year of Strengthening Local Governance for Health (HealthGov) Project in the Philippines in accordance with USAID Cooperative Agreement No. 492-A-00-06-00037- 00. This report covers the period 1 October to 31 December 2007 and presents progress made against planned activities for project management and implementation and provision of technical assistance (TA) to the Department of Health Centers for Health Development (DOH CHDs) and local government units (LGUs) in the 23 provincial project sites. Issues and concerns encountered in project implementation and anticipated activities for implementation in the second quarter of Year 2 are also outlined in the report.

HealthGov’s approved work plan for the period 1 October 2007 to 30 September 2008 states the overall strategic direction for the second year as follows:

“The overall direction of the project for the second year of implementation will build on the foundations laid in the first year. The various scoping visits and data collection activities, workshops and orientations of LCEs and local government counterparts, and capacity building of NGOs, CSOs, and other stakeholders have provided the project with a strong local network of partners and in-depth knowledge of the situation on the ground. This has enabled the project to prepare initial provincial-level work plans that respond to local conditions, needs, and priorities. The design, piloting, and evaluation of TA interventions in the first year – including improved PIPH guidelines, SDIR and SDExH approaches, and CSR planning and monitoring tools – provide a menu of strategies and tools that LGUs can select from when they address their health priorities. More TA interventions will be developed during the second year of the project.

HealthGov TA to LGUs is directed by a number of guiding principles: HealthGov assistance is demand-driven and strategic in nature; the project engages regional and local partners as technical assistance providers as described in our technical proposal and the work plan for Year 1; project activities are closely coordinated with other CAs; and HealthGov TA is guided by the DOH’s Health Sector Reform framework.

Demand-driven. HealthGov TA is based on a thorough analysis of local conditions and participating LGUs are directly involved in the identification of their needs and priorities and in the selection of appropriate TA responses. To receive TA support, LGUs are expected to contribute some of their own resources to implement TA activities: their contributions are counted as cost share to the project. The partnership between the project and the LGU is based on a mutual commitment: to be eligible for further TA support the LGU is expected to implement the recommended actions resulting from earlier assistance.

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Strategic TA provision. To maximize the use of limited (personnel and financial) resources, HealthGov needs to decide what TA is made available when and where. The project will not be able to respond to every TA demand from the LGUs but it will identify issues and priorities that fall within the scope of the project and are common to a number LGUs and that can be addressed by providing TA to a “cluster” of LGUs. TA will also be phased, depending on the situation. For instance, in providing TA for PIPH preparation priority will be given to the F1 rollout sites that need to complete their plans by October 2007, while other HealthGov provinces can be assisted later.

Sustainable engagement of TAPs. HealthGov will not directly perform the tasks of its regional and local counterparts, but empower them to improve their performance by providing technical advice, building capacity, and providing training. This approach will ensure that local capacity is created to sustain the improvements brought about with USAID support beyond the life of the project. While in the first year the main focus has been to develop the capabilities of CHDs and PHOs (particularly in the preparation of LGU investment plans for health), in the second year the variety and number of TAPs working with the project will be significantly broadened and expanded. Potential new TAPs include a number of national partners (such as the leagues of provinces, municipalities, and cities) and regional or local organizations (including universities and NGOs). The use of a voucher system will be piloted to support the development of a sustainable way of providing TA to LGUs.

Collaboration with other CAs. HealthGov will continue to coordinate and cooperate intensively with other CAs to maximize the impact of USAID assistance. In addition to our leadership and participation in national-level TWGs HealthGov staff will actively engage other CAs at the regional level in the coordination of plans, joint field visits, and collaboration in the implementation of project activities, including data collection, workshops and training, and other TA.

Health Sector Reform framework. The HSR policy of DOH will continue to provide the overall strategic framework for the project, guiding the support to the participating LGUs. Our TA will be tailored to the individual conditions and needs in each province, municipality or city, but the provinces can be grouped into three broad categories: F1 convergence sites, F1 rollout sites, and other HealthGov supported sites. Support for the preparation, improvement and/or implementation of their investment plan for health will be a common theme in every LGU.”

In line with the overall strategic direction described above, HealthGov will pursue the provision of technical assistance by capitalizing on the gains made in the first year and moving towards expanding initial initiatives like the formulation of the PIPH in non-F1 sites; downstreaming TA from provincial to selected municipal LGUs like in the case of managing the results of the Service Delivery Implementation Review (SDIR) and Service Delivery Excellence in Health (SDExH) in order to capacitate more local-level staff and enable them to address Operational Plan (OP) and monitoring and evaluation (M&E) indicators; and responding to new opportunities for technical assistance by strengthening collaborative mechanisms with other USAID cooperating agencies (CAs), CHDs, and other local government partners to effectively carry out TA interventions.

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2. Summary of Major Activities and Accomplishments during the Report Period Highlights of project activities during this reporting period are as follows: • Hired the Avian Influenza Specialist, and recruited the Regional Coordinator for Luzon, the M&E Specialist, and the Health Policy and Systems Specialist • Provided technical assistance as follows:

IR 1.1 Strengthening Key LGU Systems to Sustain Delivery of Key Health Services 1. Province-wide Investment Planning for Health (PIPH) – Continued the provision of TA to seven F1rollout provinces in Mindanao and Luzon, namely Zamboanga peninsula provinces (Norte, Sur, Sibugay), Compostela Valley, and Sarangani towards the completion of the PIPH process, including the formulation of initial drafts, generation of major requirements needed to commence the PIPH workshops in Isabela, and the writing of the draft PIPH document in Albay. Continuing technical assistance was also provided to non-rollout provinces that have adopted the PIPH in their health sector development planning, including completion of initial drafts by Aklan, Negros Occidental, and Davao del Sur, and legitimization of the PIPH in Bukidnon and Misamis Oriental 2. Contraceptive Self-reliance (CSR) – Assisted selected CHDs and Provincial Health Offices (PHOs) in planning for and conducting CSR assessments, specifically in Pangasinan, Bulacan, Aklan, Capiz, Negros Oriental, Negros Occidental, Agusan del Norte, and Sarangani; and conducting CSR planning workshop in South Cotabato 3. Procurement and logistics system – Enhanced the commodity forecasting tools and expanded materials to include procurement and distribution options, inventory control systems, and guidelines for proper transport and storage not only of family planning commodities but maternal and child health (MCH), tuberculosis (TB), and sexually transmitted infections (STI) commodities as well 4. Local health information systems – Provided orientations to local officials of Pangasinan, South Cotabato, and Misamis Occidental on the merits of the community health and living standards survey (CHLSS) as one of the tools in the development of a functional local health information system

IR 1.2 Improving and Expanding LGU Financing for Health 5. Financing – As part of the PIPH process, coached rollout LGUs on public finance management planning and resource mobilization opportunities to mobilize LGU counterpart of PIPH budget; developed diagnostic tools that will assist LGUs in their financial planning and management

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IR 1.3 Improving Service Provider Performance 6. Service Delivery Implementation Review (SDIR) – Monitored the implementation of acceleration plans and management of SDIR results in Bohol, Negros Oriental, Capiz and Aklan; assisted PHOs in the integration of SDIR results into the situational analysis of the PIPH in Isabela and Albay 7. Service Delivery Excellence in Health (SDExH) – In collaboration with DOH and CHDs 10 and 7, continued TA in the modeling of SDExH in Misamis Occidental and Negros Oriental through the completion of Modules 3 and 4 and monitoring their implementation at the municipal LGU (MLGU) level 8. Informed choice and voluntarism (ICV) – Assisted the DOH in the conduct of ICV- Responsible Parenting Movement orientation workshops in 10 regions; conducted ICV field monitoring 9. Local chief executive (LCE) orientations in HIV/AIDS sites – In collaboration with CHDs and CHOs, conducted courtesy calls on selected LCEs of high-risk areas and secured mandate to plan following request by CHOs for technical assistance in strategic and investment planning for their respective HIV/AIDS programs; conducted follow-up monitoring of SDIR including the development of service delivery acceleration plans 10. Avian influenza (AI) – In collaboration with the Technical Working Group (TWG) on AI, sponsored AI consultative workshops for regional representatives from the Department of Agriculture (DA) and DOH to provide them the venue to share the status of their AI preparedness, identify problems and their possible solutions, and identify areas or aspects of their AI programs where technical assistance is potentially needed

IR 1.4 Increasing Advocacy on Service Delivery and Financing 11. Advocacy – Provided technical assistance to focal NGOs and PHOs in eight provinces in the conduct of partnership-building initiatives: Capiz, Negros Occidental, Bohol, Misamis Occidental, Zamboanga del Sur, Albay, South Cotabato, and Aklan. TA to these provinces resulted in significant progress in NGO/CSO-PHO partnership, one of which is the PHO’s designation of a focal person who will facilitate linkages with and maintain coordination between the PHO and NGO/CSO partners

M&E 12. Prepared the 2007 accomplishment report that measured project performance against the OP indicators baseline established for 2006; tested the project’s Performance Monitoring Information System (PMIS)

Collaboration with partners and stakeholders 13. Collaborated with DOH and other USAID CAs by leading and participating in the meetings of technical working groups as well as in other project-related activities

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3. Issues and Concerns Encountered During the Report Period

Two major events affected the implementation of project activities during the quarter under review. The first was the Knock Out Tigdas measles vaccination campaign in October when DOH declared a moratorium on field activities in order to focus on the campaign from October 15-30. This particularly affected the schedule of PIPH-related activities in the rollout provinces resulting in delays in the preparation of required documents. The second was the holiday season in December when majority of national, regional, and local staff, as traditionally practiced, went on leave, thus putting on hold almost all field activities.

4. Major Project Activities Planned for the Next Report Period (Second Quarter Year 2)

IR 1.1 • Develop technical and operational guidelines for completing and appraising PIPH for F1 rollout and other provinces, orient CHDs and PHOs on the application of the guidelines, and support field operations teams in providing this TA to LGU partners • Develop technical and operational guidelines for LGU CSR planning • Finalize CHLSS questionnaire and pretest it in Misamis Occidental • Develop technical and operational guidelines on CHLSS implementation and support field operations teams in providing this TA • Develop technical and operational guidelines on implementing evidence-based legislation participatory decision-making • Finalize and pretest the integrated procurement and logistic system tools

IR 1.2 • Develop technical and operational guidelines on implementing universal PhilHealth coverage, and orient CHDs and PHOs on the application of these guidelines • Develop the framework for funds process flow, monitoring system, and financial reporting as part of the public expenditure management study • Conduct the public expenditure management study in CHD 11 • Develop the terms of reference for the PhilHealth benefit review study

IR 1.3 • Complete SDExH workshops in Oroquieta ILHZ of Misamis Occidental and Metropolitan ILHZ of Negros Oriental • Evaluate the implementation of SDExH and plan for its expansion and the training of trainers • Enhance SDExH training modules and develop guide to operationalizing SDExH • Enhance SDIR tools and manage SDIR outputs • Provide TA to DOH in developing an administrative order on ICV compliance monitoring and reporting

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• Provide TA to high-risk cities on strategic and investment planning for HIV/AIDS program • Gather TB data in non-TB LINC provinces, and data on avian influenza in 11 critical areas • Develop and provide specific TA for TB in provinces with low case detection rate and cure rate • Develop tools and plans for AI preparedness and community-based early warning system

IR 1.4

• Assess NGO/CSO capacity to participate in local health board and local development council processes • Prepare profile of local health champions • Map out the health support of provincial, municipal, and city LGU officials • Provide technical assistance in advocacy support for CSR • Identify STTA consultants and other technical assistance providers for the development of process designs and modules on advocacy planning, effective championing, and constituency building for health

5. Detailed Description of Activities Conducted During the Report Period

5.1 Project Management

Organization and Team Development

During this quarter, the project filled important vacant positions with candidates who will assume leadership in key technical areas. HealthGov received additional funds this year for the provision of technical assistance to AI critical areas, 11 of which are HealthGov sites. Accordingly, Dr. Ramoncito Navarro, who has appropriate experience in AI intervention programs, was hired as the AI Specialist of the project. The search for a qualified person to fill the position of M&E Specialist culminated in the selection of Hector Follosco from a number of candidates who applied for the position. Mr. Follosco will assume the post in January 2008. The interview of shortlisted applicants for the Luzon Regional Coordinator was also undertaken during the review period. The appropriate candidate has been chosen and hopefully will join the project in January. The vacant position of Health Policy and Systems Specialist was advertised in a major daily broadsheet and shortlisting of applicants has been started. Following the submission of the Year 2 work plan, and to gear up for project implementation, the regional teams held a consultative workshop in November to review and enhance TA identification, validation, TA team organization, TA delivery, and M&E. The consultative workshop resulted in the development of enhanced protocols for these field operation processes.

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In December, the quarterly cross-training of all staff was held in Cebu City. The two-day activity aimed to enable the staff to:

1) identify the action needed to develop/complete the main TA tools which are yet unavailable, including who does what by what date 2) determine the internal and external technical assistance providers (TAPs) needed to roll out priority TA interventions 3) understand the project’s contracting mechanism for engaging TAPs 4) differentiate the performance indicators of HealthGov/other CAs from OP indicators and explain how the achievement of the former contributes to the accomplishment of the latter 5) describe the process of collecting performance indicators data, and identify the HealthGov staff’s respective role/s in this process

In addition, there were also discussions and clarifications on some administrative and human resource issues including the staff performance appraisal system. As a result of the training, necessary actions and immediate next steps were identified and agreements to move these forward were reached. One of the agreements was for the teams to revisit the Year 2 Work Plan Gantt charts and update them for resubmission to USAID. Another important agreement is the development of TA action plans for major areas of interventions this year. The TA plan is defined as an action plan that provides and weaves together the implementation details of the provincial technical assistance plans (PTAPs). Specifically, it defines the context of TA delivery in the field and identifies the key activities that will lead to the completion of a particular TA, the milestones expected at certain points of TA delivery, who does what by when, the resources required to deliver the TA, and the OP and project indicators being addressed. Another cross-training, this time on M&E, will be conducted in the next quarter. Immediately following the cross-training, another day was spent for a team building activity which sought to: 1) strengthen the bonding and social interaction among the staff 2) instill among the staff an understanding of the vision and mission of HealthGov and connect these to the activities the project is undertaking 3) enable the staff to identify workplace practices based on core values as each one relates to the multitude of actors in the environment – employees, clients, partners, competitors, suppliers, and others who benefit from HealthGov’s work 4) clarify the staff’s role in and communication requirements within the purview of HealthGov 5) enable the staff to participate in the commitment process to practice the values consistently

This activity inspired the staff to renew their individual commitment to the objectives of the project and to work together as a team to carry out activities more effectively and ultimately deliver the results expected of the project.

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The practice of holding regular weekly meetings was maintained by the Project Management Group (PMG). Periodic consultation meetings were held with the regional teams to review the progress of project implementation and address emerging policy issues in a timely manner. Consultation meetings were also held with PNGOC, a HealthGov partner, to ensure that its activities are aligned with and woven into the overall strategic directions of the project.

Corporate Management and Technical Support Visit

Catherine Fort, HealthGov’s Technical Advisor based in RTI North Carolina visited the project on 7-22 November 2007. During her visit, Ms. Fort completed the following tasks: assisted with monitoring and evaluation work including helping to revise the M&E section of the annual work plan draft; conducted management survey as a follow-up to the visit of RTI Center for International Health Program Director Barbara Kennedy in April 2007; reviewed the role of PNGOC in the project and helped find solutions to their contract, budget, and technical issues. Ms. Fort also attended the field operations process review workshop and provided technical inputs in engaging technical assistance providers and defining their role in the project, including planning for developing mechanisms for contracting.

In November, JHPIEGO Chief Executive Officer Dr. Leslie Mancuso, on her trip to the Philippines for a separate JPHIEGO business, dropped by the HealthGov office to meet with the JPHIEGO-hired staff as well as with the Chief of Party (COP) and Deputy Chief of Party to reiterate her support to the project. In return, Dr. Mancuso received a briefing on the progress of project implementation and the important role that JPHIEGO plays in the project.

Revision of Year 2 Work Plan

Following the submission of the Year 2 Work Plan on 30 September 2007, the PMG and Regional Coordinators met with HealthGov’s Cognizant Technical Officer (CTO), Ms. Ma. Paz de Sagun, to discuss the comments and points she raised on the document. These included specifying major issues and corresponding TA support at the national, regional, and provincial levels; identifying quarterly milestones per TA; tightening inter-CA collaboration per region/province; identifying major action points for the various inter-CA technical working groups TWGs; and fleshing out the details of the provincial TA plans (PTAPs). These issues were addressed in the revised work plan which was submitted on 12 November. In relation to the annual work plan, HealthGov was assigned to take responsibility for preparing the materials and presenting them to the DOH Technical Assistance Coordinating Team the USAID SO3 inter-CA 2008 work plan for MCH, HIV/AIDS, and avian influenza. COP Harry Roovers, together with the other CAs assigned with the different programs⎯TB LINC for TB, PRISM for FP, SHIELD for ARMM, and HPDP for cross-cutting concerns⎯made the presentation on 19 November. The presentation was presided by DOH Undersecretary Mario Villaverde and supported by the Bureau of Health International Cooperation Acting Chief Dr. Marvi Ala and representatives from the various program offices of DOH. Dr. Aye Aye Thwin, Chief of USAID Office of Health

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(OH), HealthGov CTO Ms. de Sagun, and other OH key staff attended the event. Follow- up action and immediate next steps related to the results of the presentation were identified by USAID and the CAs.

Collaboration and Coordination with Other CAs and National and Regional Stakeholders

During this report period, HealthGov participated in various activities organized by DOH, other CAs, and in a few cases by other organizations which have impact on the project. The participation of HealthGov in these activities is detailed under the heading Coordinating with Partners and Stakeholders in the succeeding narratives on the project implementation activities of the different IRs.

Following the submission to USAID of the respective annual work plans of the different CAs, the HealthGov regional teams conducted coordination meetings with the other CAs to identify areas of synchronization and collaboration in the implementation of their respective TA interventions, particularly in provinces where all the CAs converge.

In Luzon, HealthGov and the CAs agreed to work together to identify the level of specificity of each TA need of the provinces in the context not only of individual CA TA interventions but also in the context of USAID SO3 concerns. They also identified the need for synchronized activities and closer coordination with the CHDs so they can keep pace with the needs of the provincial health offices. The CAs agreed to coordinate their visits and other activities with HealthGov’s Provincial Coordinators (PCs) who serve as the focal person for activities in the province. Otherwise, there is the possibility of getting information from unreliable sources. All CAs will participate in the PIPH formulation process planned for the four non-rollout provinces, namely Bulacan, Nueva Ecija, Tarlac, and Cagayan.

The Luzon inter-CA regional meetings are held monthly.

In the Visayas, HealthGov and the other CAs identified specific areas of collaboration. HealthGov and PRISM will work together to provide Regions 6 and 7 CSR TA ⎯ from planning for the CSR assessments to actual conduct of the assessment workshops. The CAs have provided inputs to the MIPH workshops and participated in the consolidation of the PIPH in Negros Occidental and Aklan, and the initial TA action planning in Bohol. All CAs agreed to work with CHD 6 in the next quarter to clarify details of their TA needs.

The Visayas inter-CA meetings are held monthly and hosting is rotated among the different CAs.

In Mindanao, the CAs in non-ARMM provinces held a meeting in November to update each other on activities conducted in the previous quarter, discuss the status of inter-CA collaboration, and agree on mechanisms to strengthen this. The CAs affirmed that the technical assistance to provinces should focus on assisting the LGUs and other stakeholders in converting the RED health indicators (those under-target) into GREEN (on a par with the target).

Accordingly they have agreed on the following areas of collaboration to strengthen the capability of LGUs, NGOs/CSOs, and private sector groups: 1) planning, implementation,

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and assessment of local CSR response; (2) achieving PhilHealth universal coverage, specifically in orienting LCEs, LGU planners, and various stakeholders on the concepts of insurance and social insurance, need for proper identification of the poor, premium subsidy sharing schemes among LGUs, investment needed for the certification and accreditation of health facilities, and utilization of revenues from reimbursement and capitation; 3) participatory and evidence-based local policy development and decision- making; 4) planning, implementation, and assessment of health information and education, and community mobilization; 5) strengthening provincial health systems, specifically health information system, M&E, inter-LGU cooperation for health, and referral system (public-public and public-private); and 6) developing private sector providers.

The CAs agreed to meet bi-monthly to operationalize the agreements mentioned above.

5.2 Project Implementation Activities

HealthGov activities during the review period focused on technical assistance provision. These activities are described below:

IR 1.1 Strengthening Key LGU Management Systems to Sustain Delivery of Key Health Services

Investment Planning for Health

With HealthGov technical assistance, F1 rollout sites and other provinces carried through activities leading to the completion of their Province-wide Investment Plan for Health. These project sites are now at different stages of PIPH development.

y F1 Rollout Sites

Among the seven F1 rollout sites, Compostela Valley was the first to complete its PIPH draft. The PIPH underwent three reviews during the review quarter: during the CHD F1 team review in October; the spot checks in November and early December; and lastly, the validation meeting with the Governor, the PIPH planning team, and some mayors. A Sanggunian-approved draft is expected to be ready in January 2008 for submission to DOH.

As the first completed PIPH draft among F1 rollout sites, Compostela’s health investment plan was used as a test case for reviewing the DOH guide questions for assessing the quality and completeness of PIPHs in rollout sites.

The three Zamboanga provinces (Norte, Sur, Sibugay) are well on their way to completing their PIPH draft. On 18 December, the CHD 9 PIPH appraisal team and the PHO staff of the three provinces, with HealthGov technical assistance, reviewed the drafts using the PIPH appraisal guidelines issued by DOH. The review pointed out the need to tighten the write-up, particularly the link between and among goals, performance indicators, gaps, interventions, activities, and cost. The timeline of the activities and the phasing of investments need to be determined as well.

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The CHD Assistant Regional Director presented the status of PIPH preparation in Zamboanga Peninsula to USAID CAs in a consultative meeting held 23-24 October. Based on the gaps and issues in PIPH preparation, the following TA from USAID CAs was identified: CSR planning; facility mapping; health promotion; quality assurance program through SDExH; quality improvement through capacity building for the TB- DOTS program; achieving universal PhilHealth coverage including identifying the poor, accreditation, and revenue retention schemes; advocacy; local policy development; health management information system; and public finance management, among others

During the quarter under review, Sarangani focused on completing the components of its PIPH, particularly the sub-plans. A CHD 12-led review of the PIPH conducted in November contributed to an improved version of the draft, as shown in the second assessment in December, despite the difficult time the PHO staff had in preparing the narrative part of the plan.

Albay and Isabela have both generated the major information needed to write up the PIPH draft. The Albay PHO staff, however, have found it difficult to put the information together into a coherent PIPH document and asked HealthGov for technical assistance. In response, the project will provide a PIPH integration guide and support the PIPH integration workshop slated for the first week of January 2008.

With their partnership firmly established during the HealthGov-assisted LGU-NGO/CSO partnership-building workshop held on 3-4 December, the Albay PHO has integrated in the PIPH the health programs of local NGOs/CSOs. The PhP30 million cost of these programs is reflected in the PIPH as NGO/CSO funding counterpart.

During the quarter under review, Isabela completed four batches of health investment planning workshops. These included completion of the SDIR forms that contain the data needed in PIPH. As a follow-on, HealthGov will provide the tool for consolidating the municipal/city investment plans and the guide for the technical review of PIPH.

The provincial government of Isabela has allocated PhP1.5 million as initial counterpart support to the management and operations of PIPH programs and projects.

y Other Provinces

In other provinces, HealthGov tried to influence the investment planning process along the same track that F1 rollout sites adopted. This translates to the other provinces’ adopting the PIPH planning process and using the same planning design, tools, and approaches used by the F1 rollout sites.

During the period under review, HealthGov provided technical assistance to three of the 11 other provinces⎯Nueva Ecija, Tarlac, and Bohol⎯to help them prepare for the process of developing their PIPH, and to six others to help them formulate and complete their PIPH.

With all the needed inputs organized into a coherent draft, Aklan presented its PIPH to the Provincial Health Board (PHB) on 24 October. The draft is due for review by the Technical Review Committee in January 2008. The PIPH is expected to be completed in March 2008.

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In November, the PIPH Technical Working Group in Negros Occidental reviewed the initial draft of the province’s health investment plan. The committee’s suggestions were reflected in the revised MIPH/PIPH which was presented to the Provincial Health Board on 6 December. The PHB endorsed the interventions identified in the draft and the issuance of an executive order creating a technical review committee. It also committed to provide funds for packaging the PIPH document. Integration of all PIPH documents is scheduled for January 2008.

The PIPH of Bukidnon and of Misamis Oriental are nearing completion. During the review quarter, the two provinces started the process of legitimizing their PIPH. This means getting the imprimatur of the Provincial Health Board, the Sangguniang Panlalawigan (SP, provincial legislative council), and the governor.

Davao del Sur meanwhile worked on completing the major components of PIPH, namely the public finance management sub-plan and the identification of systems that need to be strengthened. In December, the draft PIPH was reviewed by the PLGU offices, including the Sangguniang Panlalawigan, the budget and planning offices, and other concerned regional agencies. The review surfaced suggestions to improve the PIPH, namely the inclusion of advocacy to ensure local legislators’ support for the plan, inclusion of more training activities, and the expansion of the local health system. The mayors present during the review expressed their support for the PIPH.

In Agusan del Norte, the MIPHs have been completed and are ready for presentation to the Sangguniang Bayan (SB, municipal legislative council). The province is conducting a rapid appraisal of inter-local health zones to see how these are working and to enable the crafting of informed ILHZ plans as a component of the PIPH. The provincial investment plan for health is expected to be completed by June 2008 in time for the budgeting cycle.

Improving Health Systems to Strengthen LGUs’ Ability to Deliver High Quality Health Services

y Ensuring the Availability of FP Commodities through the Contraceptive Self- reliance (CSR) Strategy

To help achieve IR 1.1, HealthGov supports interventions that will lead to the successful implementation of the CSR strategy at the LGU level. Thirteen of the project’s 23 sites had developed their CSR plan through the USAID-LEAD project. Now well into the third year, some CHDs and provincial local government units (PLGUs) expressed the need to assess CSR implementation to see how well the CSR systems and structures are working to respond to the phase-out of donated family planning (FP) commodities in 2008 and how the plans can be enhanced.

During the quarter in review, Pangasinan developed with HealthGov technical assistance the beginnings of a CSR+ assessment and monitoring tool that would capture the key information the PLGU needs to decide on CSR policy and program directions. HealthGov’s TA included a framework for developing a CSR+ assessment and monitoring tool. The Living Standards Survey (LSS) team of the province was also given technical advice on alternative methodologies for coming up with household ranking even as there are municipalities with completed and processed surveys as well as those with

HealthGov Project—First Quarterly Report Year 2 (October– December 2007) 12

incomplete surveys1. Further work on the draft CSR assessment tool will be carried out by a small group composed of the Provincial Health Office and the Provincial Population Office (PPO) staff. Meanwhile, the LSS team will proceed with ranking households in municipalities with completed surveys to provide timely information to the Governor.

With HealthGov and CHD 3 shepherding the process and with the participation of PRISM, Bulacan has started to develop its CSR+ assessment tool. This is due for pretesting, finalization, and presentation to the MHOs in mid-January 2008.

With HealthGov technical assistance, Aklan, Capiz, Negros Occidental, and Negros Oriental assessed their CSR implementation using the assessment tool developed in Region 10. Assessment results have been forwarded to their respective regional family planning coordinator. HealthGov technical specialists will review these results to determine how best to provide TA on CSR implementation.

y Strengthening the LGU Procurement and Logistics System

During the period under review, HealthGov worked on improving the logistics management systems presentation materials which were initially used during the Bohol SDIR-CSR planning workshop held in September 2007. These materials include tools and guidelines on forecasting, procurement, distribution, inventory, and storage of FP commodities. The consumption-based method was selected as the forecasting tool as this was found in a pretest in two Pangasinan municipalities to be simpler, easier to use, and yield a more realistic commodity forecast.

The improved version of the logistics management systems materials was used in the 9- 11 October South Cotabato workshop on enhancing the CSR plan. In this workshop, HealthGov provided the participating LGUs (province, city, municipalities) TA in updating and enhancing their respective CSR plan and integrating them into their PIPH catch-up plan. In this forum, the population-based forecasting method was used to allow for a more comprehensive forecasting that covers FP commodities as well as services, poor as well as non-poor clients, and for consistency with the five attributes of the new expanded Administrative Order on CSR. Other CSR-related tools and technical inputs for planning, segmenting clients, cost recovery, public-private referral, monitoring were provided by HealthGov and other resource persons. Using these technical inputs, the LGU participants identified strategies, activities, and policy choices which they used to enhance their CSR plan.

Taking off from this activity, HealthGov drafted an expanded and enhanced logistics management tool kit intended for program managers/coordinators and supply personnel at the provincial, municipal, and city levels. The kit consists of tools and guidelines for forecasting, a menu of procurement and distribution options, inventory control system models, and guidelines for proper transport and storage not only for FP but for MCH, TB, and STI commodities as well. The materials have been prepared in a manual with supporting presentation materials. HealthGov will refine the kit based on comments of key national, regional, and municipal stakeholders before rolling them out to LGUs.

1 Household ranking based on living standards indices will allow the identification of households that are eligible for public subsidies such as free contraceptives. Ideally, data from all municipalities should be pooled and the ranking done using the pooled data.

HealthGov Project—First Quarterly Report Year 2 (October– December 2007) 13

y Strengthening LGU Health Information System

During the period under review, a number of provinces geared themselves up for a better understanding of health information systems for evidence-based health planning. In Pangasinan, HealthGov provided technical inputs in the consultative meeting on poverty mapping held on 16 October. In this meeting, HealthGov oriented the staff of the provincial health, population, planning and development, and social welfare and development offices on the concept and measure of poverty, and approaches to identifying program beneficiaries. HealthGov also highlighted the recent PhilHealth Board resolution adopting the community-based monitoring system and other LGU data systems as data source for means test for the PhilHealth Sponsored Program. Information on how to generate local data on unmet needs and living standards (i.e., through the community health and living standards survey) that could be used to update and consolidate existing approaches to poverty mapping was also provided.

Similarly, South Cotabato underwent an orientation on generating local data to identify the poor and those with unmet need for FP and other services. This was during the workshop on enhancing the CSR plan held on 9-11 October. In Misamis Occidental, the League of Municipalities was oriented on the advantages of using CHLSS.

Coordinating with Partners and Stakeholders

y CSR

In October, HealthGov participated in the CSR orientation package validation workshop organized by HPDP. Among other things, the forum sought to validate the main content and key messages of the basic materials in the orientation package, and formulate the general design, mechanics, processes, and relevant templates of the package. The CSR orientation package consists of three major content areas: overview of CSR, enhanced CSR strategy, and CSR instruments and tools. Workshop participants, which included DOH personnel from the central and regional offices, commented that more than the orientation package, what was needed was an update on CSR and assessment of CSR implementation. They put forward various suggestions that centered on the message of the materials, the tools that should be included in the package, and the manner of delivering the package (e.g., this should be done by the CHDs as a DOH activity).

Results of the validation workshop will be integrated in the current set of materials. The new set of materials will be pretested in Mindoro prior to finalization.

HealthGov participated in the inter-CA CSR TWG meeting held in November. The meeting was called to discuss updates on CSR-related developments and activities, and the status of CSR TA plan implementation of the different CAs. Consultant Mario Taguiwalo reported that the final draft of the new administrative order (AO) on CSR has been forwarded to the policy unit of DOH, which had no substantive suggestion except on formatting. He also disclosed that the family planning budget of PhP180 million had been signed and the release request forwarded to the Department of Budget and Management, and the Office of the President.

HealthGov Project—First Quarterly Report Year 2 (October– December 2007) 14

For its part, HealthGov reported that the logistics management systems materials have been improved and used in the 9-11 October South Cotabato workshop on enhancing the CSR plan. As a follow-on, HealthGov will develop the guide on the use of the tools, which will be presented in the next DOH CSR TWG meeting. HealthGov will share the tools and guides with SHIELD. The latter will coordinate with the former in adapting the tools for region-wide use in ARMM.

y PhilHealth Benefit Review

On 19 October, HealthGov participated in the inter-CA PhilHealth Technical Working Group meeting on the PHIC benefit review plan. Discussion focused on the inter-CA strategy to support the benefit review. The CAs identified areas where they can provide TA based on their respective mandate and capacities.

On 29 November, HealthGov participated in the presentation of the PhilHealth benefit review plan by the PHIC Senior Vice President for Health Finance Policy Sector. The plan was organized into five tasks representing distinct clusters of related policy concerns under each of which were activities⎯study or meeting⎯necessary to accomplish the task. Specifically, the tasks are as follows:

1) Participate in a DOH-led initiative to formulate an official government proposal for a basic national health financing framework 2) Undertake studies on PhilHealth benefits in relation to performing PhilHealth’s role under the national health care financing framework 3) Review current mechanisms for PhilHealth to continuously improve benefits 4) Review existing institutional arrangements to implement National Health Insurance Program benefits 5) Enable stakeholders to influence and learn about the benefit review

Based on the comments and observations of the various stakeholders in the meeting, the challenge is to think about, design, and eventually implement a set of benefit packages that generates an appropriate supply response (to ensure adequate providers) and demand response (to ensure universal coverage) subject to such parameters as effectiveness in producing desired health outcomes, efficient use of resources, affordability and sustainability, institutional capacity, and political acceptability.

The inter-CA TWG on PhilHealth has discussed an earlier draft of the PhilHealth benefit review plan. In support of this plan, the CAs will finalize in January 2008 the areas of assistance they have earlier identified.

y Flagship Course on Health Sector Reform and Sustainable Financing

The LGU Governance Team Leader of HealthGov served as resource person in the Third Flagship Course on Health Sector Reform and Sustainable Financing sponsored by DOH and the World Bank and organized by the Development Academy of the Philippines. His lecture, “Equity and Financial Protection: The Philippines Case,” analyzed the financial burden of financing health care through different means (e.g., taxation, social health insurance, out-of-pocket) as well as the benefit incidence of health spending (e.g., government, social health insurance, out-of-pocket). Participants were

HealthGov Project—First Quarterly Report Year 2 (October– December 2007) 15

mainly from LGUs. Given that HealthGov’s primary clients are LGUs, the project needs to be more proactive in recommending course candidates to be funded by USAID.

IR 1.1 activities planned for 2nd Quarter Year 2

• Develop technical and operational guidelines for completing and appraising PIPH for F1 rollout and other provinces, orient CHDs and PHOs on the application of the guidelines, and support field operations teams in providing this TA to LGU partners • Develop technical and operational guidelines for LGU CSR planning • Finalize CHLSS questionnaire and pretest it in Misamis Occidental • Develop technical and operational guidelines on CHLSS implementation and support field operations teams in providing this TA • Develop technical and operational guidelines on implementing evidence-based legislation/participatory decision-making • Finalize and pretest the integrated procurement and logistic system tools

IR 1.2 Improving and Expanding LGU Financing for Health

Technical Assistance Provision

HealthGov supported the health investment planning of Isabela and Albay through technical assistance in costing, financial planning, and fund management. In Isabela, HealthGov discussed in detail the preparation of the PIPH working and costing tables. It provided two costing manuals to serve as standard reference guide for costing the components of each identified PPA (program, project, activity). Fund sourcing options and possible cost-sharing arrangements were explained and clarified with the LGUs.

In financial planning, the PLGU was briefed on the broad range of actions that would support the financial needs of PIPH. Since investment implies additional resources for health, discussions highlighted the need to allocate extra budgetary resources for health. These include generating additional revenues for health, enhancing the efficiency of fund utilization to generate savings, utilizing the power to borrow, attracting health investments, and engaging in innovative arrangements with the private sector. HealthGov will engage the Local Finance Committee (LFC) in detailed discussion of the tools and techniques for doing all these after the completion of the PIPH.

Realizing the need to start implementing PIPH activities in 2008, the PHO negotiated with the Provincial Planning Development Office (PPDO) the inclusion of some PIPH activities in the 2008 Annual Investment Plan chargeable against the 20% economic development fund. This led to the allocation of PhP1.5 million in support of PIPH.

As the total cost of PIPH implementation took shape, HealthGov’s discussion with the LFC of Albay confirmed the lack of a resource base to support the initial estimated counterpart requirements of PIPH implementation. This prompted the LFC to consider imposing user fees selectively and improving tax collection efficiency, but has to discuss adjustment of tax rates with local policy makers first. The LFC did agree to reconcile the cost of PIPH and the province’s financial capacity.

HealthGov Project—First Quarterly Report Year 2 (October– December 2007) 16

HealthGov designed a generic organizational structure for PIPH financial management which was accepted by the PHO. The structure involves the creation of a local implementation and coordination team (LICT) to be led by the provincial governor, and the designation of the PHO as project coordinator. The LICT will utilize the existing provincial organization in all aspects of financial management.

The PIPH experience of Albay is being used by the CHD as a model for extending assistance to three other F1 rollout sites in Region 5.

Tools Development

During the review period, HealthGov developed two diagnostic tools that will help LGUs improve their understanding of financial planning and management. The first tool is the Public Finance Management Assessment Checklist designed to identify existing systems and procedures in downloading and utilizing funds. The use of the tool is being tested in Region 9. Based on the test results, HealthGov will provide follow-on TA that will help the five LGU offices concerned with financial management (viz., PPDO; the provincial budget, treasury, accounting, and general services offices) improve the financial management set-up for PIPH. The TA will help them assess the system’s deficiencies, anticipate potential problems, and plan for minor changes, if there are any.

The other diagnostic tool is the Resource Mobilization Assessment Checklist which enumerates possible options for revenue raising within the framework of the Local Government Code, and identifies those being implemented at the LGU level. This was developed in response to the observation in the Visayas provinces that despite their eagerness to pursue PIPH preparation and their concurrence with the need to raise resources, health planners and Sanggunian members are not as quick to mobilize resources. This may be due to their lack of understanding of the resource mobilization options available to LGUs. The checklist will help LGUs reflect on local resource mobilization initiatives, and provide policy makers with a clear idea of where to focus their initiatives on. The checklist will be finalized in January 2008 based on the results of the test conducted in Aklan.

Coordinating with Partners and Stakeholders

On October 26, HealthGov participated in the DOH meeting on expenditure management intended to discuss health expenditure tracking starting from the Department of Budget and Management to DOH to CHDs and other programs. Participants in the meeting included donors (viz., EC and USAID) and DOH staff. Seven types of funds flow were identified in the meeting, one of which (DBMÆCHD 11ÆLGU funds flow) was assigned to HealthGov for study. In the next quarter the project will develop the framework for funds process flow, and design a monitoring and reporting system appropriate for this type of funds flow.

IR 1.2 activities planned for 2nd Quarter Year 2

• Develop technical and operational guidelines on implementing universal PhilHealth coverage, and orient CHDs and PHOs on the application of these guidelines

HealthGov Project—First Quarterly Report Year 2 (October– December 2007) 17

• Develop the framework for funds process flow, monitoring system, and financial reporting in relation to the public expenditure management study • Conduct the public expenditure management study in CHD 11 • Develop the terms of reference for the PhilHealth benefit review study

IR 1.3 Improving Service Provider Performance

Technical Assistance Provision

y Service Delivery Excellence in Health (SDExH)

Building on the results of the modeling activities for Service Delivery Excellence in Health conducted in the previous quarter, HealthGov moved on to providing SDExH Modules 3 and 4 to 12 LGUs in Misamis Occidental and Negros Oriental. SDExH is a continuing quality improvement intervention which integrates two best practices of quality assurance, namely Public Service Excellence Program (PSEP) adopted by the Civil Service Commission and the Standards-based Management and Recognition approach of JPHIEGO.

The 12 LGUs include Oroquieta City, Aloran, Jimenez, Lopez Jaena, and Panaon in Misamis Occidental, and Amlan, Bacong, Dauin, San Jose, and Valencia in Negros Oriental as well as the PLGU of the two provinces represented by their PHO and provincial hospital. Health personnel of these LGUs have completed four of the five SDExH modules. These consist of 1) Visioning, 2) Setting local standards, 3) Implementing service improvements, and 4) Measuring progress, which were provided in three workshops. The LGUs will have Module 5 in a fourth workshop scheduled in January 2008.

Monitoring and coaching of the participating LGUs showed significant progress in completing the SDExH steps and some headway in the implementation of their service improvement plans. Table 1 presents these accomplishments.

In Misamis Occidental, all participating LGUs/offices except the municipality of Aloran have finalized their vision and service values and posted them in conspicuous places. Of the seven participants, only Jimenez and Panaon have translated their vision and value statement in the local dialect. The other facilities were encouraged to do the same.

All four MLGUs have completed the local service standards (LSS) for four programs, viz., maternal care, FP, child care, and TB. Oroquieta City meanwhile has completed the LSS for the same four programs plus HIV/AIDS.

All seven participating LGUs/offices have completed and enhanced their standard assessment tools, and have created an SDExH management team. But so far only Jimenez municipality has issued an office order mandating the team. Except for Aloran, all the participants have started to implement their service improvement plan.

In Negros Oriental, HealthGov monitored and coached all participating LGUs/office except the municipality of San Jose which will have its turn in January 2008.

All five LGUs/office that were monitored have finalized their vision and service values although they have yet to post them. They have also completed their local service

HealthGov Project—First Quarterly Report Year 2 (October– December 2007) 18

standards as well as their service improvement plan. The Knock Out Tigdas measles vaccination campaign and the Christmas holiday precluded the LGUs from completing the SDExH process and implementing its various activities. The LGUs have thus requested for another round of monitoring and coaching in January by which time they would have made some significant strides.

y Service Delivery Implementation Review (SDIR)

Program implementation review (PIR) is one of the tools for monitoring the progress of public health programs. It effectively identifies areas and programs for acceleration; it is thus a good strategy for improving service delivery. The DOH has implemented PIRs at different levels since the late 1980s. When health services were devolved in 1991, DOH and some PHOs continued to conduct PIRs with or without project support. However, no standard review tool was used across program levels.

In 2007, Capiz, an F1 province, requested for technical assistance in conducting PIR. While the province has been doing well in governance and financing, its high maternal mortality rate remained a challenge, and this warranted a PIR. Thus HealthGov, in consultation with DOH National Center for Disease Prevention and Control (NCDPC) and other USAID CAs, developed an enhanced PIR tool. Called service delivery implementation review, the new tool monitors progress in service delivery performance by program and by area. The SDIR tool guides service providers and managers in identifying facilitating factors and challenges in achieving performance standards, determining strategic interventions, and formulating acceleration plans. All service providers, including selected barangay (village) health workers (BHWs), participate in the review.

During the reporting period, HealthGov supported three major SDIR TA activities:

1) Conduct of SDIR/PIPH in Isabela (four batches); 2) Managing SDIR outputs for follow-on action in the provinces of Bohol, Negros Oriental, and Aklan; and 3) Monitoring the progress of indicators and implementation of acceleration plans in Bohol and Capiz.

Isabela

The province of Isabela used the SDIR process to generate data for the situational analysis in formulating the PIPH. HealthGov supported the conduct of four batches of SDIR for PIPH. LGUs that followed the SDIR process, that is, conducted internal assessment and completed the SDIR pre-workshop forms and tables, were found to have had an easier time preparing their situational analysis, and identifying their goals, targets, and critical interventions.

Bohol

The complex dynamics in the province’s health sector are a force to be reckoned with. Since the devolution, the PHO and DOH Reps in Bohol have rarely held joint meetings

HealthGov Project—First Quarterly Report Year 2 (October– December 2007) 19

Table 1 SDExH results led to service improvements in Misamis Occidental and Negros Oriental

VISION SETTING STANDARDS IMPLEMENTING SERVICE IMPROVEMENTS LGU/ Office Vision/ Customers’ Local SDExH Service Service Value standards service manage- improve- improve- state- validated standards ment ment plan ments ments1 completed team completed created2 OROQUIETA INTER-LOCAL HEALTH ZONE, MISAMIS OCCIDENTAL

Provincial      Conducted Health For health maternal death Office program review using management, recommended maternal forms death review (MDR), procurement and logistics, monitoring, and coaching

Provincial      Posted copy of Hospital For maternal workflow at care services OPD; installed for OPD number system for patients, ramp at entrance door, and paging system; reopened exit door

City      Procured Health For MCH, electric fans Office FP, TB, and clinic forms STI/HIV/ AIDS; need to be reviewed and validated

1  Finalized, posted, and translated into dialect  Finalized and posted/shared  Finalized 2  Management team created and office order mandating the team issued  Management team created but office order mandating the team has yet to be issued

HealthGov Project—First Quarterly Report Year 2 (October– December 2007) 20

Table 1 SDExH results led to service improvements in Misamis Occidental and Negros Oriental (cont’d)

VISION SETTING STANDARDS IMPLEMENTING SERVICE IMPROVEMENTS LGU/ Office Vision/ Customers’ Local SDExH Service Service Value standards service manage- improve- improve- state- validated standards ment ment plan ments ments1 completed team completed created2 OROQUIETA INTER-LOCAL HEALTH ZONE, MISAMIS OCCIDENTAL

Aloran x     No report For MCH, FP, TB; need to be reviewed and validated

Jimenez      Procured FP Accomp- For MCH, commodities lished by all FP, TB; need RHMs to be reviewed and validated

Lopez      Installed floor Jaena For MCH, tiles and FP, TB; need repaired to be leaking ceiling reviewed and of RHU validated

Panaon      Prepared and Service submitted improvement project plan proposal for formulated TB-DOTS for MCH, FP, center; dug up TB a new compost pit for sharps

HealthGov Project—First Quarterly Report Year 2 (October– December 2007) 21 Table 1 SDExH results led to service improvements in Misamis Occidental and Negros Oriental (cont’d)

VISION SETTING STANDARDS IMPLEMENTING SERVICE IMPROVEMENTS

LGU/ Vision/ Customers’ Local SDExH Service Service Office Value standards service manage- improve- improve- state- validated standards ment ment plan ments ments completed team completed created METROPOLITAN INTER-LOCAL HEALTH ZONE, NEGROS ORIENTAL

Provincial      Integrated Health For health monitoring Office program checklist management, developed procurement and logistics, monitoring, and coaching

Provincial      Functional Hospital For ER, buzzer, Medicine, additional Surgery, chairs for Obstetrics, watchers, Therapeutics stretchers Committee, made available referral at all times, system emergency drugs ready for use in ER and OPD, uses of ID priority number in OPD, comp- liance with TB- DOTS protocol, cross-training on services updating for RHUs and hospitals

Amlan      No report For MCH, FP, EPI, TB

Bacong      PhP40,000 For MCH, budget for FP FP, and commodities governance approved by LGU

Valencia      FP Finalized, For MCH, FP, commodities translated EPI, TB procured

HealthGov Project—First Quarterly Report Year 2 (October– December 2007) 22

and regular feedbacking. Monitoring and supervision of rural health units (RHUs) were not regularly carried out. Any such activities when implemented were usually project- driven. The planned reduction in the number of ILHZs from nine to five has sown confusion and frustration among RHU, hospital, and PHO technical staff.

Against this discouraging backdrop Bohol conducted in September 2007 an SDIR that integrated CSR planning, and which yielded very positive results. An SDIR cum contraceptive self-reliance planning was deemed timely at that time because most LGUs were not allocating funds for contraceptives despite the imminent phase-out of family planning commodities. Integrating SDIR and CSR planning allowed the LGUs to prepare the coming year’s budget for contraceptives.

During the review period, HealthGov provided follow-on TA to 10 PHO technical staff, 10 DOH Reps, as well as CHD Local Health and Development Family Health representatives. The TA was designed to 1) review the progress of implementing the SDIR acceleration plan, CSR strategic options, forecasting, and the annual investment plan; 2) determine major areas of TA to RHUs; 3) define the roles of DOH Reps and the PHO; and 4) identify areas of DOH Reps-PHO collaboration to assist LGUs in implementing their plans.

The review of implementation progress showed that SDIR workshop outputs were an effective tool for budget lobbying and for getting LGU support for health service delivery improvement. Presented with the SDIR results, the LGUs of Calape and Tubigon approved 95% of their respective acceleration plan and its corresponding budget. The municipality of Inabanga provided a budget for supplies such as syringes which clients normally pay for. Duero allocated funds for birthing facilities. Other LGUs budgeted for dental supplies, an item which previously was not given attention. LGU support to service delivery improvement resulted in increased deliveries in the health facilities of San Isidro, Catigbi-an, Balilihan, and Guindulman. Loboc, on the other hand, drew from its own coffers to cover the cost of the basic emergency and obstetric care (BEMOC) training of its Municipal Health Officer (MHO), Public Health Nurse (PHN), and Rural Health Midwife (RHM).

The persistent follow-up that the HealthGov Provincial Coordinator made with 10 participating LGUs proved to be an important part of managing SDIR results. This accounted for the abovementioned progress in the acceleration plan implementation in Bohol.

Based on the results of the SDIR-CSR planning exercise, the PHO and DOH team identified six major areas of technical assistance to RHUs. These consist of:

1) capacity building on MCH, FP, nutrition, TB, STI, environmental sanitation, basic dental services, lifestyle diseases, blindness program, disease surveillance, and Field Health Services Information System (FHSIS); 2) monitoring and supervision; 3) logistics system; 4) strengthening the local health board and inter-local health zone; 5) strengthening standards and regulations to comply with the requirements for Sentrong Sigla (center of excellence) 2 certification and PhilHealth accreditation of outpatient benefit (OPB), TB-DOTS, and maternity care packages; and

HealthGov Project—First Quarterly Report Year 2 (October– December 2007) 23

6) advocacy and policy development.

The SDIR-CSR planning activity pointed out that DOH Reps and the PHO technical staff have similar roles. They both contribute to monitoring, training, mentoring and coaching, planning, liaising, and disease surveillance. This realization highlighted the need for appropriate training to improve their skills in carrying out their identified roles.

The PHO and DOH Reps identified two major areas on which they can collaborate to help LGUs implement their acceleration plans. These are 1) strengthening PHO-DOH Reps partnership and team work through regular meetings, and 2) monitoring and supervision using the team approach.

Monitoring the acceleration plan implementation of 10 MLGUs revealed positive developments in service delivery. For instance, the mayor and Sangguniang Bayan health representative in the municipality of Alicia allocated for CSR PhP85,000 from their supplemental budget. The mayor of Inabanga has started to give 10% of the Magna Carta benefits for health personnel. Apart from this, he has signed with DKT a Pop Shop franchise to ensure the availability of pills and condoms in the LGU.

Aklan

In Aklan, SDIR was used as a tool for the situational analysis that the municipal health investment planning requires. Service delivery implementation review was conducted in September 2007. As a follow-on, the PHO and DOH Reps with HealthGov assistance went through an SDIR provincial support planning activity. The objective was to assist the PHO-DOH Reps team to 1) develop a provincial support plan to help MLGUs improve service delivery, 2) track the implementation of interventions, particularly those that are within the control of service providers, 3) ensure the integration of major interventions into the local development plan of the MLGUs, 4) work toward the institutionalization of the SDIR process at the provincial and municipal levels, 5) monitor the progress of program indicators with focus on the Operational Plan indicators, and 6) provide RHUs with feedback on program performance.

HealthGov’s TA resulted in the formulation of a provincial service delivery support plan which identified five major areas of support to MLGUs: 1) capacity building on MCH, nutrition, Expanded Program on Immunization (EPI), family planning, TB, STI, environmental sanitation, FHSIS, blood program, and Sentrong Sigla certification of OPB, TB-DOTS, and MCP; 2) monitoring and supervision; 3) logistics, including procurement of essential commodities for the different programs mentioned above; 4) strengthening ILHZs and local health boards; and 5) social mobilization and advocacy for health personnel’s Magna Carta benefits and hazard pay.

HealthGov will track the implementation of the provincial service delivery support plan and the province’s contribution to the achievement of the OP and HealthGov performance indicators.

Negros Oriental

In Negros Oriental, 22 of the province’s 25 municipalities and cities conducted SDIR in September 2007. Subsequently, service delivery support planning was conducted on October 8-9 as follow-on TA to achieve the same objectives as that in Aklan’s service

HealthGov Project—First Quarterly Report Year 2 (October– December 2007) 24

delivery support planning. Similarly, the activity yielded a service delivery support plan which identified the following interventions:

1) regular conduct of program implementation review 2) organizing rural health midwives in the ILHZ for better coordination 3) organizing TB community task forces in areas that are consistently low performers 4) expanding referral training for RHMs 5) organizing RHMs in ILHZs for better coordination and updating 6) development of an M&E plan that covers all programs as well as trainings participated in by service providers 7) policy support for regulating hilot (traditional birth attendant)-attended deliveries 8) strengthening the local health board 9) linking up with the Department of Education to intensify the IEC campaign on MCH, EPI, and other programs 10) advocacy for masterlisting the eligible population for MCH and antenatal care from pre-marriage counseling participants 11) linking up with NGOs 12) organizing community women’s groups

Given the SDIR experience in Negros Oriental, various TA areas were identified. These include the use of SDExH as a strategy for providing RHUs feedback on their performance. The project will extend TA in the conduct of SDIR in the three LGUs (viz., Dauin, San Jose, and Valencia) that were not able to do their SDIR together with the other LGUs. Low-performing LGUs will be given TA to validate, through a rapid coverage survey, their reported weak performance.

Capiz Table 2 Capiz is the first province to Capiz posts progress in achieving successfully use the SDIR tool in performance indicators the formulation, review, and implementation of acceleration Accomplishment plans as well as a strategic and an Indicators 2006 Jan-Jun operational plan for PIPH. A 2007 follow-on activity held in November allowed the Provincial Health Contraceptive 86% 87% Officer to present to MHOs the prevalence rate

2007 mid-year program Percent of 6-72 mo accomplishments. Compared with children given Vitamin A 92% 94% the annual accomplishments in capsules during the 2006, performance in 2007 was Garantisadong Pambata striking, particularly in the number campaign

of deliveries in health facilities. TB cure rate 97% 98% Mid-year data for 2007 showed 959 actual deliveries compared TB quality of direct with the 1,041 annual figure for sputum-smear 48% 53% microscopy 2006. Similarly, the RHU of Dao, which charted a miniscule five No. of facilities deliveries in 2006, pulled off 85 accredited for PHIC 3 5 deliveries mid-year of 2007. maternity care package

HealthGov Project—First Quarterly Report Year 2 (October– December 2007) 25

Other encouraging results are presented in Table 2.

The inherent features of SDIR, which allow service providers to assess the status of health service delivery and see it graphically as red (below target) and green (target achieved) marks as well as analyze gaps and find doable solutions positively reinforce the need to improve performance. With focused and determined implementation of identified solutions, performance improvement becomes increasingly feasible. These steps enabled Capiz to make significant headway in its performance indicators.

HealthGov has noted the following from the SDIR experience in five provinces:

1) LGUs that adopted the SDIR process, that is, conducted an internal assessment and completed the SDIR pre-workshop forms and tables, were better prepared for and had an easier time doing the situational analysis and identifying the goals, targets, and critical interventions for their PIPH. This was shown in Isabela. In Capiz, following the SDIR process facilitated the formulation of the PIPH strategic plan and the 2008 operational pan.

2) If SDIR is used as a situational analysis tool for PIPH, managing SDIR outputs can facilitate planning for first-level interventions as exemplified in Aklan. This will ensure that interventions within the control of health personnel and which may be funded using existing resources are planned and implemented.

More than 50% of planned interventions identified in most of the LGU acceleration plans are first-level interventions, which means they are within the control of the health personnel and may be implemented using available resources. Examples of this are reviving the practice of updating the masterlist, following up defaulters, conducting monitoring visits, and designating a logistic system personnel.

3) Following up on LGUs and advocating with the LCE immediately after generating the SDIR results lead to faster implementation of acceleration plans as shown in Bohol.

4) A strong PHO leadership as exemplified in Capiz significantly influences acceleration plan implementation and consequently improvement in program indicators. It is also vital in institutionalizing SDIR.

5) Role identification for the PHO technical staff and DOH Reps can help strengthen their partnership and collaboration in helping LGUs implement their acceleration plans.

6) The performance gaps analysis was shown to facilitate intervention planning. For instance, in Capiz the high projected target population for a specific program uncovered during the gaps analysis led to the province’s plan to conduct a rapid coverage assessment in low-performing LGUs.

HealthGov Project—First Quarterly Report Year 2 (October– December 2007) 26

y Informed Choice and Voluntarism (ICV) Compliance Monitoring

During the reporting period, HealthGov provided technical assistance in the conduct of 13 orientation activities on ICV that reached a total of 483 individuals representing 36 provinces and 30 cities across 10 regions (see Table 3). Those oriented consisted of 109 males and 374 females.

The orientation activities were of two types. The first consisted of orientations/trainings on ICV and Responsible Parenting Movement (RPM) conducted in partnership with DOH and POPCOM. The other type comprised of ICV orientations which were integrated in the province-wide investment planning for health workshop.

In Isabela (Region 2), orientations on ICV were integrated in four workshops on PIPH formulation and reached 226 MHOs, PHNs, NGO representatives, and MLGU personnel that included budget officers, planning officers, and Sangguniang Bayan members.

Table 3 483 health staff from 36 provinces and 30 cities across 10 regions were oriented on ICV from October to December 2007

Region No. of No. of provinces cities Male Female TOTAL represented represented NCR - 13 2 50 52 CAR 6 1 3 28 31 Region 1 4 1 1 20 21 Region 2 1 - 78 148 226 Region 9 3 4 4 19 23 Region 10 4 2 5 22 27 Region 11 4 2 6 16 22 Region 12 5 3 7 20 27 Caraga 5 3 2 32 34 ARMM 4 1 1 19 20

TOTAL 36 30 109 374 483

During the review period nine orientations/trainings were conducted on ICV and RPM. These covered a total of 257 personnel of CHDs (32), PHOs (93), CHOs (74), POPCOM (23), Social Welfare and Development Office (7), Provincial Planning Office (19), as well as 9 DOH Reps. Those trained comprised 78 males and 148 females.

The orientation/training highlighted the dissemination, implementation, and use of the compliance monitoring tool for ICV and the reporting forms for Responsible Parenting Movement and Natural Family Planning (RPM-NFP). The ICV compliance monitoring tools were discussed to get suggestions on ensuring that they capture compliance issues regularly so that these may be addressed. The tools will be used nationwide. The RPM- NFP reporting forms meanwhile will be used to monitor the implementation and coverage of the NFP program.

HealthGov Project—First Quarterly Report Year 2 (October– December 2007) 27

In the session on ICV, the term “target” generated a long discussion. The principles of ICV preclude the use of targets that refer to service providers’ numerical quota. Hence, DOH clarified that the target which they set refers to estimates that will help increase contraceptive prevalence rate; it is not intended as individual service provider’s numerical quota.

At the end of each orientation, participating cities and provinces formulated an action plan for the roll-out of the orientation/training at the district and municipal levels. The participants also agreed on specific action steps:

1) all health facilities within their jurisdiction (viz., CHO, RHU, barangay health station, and hospitals) will be monitored at least once a year,

2) all health personnel in the health facilities (viz., MHO/CHO/medical officer, PHN, RHM, BHW) will be interviewed, and

3) at least three clients per health facility will be interviewed on ICV.

A team composed of the CHD, DOH Reps, CHO, PHO, population officers, regional POPCOM representatives will conduct the monitoring. DOH facilitators committed to provide ICV monitoring forms through the CHDs.

To date, 17 of the 18 scheduled batches of ICV-RPM orientation/training have been conducted covering 468 FP coordinators, technical staff, and DOH Reps at the regional and provincial levels. These include 420 female and 48 male health personnel who will roll out the ICV orientation to service providers. The last batch of orientation will be held in Albay in January 2008.

Following the conduct of the orientations, DOH-NCDPC and HealthGov staff refined the ICV compliance monitoring and reporting forms and sent these to the CHDs for reproduction. In addition, DOH requested HealthGov to develop an administrative order that will provide the legal basis for monitoring and reporting ICV compliance.

Improving Local Response to HIV/AIDS and Avian Influenza

y HIV/AIDS

Monitoring visits and courtesy call on LCEs in selected HIV/AIDS high-risk cities

HealthGov conducted monitoring visits to the cities of Angeles, Quezon, Bacolod, Cebu, Mandaue, Lapu-Lapu, Davao, and Zamboanga to 1) follow up on the implementation progress of the HIV/AIDS service delivery acceleration plan; 2) discuss the project’s TA plan that was formulated based on the sites’ respective SDIR outputs, the rapid needs assessment, and results of the census made in the 11 high-risk cities; and 3) meet with the respective mayor to present HealthGov’s TA package and secure their mandate to plan for a comprehensive HIV/AIDS prevention and control program.

The monitoring visits yielded the following findings:

HealthGov Project—First Quarterly Report Year 2 (October– December 2007) 28

SDIR

1) For various reasons like lack of time and inability to gather together the stakeholders, the sites visited have not finalized the SDIR acceleration plan. Only Angeles City was able to formulate a comprehensive HIV/AIDS strategic plan. The respective point person for the other sites, however, committed to complete the SDIR acceleration and investment plans.

2) Davao City has validated its SDIR acceleration plan with NGOs. This was accomplished during the NGO forum on HIV/AIDS held in the second week of October 2007. The NGOs committed to harness their outreach activities for men who have sex with men (MSM) and prostituted children.

3) Cebu City has integrated some of the identified interventions in SDIR into the annual investment plan of the LGU.

Mandate to plan

Prior to activities implementation in the HIV/AIDS sites, HealthGov presented to the city mayors and other stakeholders a situational analysis of HIV/AIDS in their respective area and the technical assistance that HealthGov is offering. Listed below is the response of some LCEs:

1) Angeles City Mayor Francis Nepomuceno committed an additional PhP3.6 million to augment the budget for STI/HIV/AIDS prevention. He also gave the mandate to plan for a comprehensive HIV/AIDS prevention and control program.

2) Mandaue City trained 20 new peer educators through PNGOC funding. Mayor Jonas Cortes welcomed USAID support to strengthen the LGU’s HIV/AIDS prevention program.

3) Bacolod City Mayor Evelio Leonardia welcomed HealthGov’s HIV/AIDS technical assistance and gave the mandate to plan.

4) The CHD Regional Director of Central Visayas, the Mandaue mayor, and the city health officers of Lapu-Lapu and Cebu cities all welcomed HealthGov TA and the implementation of the zonal collaboration strategy.

Based on the above findings, the HealthGov regional field representatives, particularly the Provincial Coordinators, will regularly monitor the implementation progress of the acceleration plan but CHDs also need to monitor and provide TA to the LGUs.

HealthGov oriented the Regional Director of Central Visayas on the project’s TA package for Metro Cebu that was developed based on the city’s acceleration plan. The vital role of the CHD in providing TA and sustaining initiatives beyond HealthGov’s project life was highlighted during the orientation. The Regional Director identified the CHD STD/AIDS Coordinator and the CHD RESU Sentinel Nurse as the point persons who will assist HealthGov in implementing HIV/AIDS activities in Metro Cebu.

HealthGov Project—First Quarterly Report Year 2 (October– December 2007) 29

y Avian Influenza (AI)

The Philippines is still bird flu-free. Along with Singapore and Brunei, the country struggles to maintain its status as outbreaks occur in its neighboring countries. To help maintain the country’s bird flu-free status, USAID, through the HealthGov, SHIELD, and TB LINC projects, provided assistance to DOH, the Department of Agriculture (DA), and LGUs through a series of consultative forums for avian influenza program coordinators in Luzon, Visayas, and Mindanao in December 2007. The forums were designed to provide DA and DOH regional AI coordinators the venue to share the status of their AI preparedness, identify problems and their possible solutions, and identify areas of their AI programs where technical assistance is potentially needed.

The exchange of information showed that preparedness planning for AI and human pandemic influenza was, across the country, wanting or in need of enhancement. Out of almost 1,500 municipalities nationwide, only 321 (21%) have preparedness plans, and only 540 (36%) have organized AI task forces. Factors of preparedness especially early warning system, policy and political support, and IEC need to be improved. There is a need to look at AI preparedness plans of LGUs especially in high-risk areas, implement the community-based early warning system in identified high-risk communities, and enhance AI information campaign and public-private engagements.

To address these problems, USAID, HealthGov, TB LINC, SHIELD, DA, and DOH will hold in February and March 2008 a series of preparedness workshops for the provinces, cities, and municipalities deemed critical sites for avian influenza. These workshops aim to orient regional AI coordinators on the USAID AI intervention plan, identify potential roll- out sites for community-based early warning system, formulate guidelines on how to review existing LGU preparedness plans, and agree on schedules and tasks for LGU workshops/roll-out activities.

Coordinating with Partners and Stakeholders

y Participation in HIV/AIDS Activities

DOH consensus meeting on the 2007 HIV estimates in the Philippines

HealthGov participated in the consensus meeting on the 2007 HIV estimates in the country organized by the DOH-National Epidemiology Center. The estimates presented were products of a series of workshops participated in by representatives from national and local governments; UNAIDS; WHO; and funding agencies like USAID and Global Fund for AIDS, TB, and Malaria. Using the Workbook method, the estimated number of adults living with HIV for 2007 was 5,105 as opposed to the 2005 estimate of about 12,000.

A number of issues raised during the meeting put the 2007 estimates into question. These issues include the inclusion of overseas Filipino workers (OFWs) as a high-risk population, which others contend is not really accurate. While OFWs are vulnerable, not all of them are high-risk. Then, too, the female sex worker (FSW) population was overestimated. From an advocacy point of view, it would be difficult to explain to LCEs the reason behind the decline in the number of HIV-positive individuals in the country. Apart from this, LGUs may put lesser resources into STI/HIV/AIDS prevention.

HealthGov Project—First Quarterly Report Year 2 (October– December 2007) 30

It was thus recommended that the HIV/AIDS Technical Working Group resolve the issues raised. They need to review the estimation method used, recalculate the 2007 estimate using the most plausible assumptions, and explain in detail how the estimates were arrived at.

Local dissemination forum for the 2007 IHBSS for Quezon City and other parts of the National Capital Region (NCR)

HealthGov attended the dissemination forum for the 2007 IHBSS for Quezon City and other parts of NCR. Held 10 December 2007, the forum was participated in by STI/HIV/AIDS stakeholders including managers of fun houses in the city; DOH-NEC; CHD-NCR; Tropical Disease Foundation; UNICEF; NGOs; and LGU personnel of Quezon, Makati, Marikina, and Pasay cities. In a nutshell, the 2007 integrated HIV/AIDS behavioral and serological surveillance (IHBSS) indicated that while there is good knowledge on ways to prevent HIV transmission, high-risk practices are prevalent and there is limited exposure to interventions among most-at-risk populations.

In reaction to the presentation, HealthGov, through its HIV/AIDS Specialist, lauded the Quezon City government for prioritizing IHBSS, but reminded the LGU that IHBSS alone will not stop the spread of HIV. It is merely a tool that will guide the city in crafting targeted interventions and evaluating program implementation. He stressed that HealthGov and DOH are committed to support the city government in its HIV surveillance, prevention, and control efforts and that the two organizations will help address specific TA needs that the LGU will identify.

World AIDS Day commemoration in Angeles City

The Angeles City government acknowledged USAID assistance to the LGU’s HIV/AIDS program during the World AIDS Day commemoration held in December 2007. In her short talk, the City Health Officer-in charge welcomed HealthGov as the city’s newest partner in the fight against HIV/AIDS. The representative of the Reproductive and Wellness Center, meanwhile, recounted the city’s long-running partnership with USAID which started with the AIDS Surveillance and Education Project in 1996, the LEAD for Health project’s TA in 2005, and currently the HealthGov’s technical support. For his part, Angeles City Mayor Francis Nepomuceno recognized the urgent need to support the work on HIV/AIDS and committed to release PhP3.6 million to augment the budget for STI/HIV/AIDS prevention.

The commemoration featured an open forum on HIV/AIDS, an interpretative presentation, a testimonial from an HIV-positive former FSW, and a parade around the city plaza.

Inter-CA HIV TWG meetings

In October 2007 the HIV Inter-CA TWG members reviewed and finalized the design and timeline for data gathering for the census on project indicators in the 11 USG-assisted HIV/AIDS high-risk cities. Prior to full implementation, the design will be pretested in Cagayan de Oro City. Preliminary results were presented in the November 2007 TWG meeting. The findings were reliable except for the results for certain indicators that may be

HealthGov Project—First Quarterly Report Year 2 (October– December 2007) 31

under- or over-reported (i.e., number of individuals reached through community outreach), unvalidated (i. e., trainings received), and non-exclusive due to confusion in the indicator definition (i.e., VCT-related indicators). The findings will be reviewed and the TWG members will examine the definitions for all indicators and set clear parameters on what should be counted.

The Year 2 work plans of HealthGov, SHIELD, and HealthPRO were reviewed in the November TWG meeting. HealthGov’s Year 2 workplan focused on two major challenges, 1) the limited most-at-risk populations (MARPs) coverage by the LGUs for a comprehensive STI/HIV/AIDS prevention package, and 2) the lack of system in the LGUs that would provide strategic information. SHIELD’s work plan for the ARMM was more applicable to HIV high-risk sites than to ARMM. SHIELD’s focus for HIV/AIDS is the community as opposed to the HIV sites where the targets are the MARPs. The community trainings should deal on basic HIV/AIDS and training of trainers ToT for message development. HealthPRO’s work plan focused on the participatory action research (PAR), the initial activity in their workplan.

The December 2007 HIV Inter-CA TWG meeting looked into the implementation plan for the technical and financial evaluation of IHBSS and HealthPRO’s PAR and behavior change communication (BCC) framework. For the former, a local and foreign consultant will be commissioned to respond to DOH-NEC’s request to analyze the current IHBSS protocol as implemented, and assist NEC in improving the design and methodology of IHBSS that will provide valid, quality, timely, and regular information that is less resource- intensive. Pretesting of the redesigned IHBSS will be covered by HealthGov and cost- sharing with DOH-NEC will be explored.

HealthPRO’s BCC framework, where research plays a major role, aims to develop tailored messages and approaches for various target audiences for positive behavior change and maintenance of positive behavior. HealthPRO will design trainings for health promotion and communication, provide TA during actual trainings, and collaborate with other CAs during ToTs. A different communication strategy and set of messages may be needed in ARMM areas. Since the objective in ARMM is to increase the general population’s HIV/AIDS awareness, it was suggested that HIV/AIDS messages be integrated into the other health messages. The PAR that HealthPRO will conduct to determine factors affecting clients’ behaviors on HIV/AIDS was conceptualized to provide bases for the HealthPRO workplan development and to guide BCC interventions. For HIV/AIDS, the qualitative studies will be conducted in the cities of Pasay, Iloilo, and Zamboanga.

y TB-DOTS

In December 2007, HealthGov participated in the TB meeting of DOH and USAID cooperating agencies where USAID proposed to provide technical assistance on the following:

1) Development of alternative service delivery approaches for hard-to-reach areas 2) Intensification of a communications program on advocacy and behavior change to improve case detection rate 3) Improvement of case management and quality assurance 4) Development of costs and financial plans for TB in the context of PIPH and the national budget

HealthGov Project—First Quarterly Report Year 2 (October– December 2007) 32

5) Engagement of partners to roll out the Comprehensive Unified Policy on TB control in selected provinces 6) Mobilization and rationalization of TB funds, with clear delineation between local, central, PhilHealth, private sector, and donor-provided funds 7) Addressing national cross-cutting issues: a) PhilHealth support to TB control, b) service-level agreements as applied in the TB program, c) TB financing strategies like multiyear budget legislation and PCSO support, d) strengthening the roles of CHDs in monitoring priority areas’ DOTS compliance

DOH, on the other hand, planned to review three major points of reference in aligning and updating its efforts, namely policy, mandate, and existing plan; organizational set-up; and current resources.

As a follow-on, USAID and DOH will convene a strategic policy dialogue with DOH and key partners in TB control and, based on the results of the policy dialogue, the health department will update the national TB control strategy. They will work together in developing 1) strategies to review the performance of priority provinces, 2) a framework for coordinating donor support, and 3) implementation arrangements for USAID projects.

y Participation in the Crafting of the Maternal and Newborn Health Policy and Strategy Framework

During the review period, HealthGov actively participated in the DOH-led development, revision, improvement, and finalization of the maternal and newborn health policy and strategy framework. Major stakeholders, including Women’s Health, the Philippine Society of Newborn Management, selected individuals, and two consultants identified four major strategies for pushing forward the maternal and newborn health program, as follows:

Strategy 1: Universal access to maternal-newborn service package. Universal access to a standard service package of maternal and newborn health services must be provided as a basic right of all mothers, newborns, and women of reproductive age. The maternal-newborn service package consists of both clinical case management services and public health measures available to women and their newborn at various lifecycle stages starting from pre-pregnancy to post-partum. The service package is presented from the perspective of: 1) the recipient of the services, 2) the beneficiary of the services, and 3) the service outlets where these are expected to be offered.

Strategy 2: Establishment of a capable, functioning, and well-coordinated maternal-newborn service delivery module. This requires a customized adaptation in all localities of a specific service delivery module capable of providing beneficiary populations all services in the service package. The service delivery module is based on a service area with 500,000 population served by a comprehensive emergency obstetrics and newborn care (CEmONC) center, its associated network of basic emergency obstetrics and newborn care (BEmONC) centers, primary facilities offering skilled- attended deliveries, and community-based team providing public health interventions.

Strategy 3: Application of system development instruments to foster desired behavior changes in the maternal-newborn service area. Organized application of health systems development instruments is necessary to induce localities to create and sustain their respective service delivery modules providing the service package to all.

HealthGov Project—First Quarterly Report Year 2 (October– December 2007) 33

The systems development instruments consist of regulatory, financing, and governance mechanisms needed to enable localities to set up and sustain their service delivery modules.

Strategy 4: Build up capacities of DOH and PhilHealth. There must be a rapid build- up of institutional capacity requirements at DOH and PhilHealth as the two lead national government agencies applying the corresponding systems development instruments. The DOH and PhilHealth capacities are the technical, organizational, financial and human resources necessary to effectively apply the systems development instruments nationwide.

While the planning and specification of the strategy proceed sequentially from 1 to 4, the actual implementation of the strategy will proceed from 4 to 1. In summary, the maternal and newborn health strategy entails universal access to and use of a maternal and newborn service package that is provided and delivered by the service delivery module organized and operated in all localities of the country, which in turn is established and supported through the application of system development instruments using deliberately built-up DOH and PhilHealth capacities.

The maternal and newborn health policy and strategy framework will be presented to the DOH Executive Committee for review and approval.

IR 1.3 activities planned for 2nd Quarter Year 2

• Complete SDExH workshops in Oroquieta ILHZ of Misamis Occidental and Metropolitan ILHZ of Negros Oriental • Evaluate the implementation of SDExH and plan for its expansion and the training of trainers • Enhance SDExH training modules and develop guide to operationalizing SDExH • Enhance SDIR tools and manage SDIR outputs • Provide TA to DOH in developing an administrative order on ICV compliance monitoring and reporting • Provide TA to high-risk cities on strategic and investment planning for HIV/AIDS program • Gather TB data in non-TB LINC provinces and data on avian influenza in 11 critical areas • Develop and provide specific TA for TB in provinces with low case detection rate and cure rate • Develop tools and plans for AI preparedness and community-based early warning system

IR 1.4 Increasing Advocacy on Service Delivery and Financing

Partnership Building

During the quarter under review, HealthGov provided technical assistance to focal NGOs and PHOs in eight provinces as they conducted partnership-building initiatives (see Table 4). These provinces are Capiz, Negros Occidental, Bohol, Misamis Occidental, Zamboanga del Sur, Albay, South Cotabato, and Aklan. TA to these provinces resulted in

HealthGov Project—First Quarterly Report Year 2 (October– December 2007) 34

Table 4 8 provinces pursued partnership-building activities in October-December 2007

No. of Participants LGU Province Activity Date/ NGOs/ officials/ Regional Other Total type Venue CSOs Health partners CAs staff F1 sites Capiz Provincial 9-10 Oct 28 10 9 7 54 Partnership- Roxas City building Workshop Misamis 20-21 Nov 23 21 4 3 51 Occidental Oroquieta City Workshop on Streamlining Health Promotion and Advocacy Capiz Alliance 18-19 Dec 22 5 − 3 30 for Health Roxas City Workshop South Cotabato 15 Dec 43 394 10 3 450 Health Summit Gen. Santos City F1 rollout Zamboanga del 3-4 Dec 20 27 3 1 51 sites Sur Provincial Pagadian City Partnership- building Workshop Albay Provincial 3-4 Dec 22 26 2 − 50 Partnership- Legaspi City building Workshop Other Negros 22-23 Oct 23 10 4 5 42 provinces Occidental Bacolod City Partnership- building Workshop Bohol 15-16 Nov 32 12 2 1 47 Partnership- Tagbilaran building City Workshop Aklan Workshop 20 Dec 14 11 − 3 28 on Streamlining Kalibo Advocacy Support to PIPH Implementation

significant progress in NGO/CSO-PHO partnership, one of which is the PHO’s designation of a focal person who will facilitate linkages with and maintain coordination between the PHO and NGO/CSO partners.

HealthGov Project—First Quarterly Report Year 2 (October– December 2007) 35

Local health boards (LHBs) are an important area of partnership in health policymaking. Making them functional is a TA challenge in many of HealthGov’s project sites. In the Visayas, for instance, two of the five project sites, namely Capiz and Bohol, have not convened their LHB for many years now. To address this need, HealthGov together with PNGOC convened partnership forums in the Visayas not only to build and strengthen local alliances for health but also to impress upon the LGUs the urgency of convening local health boards to ensure greater stakeholder participation in health planning and decision-making.

As a result of these partnership forums, the Capiz Alliance for Health composed of PHO staff, MHOs, and health advocates from 33 local NGOs was organized. The Alliance has formulated its vision and mission, and moved to formalize itself as an organization. It drafted an advocacy plan that identifies areas of collaboration (e.g., child health, HIV/AIDS, cheaper medicines). The PHO, recognizing the role of NGOs/CSOs in health sector reform, offered the Alliance a physical base in the Provincial Health Office. The PHO also designated a focal person who is tasked to sustain linkage with the local CSOs.

The Capiz Alliance for Health promised to get, with the help of the local Department of the Interior and Local Government (DILG) and the PHO focal person for NGO/CSO activities, the Governor’s approval to convene the Provincial Health Board. Additionally, the Alliance took part in a blood-letting activity called Dugong NGO (literally, NGO blood) which called on members of the NGO community to donate blood. Lastly, the PHO included in the 2008 Operational Plan of PIPH an allotment of PhP1 million for community empowerment activities, including advocacy and community mobilization activities of the Alliance.

In Negros Occidental, the provincial partnership-building workshops (PPBWs) were convened by the PHO and the NGO convener through the six inter-local health zones in the province. They agreed on how best to engage the local NGOs in improving the quality of and access to health services in the different municipalities. Preparations for advocacy planning on 10-11 January 2008 are underway.

In Bohol, the PPBW resulted in the commitment of the stakeholders to participate in the PIPH formulation process in time for the budget preparation in June 2008. The stakeholders also called for convening the Provincial Health Board which is currently non-functional. In response, the provincial LGU, through the PHO, has agreed to convene its PHB in January 2008. One of the agenda is the proposal to initiate provincial health investment planning.

In Aklan, each NGO-participant in the partnership workshop crafted an advocacy action plan in support of the PHO’s PIPH implementation activities.

The partnership forums in Mindanao were convened as part of the PIPH validation process in order to surface the consumer perspective and build support for the implementation of the health investment plan. The Zamboanga del Sur partnership- building workshop was the first time the PHO convened local CSOs and rallied them to support health programs. All representatives of NGOs in the Provincial Development Council, most of which were cooperatives, faith-based organizations such as the Social Action Center, and local Protestant churches participated in the workshop. They were

HealthGov Project—First Quarterly Report Year 2 (October– December 2007) 36

made aware of the local health challenges and their involvement in improving health service performance and coverage.

The South Cotabato health congress served as a venue for apprising the newly elected barangay officials on PIPH and the health challenges in the province. Some 450 representatives of LGUs, CSOs, and national government agencies participated in the event. The multi-sectoral Provincial Coordinating Council for Health Concerns (PCCHC) organized by the PHO played a key role in the congress as it highlighted the role of civil society in health sector reform. The PCCHC presents a good model of LGU-NGO/CSO partnership for health. From its inception in 1990, it has initiated, together with the PHO, a number of health-related projects, activities, and campaigns. Recently, Mahintana Foundation, the lead NGO of PCCHC, was granted PhP1.5 million for the distribution of essential drugs and FP commodities through the Botikang Panlalawigan (provincial pharmacy).

In Misamis Occidental, HealthGov provided TA in streamlining advocacy and health promotion in support of PIPH implementation.

During the review period, HealthGov ensured in Luzon the participation of NGOs/CSOs in 1) PIPH formulation in the provinces of Isabela and Albay, and 2) the annual investment planning in Tarlac and Nueva Ecija. In Albay, HealthGov facilitated the coming together of local NGOs and civil society groups, most of which are grassroots organizations, to unite on a common health agenda which they will pursue in partnership with the provincial and municipal health offices. In the provincial partnership-building workshop held on 3-4 December, the LGU health staff and the NGOs/CSOs agreed to work together for health sector reform. This initiative led to the PHO’s recognition of the NGOs/CSOs as partners in health development. The health programs of the NGOs/CSOs have been integrated in the PIPH and their cost (i.e., PhP30 million) reflected as NGO/CSO funding counterpart.

Monitoring of partnership activities in the other provinces revealed NGO/CSO’s active involvement in health-related activities. In Bulacan, Bantay Kalusugan ng Bulakan (BKB, Bulacan HealthWatch), which was organized to boost community-led health advocacy and monitoring, participated in DOH’s Knock out Tigdas measles vaccination campaign. The PHO mobilized local CSOs which shared resources, including transportation, to meet the measles vaccination campaign target in the province. The BKB health coalition, which was formally launched in December 2007, is now an accredited member of the Provincial Health Board. It is preparing for an advocacy planning session with LGUs in February 2008.

Meanwhile, Governor Amado Espino welcomed the Pangasinan Federation of NGOs during a courtesy call on the LCE in October 2007. The Governor issued an executive order recognizing their role and contribution as health partners.

In Agusan del Norte, HealthGov followed up on the partnership meetings of the Ad Hoc Committee on Health. The project explored the possibility of collaborating with the Health Sector Reform Group in terms of strengthening the ILHZ and advocacy for indigent enrollment in PhilHealth under the province’s multi-payer scheme.

During the quarter under review, HealthGov, through its partner-NGOs and PHOs, continued to monitor NGO/CSO participation in LGU special bodies. This is to ensure that local civil society groups are involved in LGU policy-making processes. Currently, 21

HealthGov Project—First Quarterly Report Year 2 (October– December 2007) 37

provinces assisted by HealthGov have NGO/PO/private organization representative/s in their provincial health board or development council. The updated list of these NGOs/CSOs is presented in Table 5.

Materials Development

In preparation for the development of the Guide to Building Partnerships for Health slated for the next quarter, HealthGov, through PNGOC, compiled the reports, PowerPoint presentations, and other reference materials used and disseminated in the partnership- building activities conducted in the project’s first year. The guide, to be developed in collaboration with HealthGov partners at DOH National Center for Health Promotion, selected CHDs, and PHOs, is intended as a practical toolkit for use by LGUs and NGOs/CSOs as they build support for health sector reform and forge local partnerships for health.

IR 1.4 activities planned for 2nd Quarter Year 2

y Assess NGO/CSO capacity to participate in local health board and local development council processes y Prepare a profile of local health champions y Map out the health support of provincial, municipal, and city LGU officials y Provide technical assistance in advocacy support for CSR y Identify STTA consultants and other technical assistance providers for the development of process designs and modules on advocacy planning, effective championing, and constituency building for health

HealthGov Project—First Quarterly Report Year 2 (October– December 2007) 38

Table 5 21 HealthGov-supported provinces have NGO/PO/private sector representatives in their provincial health board/development council

Province NGO/PO/private sector representative in the provincial health board/development council

F1 sites Pangasinan Pangasinan Federation of NGOs

Misamis Himaya, Federation of Women’s Associations Occidental South Cotabato Provincial Council for Health Concerns (PCHC)

F1 rollout sites Isabela BHW Federation

Albay Simon and Cyrelle Rehabilitation Program

Sarangani COMDEV

Zamboanga Philippine Medical Society – Sibuguey Chapter Sibugay Coalition of Development NGOs in Sibuguey

Zamboanga del Philippine Medical Society, AID Foundation Sur Zamboanga del Philippine Medical Society Norte Compostela Valley Institute for Primary Health Care

Other provinces Cagayan PROCESS Luzon, Integrated Midwives Association of the Philippines

Nueva Ecija Nueva Ecija Medical Society, Family Planning Association of the Philippines (FPOP) Nueva Ecija Chapter

Tarlac Tarlac Medical Society

Bulacan FPOP, Bulacan HealthWatch

Aklan Uswag Development Foundation

Bohol PROCESS Bohol, University of Bohol Family Planning/Lying-in Center Foundation

Negros Occidental Negros Occidental Economic Development Foundation Misamis Oriental German Doctors, Philippine Medical Society – Misamis Oriental Chapter

Agusan del Norte Philippine Medical Society – Agusan del Norte Chapter, Philippine National Red Cross

Bukidnon Philippine Medical Society – Bukidnon Chapter

Davao del Sur Cor Jesu, Philippine Medical Society – Davao del Sur Chapter

HealthGov Project—First Quarterly Report Year 2 (October– December 2007) 39

6. Monitoring and Evaluation

6.1 Performance Indicators Data collection and preparation of the project’s first year accomplishment reports were done throughout the quarter under review. Separate reports were prepared for the OP indicators and HealthGov performance indicators. Guided by the forms and instructions provided by USAID Office of Health, consolidated accomplishment reports on the OP indicators by health program (MCH, FP-RH, TB, and HIV/AIDS) were prepared in collaboration with the other CAs. HealthGov took the lead in preparing the accomplishment report on the MCH program and HIV/AIDS program, while TB LINC and PRISM led the preparation of the reports on TB and FP-RH, respectively. The report preparation entailed the collection of FHSIS quarterly reports and other routine health statistics from the 23 HealthGov provinces for consolidation and comparison with the baseline data and initially-set targets. Reports collected from the 23 provinces included those on the FHSIS 4th quarter 2006 to the 3rd quarter 2007. Data for the OP indicators from these reports were consolidated to get the one-year accomplishments corresponding to the project’s first year of implementation.

HealthGov’s implementation key results during the first year were reflected in the report on the 24 project performance indicators. The report basically compares the September 2007 status of the 23 HealthGov provinces with the baseline (September 2006) and the corresponding targets.

6.2 M&E Information Storage

y Performance Management Information System (PMIS)

The PMIS web-based and stand-alone application systems were developed and tested during the period under review. The web-based application will allow authorized individuals and organizations to conveniently access HealthGov data through the Web. The stand-alone facility of PMIS meanwhile will allow users, specifically HealthGov Provincial Coordinators, to enter date into the database even in areas where Internet access is not available. The stand-alone application will be available in February 2008.

y Training Management Information System (TMIS)

TMIS enables HealthGov to consolidate and summarize data on trainings conducted with HealthGov support. A total of 1,581 individuals were recorded to have participated in HealthGov-assisted trainings and workshops at a total cost of PhP6.4 million. Of this amount, 63.5% was borne by LGU partners and 36.5% by USAID.

HealthGov Project—First Quarterly Report Year 2 (October– December 2007) 40

7. Financial Report for the Quarter

Health Sector Development Program – Local Government Unit (LGU) Systems Strengthening Component (HealthGov) CA # 492-A-00-06-00037-00

By the end of the reporting quarter, the project had expended 43% of its cumulative obligation of $11 million after five quarters of project operations (see Table 6). The quarter’s expenditures are 8% less compared with that in the previous quarter. The decrease could be attributed to the government moratorium on project activities during the Knock Out Tigdas measles vaccination campaign in the latter half of October, and the holidays. However, expenditures are expected to increase in succeeding quarters as more technical assistance providers are engaged, and a mechanism is developed to engage institutional TAPs for the long term in response to the increased demand for technical assistance in Year 2.

On the administrative front, significant activities in the next quarter include plans to purchase two project vehicles, and hiring a Grants and Subcontracts Manager.

HealthGov Project—First Quarterly Report Year 2 (October– December 2007) 41