Integrated Community Health Services Project

Completion Report

Project Number: 26321 Loan Number: 1396 November 2006

Philippines: Integrated Community Health Services Project

CURRENCY EQUIVALENTS Currency Unit – peso (P)

At Appraisal At Project Completion 30 September 1995 9 February 2005 P1.00 = $0.03849 $0.0181 $1.00 = P25.98 P55.125

ABBREVIATIONS ADB – Asian Development Bank ARI – acute respiratory illness AusAID – Australian Agency for International Development BHS – barangay health station BHW – barangay health worker BME – benefit monitoring and evaluation BOR – bed occupancy rate DBM – Department of Budget and Management DOH – Department of Health EA – executing agency F1 – Fourmula 1 FIC – fully immunized children HCF – health care financing HHRMDS – Health Human Resources Management and Development System HMIS – Health Management Information System HOMIS – Hospital Operation Management Information System HRD – human resources development HSRA – Health Sector Reform Agenda ICHSP – Integrated Community Health Services Project IHPS – Integrated Health Planning System ILHZ – inter-local health zone LGC – Local Government Code LGU – local government unit MIS – management information system NGO – nongovernment organization OPB – outpatient benefit package PCR – project completion review PhilHealth – Philippine Health Insurance Corporation PHO – provincial health office PIA – project implementation agreement PIU – project implementation unit PMO – project management office PSC – project steering committee RHU – rural health unit TB – tuberculosis TB-DOTS – Tuberculosis Directly Observed Treatment Short-course TCC – technical coordination committee

Vice President C. L. Greenwood Jr., Operations Group 2 Director General R. Nag, Southeast Asia Department (SERD) Director S. Lateef, Social Sectors Division, SERD Team Leader K. Schelzig Bloom, Social Sectors Division, SERD

CONTENTS

Page BASIC DATA ii MAP vii I. PROJECT DESCRIPTION 1 II. EVALUATION OF DESIGN AND IMPLEMENTATION 1 A. Relevance of Design and Formulation 1 B. Project Outputs 2 C. Project Costs 5 D. Disbursements 6 E. Project Schedule 6 F. Implementation Arrangements 7 G. Conditions and Covenants 7 H. Related Technical Assistance 7 I. Consultant Recruitment and Procurement 8 J. Performance of Consultants, Contractors, and Suppliers 8 K. Performance of the Borrower and the Executing Agency 8 L. Performance of the Asian Development Bank 9 III. EVALUATION OF PERFORMANCE 9 A. Relevance 9 B. Effectiveness in Achieving Outcome 10 C. Efficiency in Achieving Outcome and Outputs 12 D. Preliminary Assessment of Sustainability 13 E. Impact 14 IV. OVERALL ASSESSMENT AND RECOMMENDATIONS 15 A. Overall Assessment 15 B. Lessons 15 C. Recommendations 16 APPENDIXES 1. Project Framework 17 2. Status of Sentrong Sigla Certified Rural Health Units Constructed/Renovated Under the Project 33 3. Project Cost by Expenditure Category 34 4. Project Implementation Schedule 35 5. Summary of Transitions in Project Leadership, 1997–2004 36 6. Status of Compliance with Loan Covenants 37 7. Utilization Status of the Integrated Health Planning System by Region 43 8. Status of Systems Installation in Pilot and Replication Areas 44 9. Status of PhilHealth Accreditation 48 10. Hospital Operations and Management System Implementation Status 50

BASIC DATA

A. Loan Identification

1. Country Philippines 2. Loan Number 1396 3. Project Title Integrated Community Health Services Project 4. Borrower Republic of the Philippines 5. Executing Agency Department of Health 6. Amount of Loan SDR17.6 million 7. Project Completion Report Number 947

B. Loan Data 1. Appraisal – Date Started 13 February 1995 – Date Completed 3 March 1995

2. Loan Negotiations – Date Started 15 September 1995 – Date Completed 21 September 1995

3. Date of Board Approval 17 October 1995

4. Date of Loan Agreement 27 November 1995

5. Date of Loan Effectiveness (90 days from Loan Agreement) – In Loan Agreement 25 February 1996 – Actual 31 March 1997 – Number of Extensions 6

6. Closing Date – In Loan Agreement 30 June 2002 – Actual 9 February 2005 – Number of Extensions 2

7. Terms of Loan – Interest Rate 1% per annum – Maturity (number of years) 35 years inclusive of grace period – Grace Period (number of years) 10 years

9. Disbursements a. Dates Initial Disbursement Final Disbursement Time Interval

6 August 1997 9 February 2005 89 months

Effective Date Original Closing Date Time Interval

31 March 1997 30 June 2002 63 months

iii

b. Amount ($) Category Last Net or Original Revised Amount Amount Amount Undisbursed Subloan Allocationa Allocationb Cancelledc Available Disbursed Balance Foreign Expenditure Civil Works 3,200,000 5,539,844 400,000 5,539,844 5,489,427 53,182 Equipment and 2,880,000 3,489,475 (185,000) 3,489,475 3,234,766 268,680 Medical Supplies Vehicles 820,000 465,089 100,000 465,089 456,378 9,189 Training/Fellowships/ 330,000 1,904,792 170,000 1,904,792 1,916,613 (12,469) Workshops Consulting Services 1,850,000 3,517,757 (210,000) 3,517,757 3,640,404 (129,374) Monitoring and 20,000 278,521 (110,000) 278,521 268,381 10,696 Evaluation Replication 2,500,000 570,845 2,800,000 570,845 344,799 238,445 Activities Service Charge 2,320,000 300,522 300,000 300,522 300,522 — During Construction Unallocated 25,228 1,200,000 25,228 — 26,612 Local Expenditure Civil Works 1,600,000 — — — — — Vehicles 40,000 — — — — — Training/Fellowships/ 1,940,000 — — — — — Workshops Consulting Services 1,070,000 — — — — — Health Promotion 1,390,000 741,558 560,000 741,558 631,180 116,432 Studies and 120,000 159,322 — 159,322 125,842 35,316 Surveys Monitoring and 150,100 — — — 1,197,958 (1,263,666) Evaluation Replication 1,770,200 — — — — Activities Project 820,000 1,317,021 (225,000) 1,317,021 — 1,389,259 Management Service Charge 3,090 — — — — — During Construction Unallocated — 700,000 — — — Total 25,910,000 18,309,974 5,500,000 18,309,974 17,606,270 742,302 — = not available, ( ) = negative. a As of appraisal, SDR rate = $1.469190. b Effective January 1997, simplified monitoring of local cost financing was implemented. c Actual amount cancelled may affect the total dollar equivalent because of exchange rate fluctuations between SDR and $ during project implementation. During the first partial cancellation of the loan on 1 June 2001, SDR rate = $1.259950; at the second partial cancellation of the loan on 17 November 2003, SDR rate = $1.431780; and at the third partial cancellation of the loan on 7 May 2004, SDR rate = $1.456980. The SDR rate during the final cancellation on 9 February 2005 was $1.523870.

10. Local Costs (Financed) - Amount ($ million) 7.70 - Percent of Local Costs 43.02 - Percent of Total Cost 22.25

C. Project Data

1. Project Cost ($ million) Cost Appraisal Estimate Actual Amount % Amount %

Foreign Exchange Cost 21.5 42.1 17.6 84.0 Local Currency Cost 29.6 57.9 3.3 16.0 Total 51.1 100.0 20.9 100.0

2. Financing Plan ($ million) Cost Appraisal Estimate Actual Foreign Local Total % Foreign Local Total % Exchange Currency Exchange Currency Implementation Costs Borrower Financed 10.0 10.0 19.6 3.3 3.3 9.6 ADB Financed 13.9 12.0 25.9 50.7 9.9 7.7 17.6 50.8 AusAID Financed 7.6 7.6 15.2 29.7 8.6 5.1 13.7b 39.5 Total 21.5 29.6 51.1a 100.0 18.5 16.1 34.6 100.0

IDC Costs Borrower Financed — — — — — — — — ADB Financed 2.3 2.3 100.0 0.3 0.3 100.0 AusAID Financed – – — — Total 2.3 0.0 2.3 100.0 0.3 0.0 0.3 100.0 — = not available, ADB = Asian Development Bank, AusAID = Australian Agency for International Development, IDC = interest during construction. a Inclusive of taxes and duties, physical and price contingencies, and service charges equivalent to $6.13 million. b $1 = A$1.351625.

3. Cost Breakdown by Project Component ($ million) Component Appraisal Estimate Actual Foreign Local Totala Foreign Local Totalb Civil Works 3.2 1.6 4.8 5.5 3.7 9.3 Equipment and Medical Supplies 2.9 — 2.9 5.2 0.9 6.1 Vehicles 0.8 — 0.9 0.4 0.1 0.5 Training/Fellowships/Workshops 0.3 1.9 2.3 0.4 3.6 3.9 Consulting Services 1.9 1.1 2.9 6.4 5.0 11.4 Monitoring and Evaluation — 0.2 0.2 — 0.3 0.3 Replication Activities 2.5 1.8 4.3 0.2 0.2 0.4 Service Charge During Construction 2.3 3.1 5.4 0.3 — 0.3 Unallocated — — — — — — LC-Health Promotion — 1.4 1.4 0.8 0.8 LC-Studies and Surveys — 0.1 0.1 0.1 0.1 LC-Project Management — 0.8 0.8 1.4 1.4 Total 13.9 12.0 25.9 18.5 16.1 34.6 — = not available. Note: Numbers may not add up because of rounding. a As of appraisal, SDR rate = $1.469190. b Details of actual cost by category under Australian Agency for International Development (AusAID) component not provided.

4. Project Schedule Item Appraisal Estimate Actual Date of Contract with Consultants Benefit Monitoring and Evaluation Specialist June 1997 4 November 1997 Project Management Specialist (firm) June 1997 17 February 1998 Project Management Specialist (individual) June 1997 13 May 1998 Telecoms Specialist July 2002 5 December 2003

Civil Works Contract Date of Award June 1998 17 December 1998 Completion of Work December 2002 31 December 2003

Equipment and Supplies First Procurement June 1998 5 October 1999 Last Procurement December 2002 18 June 2004

Installation of System (Local Area Network) Completion of Installation February 2000 11 October 2000 Completion of Test February 2000 11 October 2000 Start of Operation March 2000 16 November 2000

5. Project Performance Report Ratings (PPR) Ratings

Development Objectives Implementation Progress Implementation Period From 1 December 1998 to 31 July 2005 S S

Rating used in PPR: HS = highly satisfactory; S = satisfactory; PS = partly satisfactory; U = unsatisfactory.

D. Data on Asian Development Bank Missions No. of No. of Specialization Name of Mission Date Persons Person-Days of Membersa Fact-Finding 7–24 November 1994 5 15 a,b,f,i Appraisal 13 February– 5 25 a,b,f,c,i 8 March 1995 Inception 1 5–18 November 1996 2 22 f,e Inception 2 22 June–3 July 1997 1 10 e Review 1 10–23 February 1998 1 12 e Review 2 18–22 and 28 1 16 f September; 4, 12–14 October 1998 Review 3 5–13 April 1999 1 10 e Special Loan Administration 1–9 June 1999 2 14 e,i Review 4 18–29 October 1999 2 24 e,h Midterm Review 10–25 April 2000 2 32 a,e Review 5 23 October– 2 12 a,h 7 November 2000 Review 6 22–31 August 2001 2 20 d,h Review 7 4–12 February 2002 2 16 d,h Review 8 2–13 December 2002 1 12 d Review 9 20 October– 1 12 d 5 November 2003 Subtotal During Project Implementation Project Completion Reviewb 24 March– 3 47 g,h,i 11 May 2006 a a = health specialist, b = programs officer, c = counsel, d = senior project specialist, e = project specialist, f = project economist, g = senior project implementation specialist, h = assistant project analyst, i = consultant.

119o 00'E 125 o 00'E

Babuyan Channel o 122 00'E PHILIPPINES o o 21 00'N 21 00'N Itbayat INTEGRATED COMMUNITY BATANES HEALTH SERVICES PROJECT Basco APAYAO Kabugao Sabtang (as completed) o 122 00'E Bangued KALINGA REGION II ABRA Cagayan Valley REGION I CAR Tabuk Ilocos MT. PROVINCE Bontoc S o u t h C h i n a S e a IFUGAO Lagawe BENGUET N La Trinidad Baguio

0 50 100 150 o 16 o 00'N 16 00'N

Kilometers

REGION III Central Luzon P A C I F I C O C E A N Manila Social Reform Agenda (SRA) Priority Provinces NCR REGION V REGION IV-A Bicol Project Provinces CALABARZON National Capital City/Town Main Road Calapan Provincial Boundary P h i l i p p i n e S e a Regional Boundary ORIENTAL Sibuyan Sea Boundaries are not necessarily authoritative. MINDORO REGION IV-B MIMAROPA REGION VIII Eastern Visayas

Borongan Roxas Visayan EASTERN SAMAR CAPIZ Sea ANTIQUE

Leyte Jordan Gulf San Jose GUIMARAS SOURTHERN Panay Gulf LEYTE SURIGAO REGION VII DEL NORTE REGION VI Central Visayas Maasin PALAWAN Western Visayas Surigao Puerto Princesa Bohol Sea REGION XIII CARAGA

REGION X Northern Mindanao Prosperidad AGUSAN DEL SUR o o 8 00'N DAVAO 8 00'N REGION IX DEL Zamboanga Peninsula S u l u S e a NORTE Tagum

NCR - National Capital Region Isabela M o r o G u l f REGION XI ARMM - Autonomous Region in Muslim Mindanao Davao Region CALABARZON - Cavite, Laguna, Batangas, Rizal, Quezon BASILAN A R M M SULTAN KUDARAT Koronadal CAR - Cordillera Administrative Region SOUTH CARAGA - Agusan del Norte, Agusan del Sur, Surigao del Norte, Jolo COTABATO and Surigao del Sur MIMAROPA - Mindoro, Marinduque, Romblon, Palawan REGION XII SOCCSKSARGEN - South Cotabato, North Cotabato, Sultan Kudarat, SULU SOCCSKSARGEN Sarangani, and General Santos

Panglima Sugala C e l e b e s S e a

TAWI-TAWI 119o 00'E 125 o 00'E

06-1108 HR 1

I. PROJECT DESCRIPTION

1. The Integrated Community Health Services Project (ICHSP) was approved on 17 October 1995, comprising: (i) a project loan in the amount equivalent to $25.9 million from Special Funds resources for Integrated Community Health Services;1 (ii) grant cofinancing of $15.2 million from the Australian Agency for International Development (AusAID); and (iii) government counterpart financing of $10.0 million equivalent, for an estimated total project cost of $51.1 million. The Asian Development Bank (ADB) also approved the provision of technical assistance (TA) for Strengthening Hospital Standards, Licensing and Regulation (footnote 1) in the amount of $0.5 million equivalent on a grant basis.

2. The Executing Agency (EA) for the Project was the Department of Health (DOH). The overall impact of the Project was to improve health by reducing the incidence and severity of the main communicable diseases affecting children and the population in general through improved preventive and basic curative health services. The three intended outcomes were: (i) improved capacities of communities, nongovernment organizations (NGOs), and local government units (LGUs) to plan, manage, monitor, and finance essential health programs and services at the provincial, municipal, and community levels in a cost-effective manner; (ii) development, testing, and implementation of a number of provincial health subsystems;2 and (iii) strengthened DOH capacity at the national and regional levels to implement and support these health subsystems and to provide policy direction and technical support to LGUs, NGOs, and community groups in planning and implementing health programs and services. The project framework is in Appendix 1.

3. The ICHSP was implemented in six pilot provinces with a plan to replicate successful health management systems in other provinces. The provinces were selected by DOH using five criteria3 and were representative of different geographic and demographic typologies that affect people’s access to health services.4 The ADB loan focused on the four provinces of Kalinga, Apayao, Guimaras, and Palawan, while the AusAID grant covered activities in South Cotabato and Surigao del Norte. AusAID financed the NGO/community mobilization component for all provinces, while later replication of systems to seven additional provinces was financed from the ADB loan.

II. EVALUATION OF DESIGN AND IMPLEMENTATION

A. Relevance of Design and Formulation

4. The ICHSP was the first project to address decentralized health services delivery following the passage of the Local Government Code (LGC) of 1991. It was designed to respond to the inefficient delivery of health services under decentralization, the low utilization of health services, and the slow improvement in the health status of the population. The Project was formulated to address unclear roles between and within the DOH national and regional levels and LGUs, given evolving mandates and authorities under the LGC.

1 ADB. 1995. Report and Recommendation of the President to the Board of Directors on a Proposed Loan to the Philippines for Integrated Community Health Services Project. Manila. 2 This included: (i) health services planning, (ii) health financing, (iii) health management information systems, (iv) hospital operations and management, and (v) human resources management and development. 3 The five criteria were: (i) poor health and demographic indicators, (ii) economically disadvantaged, (iii) provincial government commitment to health, (iv) NGO capacity, and (v) stable peace and order situation. 4 The six provinces selected were the mountainous provinces of Kalinga and Apayao, the small island province of Guimaras, the large island province of Palawan, the flat, populous province of South Cotabato, and the mountainous island province of Surigao del Norte.

5. The Project comprised relevant and cost-effective interventions aimed at improving health status, especially among vulnerable groups (women and children). The Project targeted the increasing number of people suffering from communicable diseases and those residing in malaria and schistosomiasis-endemic areas. Project investments equipped LGUs to meet these health needs. The Project aimed to address: (i) staff competencies both in service delivery and health management for preventive and curative care, and the poor condition of most health facilities; (ii) the absence of basic equipment and supplies; (iii) limited mobility of service providers at the grassroots level; and (iv) poor communication among care facilities.

6. The Project focused on developing and instituting health management support systems, most of which were no longer functioning under the LGC. The Project developed and tested essential components of an integrated health care delivery system, and adapted and applied these to local conditions. The selection of diverse pilot provinces allowed the Project a more comprehensive testing of different health management systems to widen their applicability to similar settings. Later replication of workable systems to other provinces made the project design relevant, considering the large number of LGUs needing assistance. On the whole, the Project was timely, appropriate, and comprehensive.

B. Project Outputs

7. Details of the Project’s three outputs/components and performance according to the targets are in Appendix 1. Targets under the key output—to strengthen delivery of comprehensive health services in each pilot province—were largely achieved.5

1. Management and Financing Subsystems in Place

8. Provincial health accounts were established during the Project. These became the basis for charting different health financing schemes considered appropriate by each LGU. However, the goal of institutionalizing the health account system in the routine National Statistics Office studies/surveys did not materialize. This suggests that the health accounts per province have not been updated since the Project ended.

9. A hospital management and operations manual was developed to guide hospitals in assessing operations and establishing protocols and standards. Most of the ICHSP pilot and replication areas have developed their own hospital management and operations manual. Reference manuals were developed and localized by all provinces. Human resource development systems were developed in all four provinces. In Kalinga, the system entailed establishing a health selection committee which screens, selects, and endorses applicants to the provincial committee. In Guimaras, the selection criteria were made more specific, making the selection process more objective and transparent for every applicant.

10. The performance management system was particularly successful in Palawan, resulting in the establishment of a human resources management office within the provincial health office (PHO). This unit has been active in developing training programs, implementing capability building activities, and establishing a database on health staff and health workers. In Apayao, staff trained on the human resources and development management system applied their knowledge of developing personnel policies and guidelines to the whole provincial government.

5 The original project framework did not adequately distinguish between outcomes (“objectives”) and outputs (“components”): two out of the three outputs are identical to two of the three outcomes, with targets overlapping as well. This section therefore assesses performance on the first output, to strengthen delivery of comprehensive health services in each province, with its five subcomponents. The remaining two outputs/outcomes (to develop, test, and implement essential health subsystems and to increase the capacity of DOH to support health service delivery) are discussed in the outcomes section (paras. 42–53).

Training development and needs assessments were undertaken in all provinces to identify the training gaps for health staff. However, no corresponding training program was developed to address these gaps—provinces depend mainly on DOH for technical training.

2. Referral Systems Improved

11. Performance targets in this subcomponent were that all planned facilities should be built or renovated and equipped, that all pilot provinces should have functioning communications systems, and that all health facilities should meet licensing requirements. In total, the referral system was improved by: (i) renovating, upgrading, or constructing a total of 154 barangay6 health stations (BHSs) (exceeding the target of 145), 31 rural health units (RHUs) (of the targeted 32), all 15 targeted district hospitals, and 2 targeted provincial hospitals; (ii) equipping facilities with essential medical equipment, instruments, clinical supplies, and materials including kits for barangay health workers (BHWs) and midwives; (iii) providing transport facilities (158 motorcycles, 4 vehicles, and 6 ambulances); and (iv) installing radio and telephone communication systems.

12. The Project renovated and upgraded all of the planned hospitals and RHUs; and BHSs were constructed, in some cases exceeding targets.7 In Guimaras, an additional five BHSs were constructed. In Apayao, one additional RHU was renovated. Apayao, Palawan, and Kalinga provided additional funds to complete some of the civil works project in their respective provinces. The quality of work was generally acceptable, though there were some reports of low quality materials and inconsistencies of the design with licensing requirements.

13. Health facilities received the intended equipment, though delays meant that the last equipment package was not procured before the Project ended.8 There were a number of issues identified regarding the distribution/allocation, utilization, and maintenance of some equipment. Some equipment remained unused due to the absence of trained staff to operate them (for example a pulmonary machine in Guimaras Provincial Hospital). There were also some problems regarding maintenance of the procured equipment (e.g., no funds to procure ink for printers or repair computers). 9

14. The Project’s support for transportation was very successful. Ambulances provided to hospitals improved case referral, and were still in use at the time of the Project Completion Review (PCR) Mission. Vehicles provided to the PHOs facilitated monitoring and provision of technical support to RHUs. Under the motorcycle revolving fund program, 230 motorbikes were procured and distributed to the midwives (up from the original 158). However, the PCR Mission found that motorcycles were not appropriate in some areas.10 Better monitoring could have improved the use

6 The smallest political division in the Philippines, usually consisting of one or more villages with an average population of 5,000 persons. 7 Involuntary resettlement was not an issue for the ICHSP. Some civil works (particularly new construction) required acquisition of land, but in general lots were provided by local governments in fulfillment of their counterpart contributions. In many cases, the sites were within the compounds of existing medical facilities (e.g., Kalinga Provincial Hospital). Most RHUs were built on municipal governments’ lots near the municipal hall. BHS lots were either donated by private owners or bought by the barangay councils. In no cases was it necessary to clear land of informal settlers. 8 This was also a result of budget cuts by the Department of Budget and Management (DBM) during the last phase of project implementation. 9 The ventilator machine in Guimaras Provincial Hospital remained unutilized 2 years after its receipt because of the absence of health personnel to operate it. The radiology machine in Nueva Valencia District Hospital is unused because there is no x-ray technician in the hospital. The dietary refrigerator in Amman Jadsac District Hospital in Apayao did not function upon delivery, and was never rectified by the PMO. 10For some midwives in the mountainous areas of Kalinga, Apayao, and Palawan, motorcycles were not useful— horses or motorboats would have been more appropriate.

4 of the fund, as some payments remained uncollected at the time of the PCR Mission. It is also unfortunate that some midwives, as contractual staff, were excluded from the program.

15. The telecommunications systems installed by the Project were least effective. All pilot areas visited during the PCR Mission reported nonfunctional radio and telephone systems. These significant investments did not generate returns. The telephone system was reported by all areas to have functioned only for 2 to 3 months after installation. Reasons included poor weather and inability to maintain the battery supplies and antenna orientation. The terrain in some parts of the provinces hampered the use of the radios. Efforts were not made to fix these problems for a number of reasons: (i) lack of local expertise to determine the exact problems, (ii) lack of DOH technical support, and (iii) the ready availability of cell phones as an easy alternative for communicating referrals and other needs among health facilities.

16. In terms of licensing requirements, the improvement of RHUs under the Project enabled facility compliance with the Sentrong Sigla11 certification quality standards. This is a major benefit to municipalities, not only for provision of quality care to their constituents, but also to meet PhilHealth12 accreditation requirements that enable the facilities to earn income through PhilHealth capitation funds and other benefit packages (such as Tuberculosis Directly Observed Treatment Short-course [TB-DOTS] centers). Appendix 2 shows that 62.5% of the newly constructed and/or renovated RHUs are now Sentrong Sigla.13 The Project was less effective in enhancing hospital operations and services. Several of the district hospitals that were newly constructed and/or renovated/upgraded were unable to meet the licensing requirements for the expected category. Of the 17 hospitals constructed or renovated by ICHSP, only 6 obtained classification as a first level referral facility, while 11 remained in the infirmary category in 2005.

3. Communities and NGOs Participating and Mobilized

17. This subcomponent was implemented entirely under AusAID cofinancing, and aimed to improve the capacity of communities and civil society to address local priority health problems, and to increase participation in and advocacy for the health care system. The Project (i) institutionalized coordination mechanisms to promote improved links with communities through NGOs; (ii) implemented low-cost, sustainable, community-based health promotion strategies and activities to promote behavioral changes and to improve environmental health and water and sanitation; (iii) trained government health workers, civil society, and community representatives in community health issues; and (iv) instituted a small grant scheme to fund health-related development projects and infrastructure. In all, the Project has significantly improved the capacity of communities and civil society to develop and implement community health initiatives. However, the subcomponent was unable to achieve the goal of increasing the participation of NGOs in the development of health systems, which remain the domain of health experts.

4. Priority Programs Emphasized

18. This subcomponent aimed to increase (i) the rate of fully immunized children (FIC); (ii) the proportion of pregnant women with a least one prenatal visit per trimester; (iii) malaria

11 Sentrong Sigla Movement is a joint effort of the Department of Health and the local government units. It aims at promoting availability of quality health services in health centers and hospitals, and at making these services accessible to every Filipino. Its main component is the certification and recognition program that develops and promotes standards for health facilities. 12 A premier government corporation that endevors to ensure sustainable, affordable, and progressive social health insurance for all Filipinos. 13 The PCR Mission documented two underutilized RHUs: (i) the RHU I in Patag, Cullion, Palawan was abandoned because of the halted transfer of the township site to where the new RHU was built; and (ii) the RHU in Tanudan, Kalinga was only partially used as a result of political differences.

5 and/or schistosomiasis management programs; (iv) the rate of short-course chemotherapy completion for tuberculosis (TB) patients; (v) the proportion of RHUs with key equipment and drugs; (vi) the proportion of staff trained to diagnose, treat, and prevent public health problems; and (vii) health promotion activity. Results are somewhat mixed.

19. Comparing data from 1999 and 2004, the proportion of FIC in Guimaras and Palawan increased. In Kalinga and Apayao, FIC slightly decreased. The percent of pregnant women with at least three prenatal visits decreased in all four provinces. The incidence of malaria decreased. The Project supported malaria prevention through procurement of impregnated bed nets, which continue to be used. Nationwide training on TB-DOTS was started in 2003. There is only one certified TB-DOTS center (Palawan). The rate of new patients testing positive for TB and then beginning treatment decreased from 1999 to 2004 in all provinces.

20. The Project improved the competency of health staff in delivering basic health services and specialized care—training health workers on issues ranging from control of acute respiratory illnesses (ARIs), communicable disease control, the expanded program on immunization, nutrition, vascular diseases, and so on. No specific targets are listed in the project framework, but 13 medical doctors completed residency training, 88 nurses received in- service training, 57 BHWs qualified as midwives, 42 health workers obtained master’s degrees, and 98 medical doctors were trained in the management of medico-legal cases. Medical doctors who completed a master’s in health administration now serve as heads of district hospitals, while others who received a master’s in public health head the RHUs. Health staff trained in priority public health programs reported application of knowledge and skills in day-to-day provision of services. However, the PCR Mission documented a number of trained staff who left the service to join the overseas exodus of health care professionals. Hence, the benefits of the project investment could not be fully maximized.

21. A broad range of health promotion and outreach activities was undertaken at the local level, including puppet shows, films shown at community assemblies, and distribution of brochures in local dialects. PHOs and RHUs received health promotion equipment (e.g., sound systems, video cameras, computers, and LCD screens). At the national level, three social marketing workshops distilled lessons learned, documented best practices, and identified measures to sustain initiatives. Unfortunately, social marketing interventions were undertaken after replication to other areas (too late for the project beneficiaries). Although the training and orientation undertaken by the LGU participants improved their understanding of the basic principles and processes in social marketing, they were unable to use the techniques to convince their local chief executives.

5. Provinces Appropriately Managing Investment

22. The performance target for this subcomponent was timely implementation of project activities. This subcomponent was therefore less successful, as project activities on the whole were not implemented as scheduled. The installation of health subsystems was highly dependent on the pace of work of the consultants and DOH. The planning systems took time to be finalized. Only a few of the civil works were completed on time. The telecommunications systems were installed quite late, while the social marketing activities were implemented toward the end of the Project. One major reason for the delays in project implementation was a high rate of staff turnover at all levels (paras. 26–27).

C. Project Costs

23. At appraisal, project costs were estimated at $51.08 million equivalent (ADB project loan: $25.91 million; AusAID grant: $15.2 million; government counterpart: $10.0 million). Actual costs

6 were ADB project loan: $20.95 million; government counterpart funds: $3.35 million; and AusAID grant: A$18.5 million.14 A portion of the project loan ($5.6 million) was cancelled as a result of peso depreciation.15

D. Disbursements

24. Utilization was low during the first year (1997) because of delays in establishing the project management office (PMO), mobilizing the consultants, and forming the project steering and technical coordination committees. The proceeds of the project loan were channeled through the Department of Finance. The Local Government Empowerment Fund required transferring a portion of the peso proceeds of the loan to the pilot provinces through project implementation agreements signed by DOH and the pilot provinces. Separate accounts were established and maintained at the central and provincial levels.

25. A major portion of the project loan financed civil works and procurement of equipment necessary to improve the referral system in the pilot areas. A substantial portion of the project loan supported development of the different health management systems through consultancy services and capacity development activities for health managers and service providers. The government counterpart funds supported the civil works packages, procurement of minor equipment, and monitoring and evaluation of the Project. The disbursement by project components deviated from the original financing plan, with more spent on monitoring and evaluation, civil works, equipment, and project management than originally estimated. Amounts spent on training/workshops, health promotion, and replications were lower than the original allocation. The deviation of disbursements from appraisal estimates is presented in Appendix 3. Loan utilization at the end of the Project was 86.6%.

E. Project Schedule

26. ADB approved the loan on 17 October 1995. It was signed in November 1995 and became effective on 31 March 1997.16 The Project was launched on 22 May 1997. The original project end date was 30 June 2002. This was extended to 30 June 2004 after two extensions totaling 24 months. The first extension (18 months, to 31 December 2003) accommodated the completion of the health management systems to allow the replication plan to proceed and to undertake social marketing. The second extension (6 months, to 30 June 2004) was approved for procurement of several packages of medical equipment for upgraded health facilities. Appendix 4 compares the original schedule and the actual implementation schedule. The loan closed on 9 February 2005.

27. The Project saw four changes in the DOH leadership, four changes of project director, and five changes of project coordinator and PMO project manager. Provincial political leadership changed as well, and there was some turnover of project implementation unit (PIU) staff. The services of the original consulting firm had to be pre-terminated as a result of a change in DOH policy regarding management of external assistance projects. The turnover of leadership, termination of services, and changes in the management structure contributed to delays in implementation. Appendix 5 documents the degree of turnover at the national and local levels.

14 AusAID, Table 1: Australian and Philippine Government Expenditure (A$). Exchange rate $1 = A$1.351625. 15 The exchange rate in 1997 was at P30.3 per $1; in 2004, the peso depreciated to P55.74 per $1. 16 The delay in becoming effective was a result of the Overseas Development Assistance Law that took effect in 1995, requiring all foreign assistance to be covered by the Government Appropriations Act.

F. Implementation Arrangements

28. The project director was appointed by the secretary of health and supported by a project coordinator. A project steering committee (PSC) was established to provide overall policy direction. The PSC was chaired by the secretary and comprised governors from the six pilot provinces; representatives from ADB, AusAID, Department of Finance, National Economic Development Authority, and the key program directors of DOH. Six technical coordination committees (TCCs) were established for (i) health planning systems, (ii) health care financing, (iii) NGO/community mobilization, (iv) hospital management and operations, (v) health management information systems, and (vi) human resources and development. The TCCs (supported by consultants) were responsible for the identification of technical inputs and outputs of each component but were disbanded in 2001 to encourage more active participation of the DOH regional offices.

29. Day-to-day operations at the national level were managed by a PMO with 17 staff, headed by a project manager and supported by consultants in the areas of law, finance, monitoring and evaluation, and procurement. PIUs were set up in each pilot province, headed by a project executive officer. The provincial governors served as counterparts to the national project director, supported by the heads of the PHOs (provincial project coordinators). Mirroring the national level setup, the regional and provincial health offices designated technical personnel for each of the project components. PIUs were also established in the DOH regional offices, primarily tasked with coordinating the technical and financial assistance provided to the pilot provinces and providing training to the replication sites in the new health management systems. The project organization and management structure evolved over time. Several modifications were made at project inception and further restructuring was done during implementation.

G. Conditions and Covenants

30. Compliance with the major conditions and covenants was generally satisfactory. A total of 16 assurances were stipulated in the Loan Agreement, with three additional requirements prior to disbursement.17 The Government was required to give the Project high priority in annual budget allocations and to ensure that project provinces provided increasing levels of finance for project activities, adequate staffing, and operation and maintenance budget. Appendix 6 shows that all loan covenants were met.

H. Related Technical Assistance

31. The TA for Hospital Standards, Licensing, and Regulations (footnote 1) aimed to: (i) improve the capacity of DOH to set, monitor, and enforce standards for hospital services; and (ii) rationalize the hospital licensing and regulation requirements in the Philippines, which was necessary to help DOH institute required reforms in hospital operations. It was highly relevant as existing hospital standards and licensing requirements were no longer appropriate for a devolved health sector. The TA helped LGUs rationalize the number of overcapitalized, underutilized hospitals.

17 These were, for project provinces: (i) signing a project implementation agreement between DOH and the provinces, (ii) establishing a trust fund for motorbikes, and (iii) registering pharmacy cooperatives prior to financing the barangay pharmacy initiative.

I. Consultant Recruitment and Procurement

32. A total of 70 person-months of international and 473 person-months of domestic consulting services was envisaged at appraisal. Modifications were made at inception, including additional inputs for telecommunications, programming and graphic design, and development of health financing schemes. Most consultants were hired by March 1998.

33. The Project procured four major groups of items with a total value of $4.0 million: (i) medical equipment and supplies (international shopping), (ii) vehicles/ambulances (international shopping), (iii) motorcycles (international shopping), and (iv) telecommunications equipment (international competitive bidding). The pilot provinces and DOH-PMO procured sets of office equipment and audiovisual training equipment (direct purchase). The DOH Central Office Bids and Awards Committee bid most of the equipment and supplies packages, while procurement of the telecommunications equipment was coursed through the Procurement Services of the Department of Budget and Management (DBM). Delays were encountered in the procurement of medical equipment and supplies. Of the 14 project packages, 6 were outstanding in December 2003, which resulted in the second loan extension. Two packages remained uncontracted at project completion (June 2004). The procurement of vehicles and ambulances proceeded as planned and on schedule.

J. Performance of Consultants, Contractors, and Suppliers

34. Consultants’ performance was partly satisfactory. Most consultants’ outputs were delayed for various reasons. Necessary consultations often had to take place in several stages before agreement was reached. The first versions of the Health Human Resources Management and Development System (HHRMDS) were considered too theoretical. Of the seven subsystems of the HHRMDS, only four were developed and tested. Some systems were more conceptual than practical, so they were not appreciated by the targeted users. The RHU- management information system (MIS) (which aimed to automate health center consultations and link the RHUs to the higher referral levels) was described by most as too sophisticated to run, especially in RHUs in remote areas and with low computer literacy. Computer systems could not be fully operated in several municipalities because of fluctuating power supply. Early termination of consulting services by the new DOH leadership in 2001 significantly delayed the completion of systems development in the project sites, particularly affecting the telecommunications and social marketing subcomponents.

35. The performance of the contractors for the construction/renovation of the health facilities was generally satisfactory, though there were delays in the completion of civil works for several reasons. These included difficulty of haulage and shipment of construction materials because of inclement weather (particularly in Kalinga and Apayao), the relocation of RHU sites in Kalinga and Palawan, slow progress in the contractors’ work, withdrawal of some contractors from the Project, and delays in transferring funds from DOH to the provinces.

K. Performance of the Borrower and the Executing Agency

36. Both DOH and the LGUs demonstrated high commitment to ensuring that project outcomes were achieved and replicated in other areas. DOH gave the ICHSP top priority in its annual budget allocation for health, and LGUs contributed counterpart funding. However, decentralization posed a number of challenges to both DOH and LGUs during implementation, and several issues took a long time to be resolved. Weak TCC coordination is evident in the example of DOH-approved designs of health facilities (particularly the hospitals) that failed to comply with DOH licensing requirements, such as the installation of fire and smoke detectors, intercom system, and drainage system required for all provincial hospitals. The Nueva Valencia

District Hospital in Guimaras had to resurface the x-ray walls to add extra radiation shielding and the licensing team recommended widening the main lobby to allow more space for transit of patients and health staff.

37. The constantly changing composition of key project management structures at both national and local levels also contributed to implementation delays. Changes were a result of the reorganized DOH, transitions in national and provincial political leadership (the Project witnessed three national elections), and internal movements of project staff. Despite these challenges, the Project accomplished most of its objectives. Overall, DOH and the LGUs performed satisfactorily.

L. Performance of the Asian Development Bank

38. ADB performance is rated satisfactory. ADB review missions were effective in supervising project implementation and enhancing results. DOH highly commended the support and quick response of ADB to queries and proposals submitted by the PMO in trying to solve implementation problems. Toward the end of the Project, ADB ensured that enough funds remained in the imprest account to enable the PMO to pay creditors. In order to help DOH maximize loan utilization, ADB agreed to process direct payment applications below the $100,000 threshold for withdrawals. ADB’s visibility from project inception to closure was highly appreciated by DOH and the project sites. ADB might have done more to mobilize TA to assist DOH to resolve issues, explore viable options, draft policies and guidelines, or perhaps elevate major concerns to DOH top management. Given the long period of implementation, there was also some degree of ADB staff turnover, which may have limited ADB effectiveness in resolving certain issues.

III. EVALUATION OF PERFORMANCE

A. Relevance

39. The Project is rated highly relevant, both at the design stage and the PCR stage. The ICHSP responded directly to the deteriorating health care delivery system under the new decentralized administration. The fragmented local health care delivery system was characterized by (i) an ineffective referral system; (ii) absence of regular consultations and meaningful coordination among different health care providers; (iii) poor financing of health services; (iv) limited staff development opportunities for health providers; (v) deteriorating health facilities; and (vi) absence of a mechanism to pool and share resources (personnel, equipment, clinical and technical expertise) across health facilities. Hospitals intended for secondary and tertiary treatment had become congested with cases manageable and treatable at the primary health centers because people bypassed RHUs and BHSs that lacked medicines and other primary level services.

40. The Project was timely as it was the first external assistance project to address ineffective health care delivery after decentralization. It was welcomed by the pilot provinces and viewed as instrumental in re-integrating the fragmented delivery system. Interventions to improve the capacity of health service providers, the establishment of the motorcycle revolving fund program to enhance the mobility of grassroots health workers, the provision of transport and communication facilities to improve referrals, and the improvement of health facilities were all genuinely responsive to local needs.

41. The ICHSP strengthened the capacity of DOH in fulfilling its new roles under decentralization. DOH greatly appreciated the Project, which helped clarify ambiguous, overlapping roles in relation to the LGUs. The Project was instrumental in translating these roles

10 into operational functions and responsibilities. Replicating the workable systems in other provinces was essential, considering the huge numbers of LGUs that needed assistance. The Project was consistent with the DOH Medium-Term Development Plan for sustained health services and more equitable distribution of health resources. It was also in line with ADB’s health policy for primary health care interventions, improving access particularly of the poor and vulnerable groups to essential health services, and ADB’s overarching goal of poverty reduction.

B. Effectiveness in Achieving Outcomes

42. The ICHSP is rated effective. The Project was expected to achieve three main outcomes: (i) improved capacity at all levels to deliver essential health programs and services; (ii) to develop, test, and implement essential provincial health subsystems; and (iii) to strengthen DOH capacity at the national and regional levels to implement health subsystems and to provide policy direction and technical support.

43. Improved Capacity to Deliver Health Services. The key targets under this outcome were an increase in health expenditures at the provincial level, an increase in internal revenue allotment expenditure by LGUs, an increase in the percentage of barangays with BHSs, and an increase in health facilities with occupancy rates of at least 75%. Performance was mixed, so this outcome is rated partially effective.

44. The share of the total budget for health in the four provincial budgets ranged from 13.6% to 35.8% over the period 1999–2005. Data show that the share fluctuated from year to year in each of the provinces, with no clear pattern of increase over the years. Apayao’s allocation for health was in the range of 20–25% for the period 1999–2004 before falling to just 13% in 2005. Kalinga’s allocation was 35.8% in 2001 and 30.2% in 2005. Guimaras maintained a reasonably steady allocation for health from 1999 to 2005 at an average of 22%, where Palawan saw a major increase in the budget allocation for health from 1999 (21.3%) to 2005 (32.8%). The share of actual expenditures for health of the total provincial expenditures appears to be on a downward trend. Appendix 1, Table A1.2 shows the summary of budget allocation and health expenditures per province.

45. The Project was effective in increasing people’s access to health care through the construction of new BHSs—particularly in remote, hard-to-reach barangays in pilot provinces. The proportion of barangays with a BHS increased from 46% in 1999 to 57% in 2004 across the four provinces (Appendix 1, Table A1.3). The benefit monitoring and evaluation (BME) studies show respondents’ increased awareness of the BHSs in their area. Unfortunately, performance was less strong on hospital utilization rates. Of the hospitals constructed or renovated/upgraded, the provincial hospital in Kalinga reported the highest bed occupancy rate (BOR) at 82% in 2004. The district hospitals in Taytay and Cuyo in Palawan had a BOR of 80% and 76% respectively. The newly constructed district hospital in Nueva Valencia reported only 18% in 2004. The district and provincial hospitals in Apayao have BORs ranging from only 8.5–25.6% over 2002– 2005. Kalinga district hospitals had BORs from 19.8–36.4% in 2005. In Palawan, the remaining four district hospitals had a BOR of only 47.0–58.9% (2005). Appendix 1, Table A1.5 has a summary of utilization rates.

46. Essential Provincial Health Subsystems Developed, Tested, and Modeled. This outcome is rated effective, though there is some variation in degree of success from one pilot area to another. The performance target for this outcome was that all project provinces should have developed and implemented health subsystems in health services planning, health sector financing, health management information systems, hospital operations and management, and human resources and development.

47. The Integrated Health Planning System (IHPS) equipped health managers and staff with skills in strategic planning and addressing health concerns in an integrated manner. The IHPS systematized the assessment of health outcomes and needs, harmonizing RHU/health centers’ plans with those of hospitals. The IHPS was institutionalized and introduced nationwide under Executive Order 205 of 2006.18 A December 2005 DOH report shows that all LGUs in 6 of 13 regions are utilizing the system while another two regions cite that some of their LGUs use it (Appendix 7). The PCR visit to the inter-local health zone (ILHZ) in Tinglayan, Kalinga proved that the IHPS is a useful tool which can generate support from concerned local officials. However, some LGUs were unable to continue the integrated planning process after the Project ended. The health planning system did not produce increased budgets for health as envisaged by the Project since implementation was not aligned with LGU budget cycles.

48. All four pilot provinces established health accounts as a basis for developing health financing schemes. Several local health financing schemes that were established or strengthened by the Project continue to operate and provide benefits to participating beneficiaries. The Guimaras Health Financing Program and the Palawan Busuanga, Coron, Cullion, and Linapacan (BusCoCuLin) Financing Scheme have improved enrollments and benefits, although the schemes could be harmonized in a better way with PhilHealth. In Apayao, several LGUs have introduced users’ fees and established cooperative pharmacies in hospitals. Kalinga continues to showcase a number of promising local health financing schemes, not only in the hospitals, but also at the RHUs. The replication provinces have established their own health financing schemes that entail collection of users’ fees, establishment of drug revolving funds, cooperative pharmacies, etc. (Appendix 8). Unfortunately, the expectation that health accounts would be updated and analyzed periodically by the LGUs was not realized, since the plan to integrate it into routine monitoring surveys of the National Statistical Coordination Board did not materialize.

49. The Project served as the primary vehicle for introducing PhilHealth to the pilot LGUs, and successfully encouraged these provinces to participate in different benefit packages. Although some chief executives were initially reluctant, most of the municipalities have enrolled the poor in PhilHealth. A number of RHUs were accredited for the Outpatient Benefit Package (OPB) while hospitals continue to reap reimbursements from PhilHealth for enrolled members (Appendix 9). The adoption of local health financing schemes within and outside of the pilot provinces demonstrates high acceptability of these schemes. Some health facilities already benefit from either retained income or additional resources (capitation funds for RHUs).

50. The health management information system was not as successful. The RHU-MIS did not materialize as envisaged. Its overall concept and design was too complex, considering the capacity of the targeted users and local conditions. The RHUs continue manual tabulation of health statistics. The extent of installation and usefulness of Hospital Operation Management Information System (HOMIS) (Modules 1 and 2) differs from one hospital to another depending on the degree of user training, the hospital’s in-house IT system support, and the frequency of DOH follow-up/mentoring. In general, HOMIS is less effective in most of hospitals visited. Routine hospital statistics reports are done manually.

51. Under hospital operations and management, all pilot provinces effectively adapted the referral manual and undertook orientation and dissemination to health providers. The referral system is a work in progress in most areas. While some referring units observe proper protocol,

18 Issued January 2000 mandating establishment of Inter-Local Health Zones and Integrated (inter-Local Government Unit [LGU]) Health Planning, designed to encourage and facilitate inter-LGU cooperation and innovative strategies and approaches for basic health services delivery.

12 others grapple with clients’ preference to bypass lower levels for primary health care. Referral protocols are more difficult to implement in the mountainous areas of Kalinga and Apayao given distances and high costs of transportation that clients incur should they follow the level of care hierarchy. The referral scheme had to be adjusted to follow the mobility of people in barrios where market days have become the consultation day for most residents. The crux of the referral scheme is the return referral of clients, successful in two of the ILHZs visited.19 DOH has successfully disseminated the hospital operations manual. As a result, all hospitals can assess their own capacities and identify gaps.

52. New principles and practices for the HHRMDS were introduced. A health human resources unit was established under the Palawan PHO, and has been instrumental in improving personnel management and staff development through training, orientation for new recruits, and a database of BHWs. The same is true for Kalinga Province. While HHRMDS subsystems contain technically sound principles and guidelines, they are less effective in actual implementation. The recruitment and selection of local personnel remains highly politicized in many areas, and staff development has low priority in LGU budget allocation. Recruitment tends to be heavily constrained by ceilings on personnel services imposed by DBM. Many midwives are hired as contractors, depriving them of security of tenure and other employee benefits. Failure to complete the personnel retention system prevented LGUs from identifying strategically acceptable measures that could be implemented to improve the retention of staff. Staff retention is further aggravated by the exodus of health workers abroad.

53. DOH Capacity to Support Comprehensive Health Care Delivery Strengthened. This outcome is rated effective. The Project supported the delineation of roles at the national and regional levels, and was instrumental in the reorganization of DOH, a process which led to a leaner, more efficient bureaucracy. The DOH national units benefited from training and logistics support. Regional health officials and staff received orientation training as the different health systems were developed. The successful replication of selected subsystems attests to the DOH regions’ improved management and technical capabilities in providing TA to the LGUs. Though the regions were involved rather late in project implementation, they carved out a strategic role in overall health development. All DOH regions introduced the integrated health planning and health referral systems in their provinces as an integral part of the establishment of the ILHZ. Region VI has moved forward in instituting the ILHZ beyond the replication areas of Capiz and Antique. The same is true in the Cordillera Autonomous Region and in Region IV-B.

C. Efficiency in Achieving Outcomes and Outputs

54. Overall, the Project is rated less efficient. The late start-up and the inability to resolve a number of policy and operational issues within a reasonable time frame substantially delayed implementation, diminishing effectiveness. The Project was extended twice, by a total of 24 months, to allow completion of delayed activities. The procurement of medical equipment/supplies was substantially delayed because of mispackaging of items even at the beginning. By the end of the Project (June 2004), the two packages (equipment and supplies for improved facilities) had not been procured. Despite revalidation undertaken at the start of the Project to determine the final facilities and the list of equipment, a number were misallocated. However, it should be noted that procurement of logistics and the vehicles/ambulances and motorcycles packages was far more efficient.20

19 The Bailan ILHZ in Capiz and the Chico River ILHZ in Tinglayan, Kalinga. 20 With regard to the vehicles, the provinces were constrained by their inability to convert blue plate registration (AusAID) to government registration plates. The transfer of the first round of motorcycles to the beneficiaries and consequent reregistration was difficult, given that the national level originally procured these units.

55. Although civil works started later than originally scheduled, all units were completed within the life of the Project. The construction and/or renovation of health facilities generally progressed well except in a few cases.21 Some problems stemmed from the inability of LGUs to make necessary adjustments during construction as contractors refused to implement changes that deviated from their DOH-approved work program. Areas with more flexibility achieved better quality and lower costs.22 The selection process for upgrading facilities was somewhat separated from the overall rationalization of the integrated health care delivery system. Hospitals selected for renovation were not considered in the context of ILHZs as the concept crystallized only mid-project. Some hospitals that were not identified as core referral units were still upgraded. BORs show that these hospitals are not fully utilized at present. Some LGUs failed to budget for the necessary staff complement to fully utilize improved facilities and meet higher licensing classifications.

56. Some delays in the development, testing, and institutionalization of the health management systems were to be expected given the pilot-test nature of the Project. However, some interventions were not properly synchronized. On the other hand, management efficiency was demonstrated for several subcomponents. The revalidation at the start of the Project in 1997 helped improve targeting and minimized overlap. Considering the 4-year gap from project design in 1993 to actual implementation in 1997, a reassessment of the Project’s investment priorities was necessary. The recruitment of project engineers to work with the local engineering offices to supervise the civil works proved efficient to ensure construction quality. The participatory and consultative approach in designing and testing different systems allowed revalidation of project focus.

D. Preliminary Assessment of Sustainability

57. Probability is high that project gains will be sustained. Capacity development efforts supported by the Project laid the foundation for broad health sector reforms. Various systems developed, tested, and installed by ICHSP have become integral components of the Health Sector Reform Agenda (HSRA). Integrated health planning and referral systems now serve as the backbone of the organization and operations of ILHZs throughout the country. DOH, through the “FOURmula One” (F1) Strategy, continues to advocate fundamental changes in the health sector.23 Provincial health plans serve as the basis for rationalizing allocation of DOH assistance at all levels. Increased enrollment of the poor and LGU participation in PhilHealth benefit packages continue the health care financing initiatives begun under the ICHSP.24 Accreditation of RHUs is essential, given the additional sources for financing facility operations. LGU officials recognize the benefits of PhilHealth, and local health financing schemes in the project sites complement these benefits.

21 These included (i) transport of construction materials to some remote areas; (ii) poor performance of contractors in Kalinga, Apayao, and Palawan; (iii) low quality construction materials used (e.g., toilet bowls, PVC doors, window panes/jalousies); (iv) unsynchronized installation of equipment with the construction work; (v) inconsistency between DOH licensing requirements and facility designs; (vi) delayed release of funds from DOH to LGUs to pay contractors; and (vii) issuance of the last payment to contractors even without the signed acceptance of the user (Kalinga Provincial Hospital). 22 For example, building ramps for the disabled did not seem applicable in remote, hard-to-reach areas. Guimaras did not completely follow the design, so was able to construct five additional BHSs with the savings. 23 The F1 planning process evolved out of the IHPS developed under the ICHSP. The components of FOURmula- One are (i) health care finance reform, (ii) health service delivery strengthening, (iii) governance reform and (iv) regulatory reform. 24 As of project completion review, several health facilities in the pilot and replication provinces have began to participate in and avail of the PhilHealth OPB Package. Many LGUs nationwide are now equipping their facilities to become TB-DOTS accredited and maternity package-compliant (Appendix 10).

58. Continued improvements in operation and maintenance of health facilities will most likely be sustained. With reimbursement from PhilHealth, hospitals are encouraged to raise quality. Retaining their income (as in the case of the Guimaras Provincial Hospital) will fuel better management and provision of quality services. The latest HOMIS in the DOH-MIS is more advanced than originally installed. With proper orientation and training, and continued mentoring and troubleshooting by DOH national and regional staff, there is no reason why HOMIS should not be sustained by the hospitals. As of the PCR Mission, the DOH had installed the updated HOMIS-Module 1 in 46 hospitals and Module 2 in 4 hospitals (Appendix 10).25

59. The HHRMDS is the foundation for the 2004 Human Resources for Health (HRH) Master Plan for the period 2005–2030, developed by the Health Human Resource and Development Bureau. This master plan lays out the overall framework for achieving an effective well- motivated workforce in the health sector. Phase 1 of 3 aims to ensure equitable distribution of health human resources throughout the country, manage HRH migration, install critical basic systems, and support HRH policy development and monitoring. Some of the systems to be developed include those not completed during ICHSP implementation. With this master plan, it is hoped that the inequitable distribution of health workers, shortages of health human resources, unfilled vacancies, and rapid turnover of nurses and doctors can be addressed comprehensively.

60. At the local level, the commitment of provincial and municipal officials to instituting health sector reforms in partnership with DOH is central to the sustained delivery of comprehensive health services. The Project has demonstrated successful initiatives in several ILHZs in pilot areas and replication sites. The establishment of health boards, the passage of local resolutions to support health sector reform, and continued budget allocations for health indicate that initial gains will be sustained. The enhancement of systems and the continued sharing of best practices among LGUs within and outside their respective regions will further develop regional capacity to promote health sector reform.

61. Several factors threaten the sustainability of project outcomes, including (i) the continued exodus of trained health staff abroad; (ii) the inability of LGUs to maintain and repair equipment, health facilities, and transport; (iii) the non-functionality of some ILHZ management boards or local health boards, which weakens the coordination among LGUs; (iv) weakened community health promotion and outreach activities, which erodes demand for health services; and (v) absence of regular monitoring and mentoring from higher level operations.

E. Impact

62. The ICHSP focused on fundamental reforms in the health care delivery system; as such, it is too early to expect measurable impacts on the health status of the population. The impact level targets include reduction in the incidence of various diseases. Appendix 1 shows that there have not yet been major improvements in basic health indicators. Rates of childhood and communicable diseases continue to fluctuate over time, as do levels of immunization coverage, maternal care, and child health and communicable disease prevention and control. The BME follow-up report finds varying levels of awareness among the population with regard to the availability of health services and appropriate health practices.

63. The ICHSP brought the fragmented health care delivery system to the top of the DOH and LGU agendas and established the principle that integrated delivery of health services is possible

25 As part of the HSRA, DOH-MIS is finalizing the terms of reference for the development of a unified MIS aimed at integrating the existing HOMIS, Logistics Management Information System (LMIS), and other relevant existing systems to make information available to various stakeholders at various levels of the health system.

15 in a decentralized context by instituting coordinated health reforms at various levels. This principle is reflected in the functional ILHZs established nationwide, beyond the ICHSP pilot and replication areas. To a large extent, the ICHSP developed the institutional capacity of LGUs to deliver comprehensive health services, and for DOH to provide TA to them. The Project improved equity in the provision of health services by selecting some of the poorest provinces as pilot areas and as replication sites. Geographic targeting prioritized the renovation or construction of new BHSs and RHUs in peripheral or remote areas, thus benefiting the poorest. The introduction of local health financing schemes particularly benefited the poor, while enrollment in PhilHealth enabled higher income groups to cross-subsidize the health needs of the poor.

IV. OVERALL ASSESSMENT AND RECOMMENDATIONS

A. Overall Assessment

64. Overall, the ICHSP is rated successful. The ICHSP instituted incremental reforms in health care delivery for improved provision of quality health services, increased access to health services, and more efficient and effective management of the integrated health care delivery system. The Project reintegrated health services fragmented by the decentralization process, where LGUs were unprepared for their new roles as providers of health services. Though the Project did not produce all systems originally intended and some systems were not fully applicable to all the pilot provinces, it demonstrated that health management systems can be adapted to suit local conditions.

65. The Project helped redefine the relationship between DOH, its regional offices, and LGUs in managing an integrated health care delivery system. The Project significantly improved the capacity of DOH at the national and regional levels. Evidence suggests that the replication areas, benefiting from the lessons and experiences gained in the pilot provinces, were able to institute reforms in a much more efficient manner. Despite some implementation delays and the non-utilization and poor maintenance of a few facilities, the outputs of the ICHSP were largely achieved.

B. Lessons Learned

66. One principal lesson from the ICHSP is that decentralization can work to attain better health outcomes if LGUs are willing to coordinate with one another, unify their plans, harmonize their efforts, and share resources and expertise. Despite formidable obstacles brought about by decentralization, LGUs can work together to address common health problems. This is possible if the local chief executives are highly committed to reforms in their respective localities and are willing to look to DOH for policy direction and technical guidance.

67. Health management systems are essential for the delivery of comprehensive health services. However, the development and installation of systems per se, no matter how technically sound, cannot generate reform without the corresponding commitment of the stakeholders, sense of ownership by the system users, constant follow-up on the utilization and application of systems, and allocation of resources to sustain the system. Project interventions must complement other components and be implemented in a synchronized manner to obtain maximum results. For example, health facilities will not function without the minimum number of staff required, equipment cannot be operated without proper technicians, and the services of BHW midwives may not be maximized if they are not hired to function as midwives.

68. Kalinga and Apayao have fewer problems with recruitment and retention of staff than other areas, most likely because the provinces have instituted a class I civil service classification (with higher pay scales and benefits) despite a lower provincial classification. Better pay clearly accounts for lower staff turnover rates. This has an immediate budget impact,

16 but elevating the provincial civil service classification has positive benefits in terms of recruiting and retaining quality staff.

69. The visible impacts of health sector reforms take time to materialize. Reforms also incur costs, so judicious prioritization of resource use is essential. External funds are necessary for long-term investments, but LGUs must provide the necessary counterpart staff and budgets to sustain gains brought about by the Project.

C. Recommendations

1. Project-Related

70. To optimize the benefits of the Project, the national and local governments must continue to monitor regularly the status and utilization of the different investments. DOH should allocate resources for monitoring, and LGUs should allocate funds for repair, maintenance, and other operating expenses in order to sustain project initiatives.. Pilot LGUs should continue to operate their respective local health financing schemes. Some have improved collection, membership, and benefits utilization after the end of the Project, but most are still heavily dependent on local subsidies for operating expenses. With the expansion of PhilHealth benefit packages, pilot LGUs have begun to support the enrolment of the poor in PhilHealth. It is recommended that DOH, together with PhilHealth, assist the pilot LGUs to integrate local financing schemes so as to streamline the LGU subsidies and maximize available benefits.

71. A number of systems developed and tested under the Project have improved the delivery of health services. However, some systems remain in use only in the pilot and replication areas (including HOMIS, the motorcycle revolving fund, some local health financing initiatives, and health promotion strategies). On the other hand, DOH has made significant advances in health sector reforms at the local level: the FOURmula One strategy involves more focused planning of interventions in accordance with available local and national resources. The IHPS needs to be reviewed in view of the FOURmula One strategy. The PCR Mission supports the plan of the DOH Health Policy and Development Planning Bureau to revisit proposed legislation for the IHPS and broaden its scope to cover other elements that are essential for making integrated health care delivery work under decentralization.

2. General

72. In similar projects in the future, some added loan conditionality may be appropriate. An obvious concern for a functional referral system is proper staffing. Given regulatory caps on personnel, means must be found to augment the local civil service complement to allow hiring new staff for upgraded health facilities. The AusAID approach to its pilot provinces required each LGU to put in place the corresponding personnel complement before constructing another health facility in the area. Such loan conditions could also require that midwife-trained BHWs be absorbed into the official LGU staff complement for midwives. Related to this recommendation is the need for the national government to immediately take steps to address the exodus of medical doctors and nurses, as well as staffing limitations faced by LGUs, ranging from arbitrary personnel ceilings to the inability to provide incentives to retain staff.

PROJECT FRAMEWORK Performance Monitoring Design Summary Assumptions and Risks Indicators/Targets Mechanisms

1. Goal

Improved health through reduced Percent reduction in measles Sentinel Measles incidence in Palawan peaked in 2001–2002 and incidence and severity of the main incidence surveillance and decreased significantly in 2003 and 2004. Apayao and Kalinga communicable diseases affecting provincial reporting reported higher rates in 2004 than in 1999. In Guimaras, measles children (immunizable diseases, Percent reduction in number of of notifiable cases peaked in 2001, decreasing in 2004. pneumonia, and diarrhea) and the deaths in children (age 0–5) from diseases population in general (TB, malaria, ARI Pneumonia/ARI remained the leading cause of morbidity in the and schistosomiasis) in the project four provinces. Palawan and Guimaras had a lower incidence in provinces through improved Percent reduction in neonatal 2003–2004 than in 1999. Kalinga and Apayao had a higher preventive and basic curative tetanus incidence in 2004 than in 1999. health services Percent reduction in incidence of The DOH Notifiable Disease Reports from 1999–2004 from the TB, malaria, and schistosomiasis four provinces show declining patterns on the incidences of diarrhea, TB respiratory, malaria, and neonatal tetanus. The four provinces are not endemic with schistosomiasis. Table A1.1 contains a summary of these indicators.

In general, it is too early to measure the contribution of ICHSP to the impact indicators. Project inputs will take time to translate to health outcomes.

2. Purpose

2.1. To improve the capacities of Percent increase in health Provincial health The share of the total budget for health in the four provincial communities, NGOs, and expenditures in each province accounts budgets ranged from 13.6–35.8% over the period 1999–2005. Data LGUs in the project provinces allocated to primary health care in Table A1.2 show that the share fluctuated from year to year in to plan, manage, monitor, and Provincial data each of the provinces, with no clear pattern of increase over the finance essential health Percent increase of internal years. Apayao’s allocation for health was 20–25% for the period programs and services at the revenue allotment expenditure Routine health 1999–2004 before falling to just 13% in 2005. Kalinga’s allocation provincial, municipal, and on health by LGUs in each information system was 35.8% in 2001 and 30.2% in 2005. Guimaras maintained a

community levels in a cost- project province reasonably steady allocation for health from 1999 to 2005 at an 1 Appendix effective manner Health facility average of 22%, while Palawan saw a major increase in the budget Percent increase of barangays surveys and routine allocation for health from 1999 (21.3%) to 2005 (32.8%). (the smallest political division in health information the Philippines, usually system As shown in Table A1.3, the share of actual expenditures for health consisting of one or more of the total provincial expenditures appears to be on a downward villages with an average trend in the three provinces for which data is available. Tables A1.2 population of 5,000 persons) and A1.3 show the summary of budget allocation and health 17 with BHSs in each project expenditures per province.

18 Performance Monitoring Design Summary Assumptions and Risks Indicators/Targets Mechanisms

province 1 Appendix There was an increase in the percent of barangays with BHSs from Percent increase of health 46.2% in 1999 to 56.1% in 2004. Table A1.4 presents a summary facilities in each province with of BHS coverage per province. BME shows an increase in the occupancy rates between 75% proportion of respondents who became aware of the presence of and 90% the BHS compared with the baseline survey conducted in 1999.

Of the hospitals constructed or renovated/upgraded, the Provincial Hospital in Kalinga reported the highest bed occupancy rate (BOR) at 82% in 2004. The district hospitals in Taytay and Cuyo in Palawan had a BOR of 80% and 76% respectively. The newly constructed district hospital in Nueva Valencia reported only 18% in 2004. The district and provincial hospitals in Apayao have BORs ranging from only 8.5% to 25.6% over the period 2002–2005. Kalinga district hospitals had BORs from 19.8–36.4% in 2005. In Palawan, the remaining four district hospitals had a BOR of only 47.0–58.9% (2005). Table A1.5 contains a summary of utilization rates. 2.2 To develop, test, and All project provinces will have Routine project Integrated Health Planning System: All four provinces developed implement in the project developed and implemented implementation their strategic plan during the Project. Each continues to develop provinces and other provinces health subsystems in (i) health reports annual health plans but is not following the integration of plans at included in the HSRA the services planning, (ii) health the district level. RHUs develop their respective plans separate following provincial health sector financing, (iii) health from the hospitals. The provincial level consolidates these plans subsystems: (i) health services management information together. Capiz, Ifugao, and Mindoro Oriental continue to prepare planning; (ii) health financing; systems, (iv) hospital operations investment plans using the IHPS. (iii) HMIS; (iv) hospital and management, and (v) HRD operations and management; Health Financing Schemes: All provinces currently participate in and (v) human resources All key health subsystems PhilHealtha accreditation. Local health financing schemes initiated management and developed and documented under the ICHSP continue to operate except for some in Kalinga development, and community and Apayao. Guimaras continues with its Guimaras Health and NGO strategy Insurance Program while the BusCoCuLin ILHZ financing scheme development. has been copied by another ILHZ of the province. In Kalinga, the cooperative pharmacy has reached the municipal level and the Piso for Health program is thriving in Tabuk and Tinglayan RHUs. Some RHUs in Apayao collect users’ fees and their district hospitals are supported with cooperative pharmacies.

The replication areas maintain very promising health financing schemes. The Drug Revolving Fund has not only assured availability of drugs when patients need them but has also been instrumental in bringing down drug costs. In Mindoro Oriental, the Cooperative Pharmacy is also working. The Cooperative Pharmacy in the Aguinaldo-Mayayao-Alfonso Lista iILHZ in Ifugao has

Performance Monitoring Design Summary Assumptions and Risks Indicators/Targets Mechanisms helped the hospital provide the necessary medicines and treatment for its patients.

Health Management Information System: HOMIS installed during the Project is no longer functioning in most hospitals. It is working in Kalinga Provincial Hospital, Roxas Memorial Hospital in Capiz, Mayoyao District Hospital in Ifugao, and the Provincial Hospital of Mindoro Oriental, but only to some extent. Output tables and information needed by the hospitals could not be generated through the system.

2.3 To strengthen DOH capability DOH and regional staff trained in Routine project National and regional staff were trained on the subsystems at the national and regional implementation and support of implementation developed under the Project. Training was provided to all regions levels to implement and systems reports on integrated health planning and the referral system. Regional support these health staff were trained on HOMIS, enabling them to support the subsystems and to provide installation and follow-up. Several CHD and national DOH staff policy direction and technical attended training on health management at the Asian Institute of support to LGUs, NGOs, and Management, participated in observation tours to other provinces, community groups in planning and were sent to international conferences and training events. and implementing health programs and services

3. Outputs

3.1 Delivery of comprehensive All project provinces have Health plans Provincial health accounts were established during the Project. health services strengthened prepared health plans that meet submitted and These became the basis for charting different health financing in each province agreed quality standards evaluated by PMO schemes considered appropriate by each LGU. However, the intent to institutionalize the health account system to the routine National 3.1.A. Management and financing All project provinces have health Routine project Statistics Office studies/surveys did not materialize. This suggests subsystems in place accounts developed and updated implementation that the health accounts per province have not been updated since periodically reports the Project ended.

All project provinces have HMIS reports Hospital Operations and Management: Guimaras and Kalinga

relevant HMIS reporting data on provincial hospitals have developed their own hospital 1 Appendix a routine basis Annual hospital management and operations manual. Guimaras has developed its reports own clinic practice guidelines while Kalinga has developed the All provincial hospitals in project database for its BenchBook—a quality assurance program. The provinces utilize improved presence of a hospital management and operations manual has hospital management systems been incorporated as one of the licensing requirements for hospitals. Referral manuals were developed and localized by all

All project provinces have provinces, but the modified guidelines were not documented in 19 implemented key HRD systems Apayao.

20 Performance Monitoring Design Summary Assumptions and Risks Indicators/Targets Mechanisms

1 Appendix Human Resource Development Systems: The job-related recruitment and selection system developed by each of the four provinces are quite similar with what they were previously using since they must follow the requirements of the Civil Service Commission. In Kalinga, the system entailed the establishment of a health selection committee which screens, selects, and endorses applicants to the provincial committee. In Guimaras, the selection criteria were made more specific and the selection became more objective and fair for every applicant.

The Performance Management System has been highly successful in Palawan, resulting in the establishment of a human resource management office within the PHO. This unit has been very active in developing training programs, implementing capability building activities, and establishing a database on health staff and health workers. In Apayao, staff trained in human resources development management system applied knowledge on developing personnel-related policies and guidelines for the whole provincial government.

A Training Development and Needs Assessment was applied in all the provinces. The results identified training gaps for health staff. However, no corresponding training program has been developed to address these gaps. To date, the provinces depend mainly on DOH for technical training of their health staff.

3.1.B. Referral systems improved All planned facilities Routine project The referral system in the four pilot provinces was improved by: renovated/built and equipped by implementation (i) renovating, upgrading, or constructing 154 BHSs (exceeding the category per province reports and target of 145), 31 RHUs (of the targeted 32), all 15 targeted district provincial training hospitals, and 2 targeted provincial hospitals; (ii) equipping facilities All project provinces have plans with essential medical equipment, instruments, clinical supplies, functioning communication and materials (including kits for BHWs and midwives); (iii) providing systems Project progress transport facilities (158 motorcycles, 4 vehicles and 6 ambulances); reports and (iv) installing radio and telephone communication systems. All health facilities in project provinces meet licensing Hospital licensing Civil Works: All planned hospitals, RHUs, and BHSs were requirements for level of facility reports and facility constructed and renovated/upgraded by the Project. In Guimaras, surveys 5 more BHSs were constructed than planned. In Apayao, an additional RHU was renovated with funds taken from the budget allocated initially for Kalinga RHU. Apayao, Palawan, and Kalinga provided additional funds to complete some of the civil works project in their respective provinces. The quality of work was

Performance Monitoring Design Summary Assumptions and Risks Indicators/Targets Mechanisms generally acceptable but there were some reports of low quality of materials, incomplete installation of some sections, inconsistencies of the design with licensing requirements, and unsynchronized installation of equipment prior to construction.

Equipment: Health facilities received their intended equipment, except for the last package of equipment that was no longer accommodated before the Project ended. A number of issues were identified regarding the distribution/allocation, utilization, and maintenance of some equipment. In Apayao and Kalinga, there was a general complaint of incomplete and nonfunctional equipment. Some equipment remained unused because of the absence of staff trained to operate it (e.g., pulmonary machine in Guimaras Provincial Hospital). There was a general issue with regard to maintenance of the equipment and supply (e.g., no funds to procure ink for printers or repair computers).

Communications System: The telephone systems worked for 2–3 months before failing. The radio system works in limited capacity in some hospitals and RHUs. Some have not maintained the batteries, and handheld radios are no longer used. More convenient cell phones tend to be used instead.

Transportation: All ambulances procured by the Project are in use by the hospitals. Service vehicles for monitoring are deployed for the use of the PHOs. The motorcycle revolving fund program works well in the four provinces. A total of 230 motorcycles have been procured and distributed to the midwives (up from the original 158). In Apayao and Kalinga, motorcycles are not appropriate in the mountainous areas. There is a need for better monitoring of the use of the fund since some payments remain uncollected. In Guimaras, some midwives (contractual staff) are excluded from the program.

1 Appendix 3.1.C. Communities and NGOs Community health resource Project progress Subcomponent financed by AusAID. Coordinating mechanisms participating and mobilized center established and in use in reports were established in 5 of 6 pilot provinces. each project province Institutionalization of coordination mechanisms for LGUs at All grant financed health provincial, municipal and barangay level promoted improved health activities successfully meet links with communities through engagement with NGOs and

community-identified needs people’s organizations POs. 21

Quarterly meeting of Implementation of low–cost, sustainable, community-based health

22 Performance Monitoring Design Summary Assumptions and Risks Indicators/Targets Mechanisms

municipal/barangay health promotion strategies and activities enabled communities to 1 Appendix committees established undertake local health initiatives to promote health behavioral changes and improve environmental health and water and sanitation.

Training in community health development for government health workers, NGOs/POs, and community members increased capacity to participate in and advocate within the health system.

A small grant scheme funded health-related development projects and infrastructure as an incentive for sustainable behavioral change.

3.1.D. Priority programs Percent increase in fully Routine project The proportion of fully immunized children in Guimaras and emphasized immunized children per project implementation and Palawan in 2004 was higher than in 1999. In Kalinga and Apayao, province progress reports fully immunized children decreased slightly over the same period. However, immunization coverage per year fluctuated in the four provinces.

Percent increase in pregnant Focus group and The percent of pregnant women with at least three prenatal visits women with at least one prenatal sample surveys decreased from 1999 to 2004 in all four provinces. visit per trimester

Malaria and/or schistosomiasis Routine health The incidence of malaria decreased from 1999 to 2004. The management programs under information Project supported malaria prevention through procurement of way in endemic areas systems and facility impregnated bed nets, which continue to be used. In 2003, surveys Palawan, Kalinga, and Apayao received Global Fund assistance for malaria prevention and control.

Percent increase in short-course Nationwide training on TB-DOTS was started in 2003. There is only chemotherapy for TB completed one certified TB-DOTS center (Palawan). The rate of new sputum of those detected with the illness positives initiating treatment decreased from 1999 to 2004 in all provinces.

Percent increase of RHUs with 13 medical doctors completed residency training, 88 nurses key equipment and drugs received in-service training, 57 BHWs qualified as midwives, 42 health workers obtained master’s degrees, and 98 medical Increased proportion of staff doctors were trained in the management of medico legal cases. trained to diagnose, treat, and Training programs were conducted across a range of relevant prevent public health problems topics.

Increased health promotion Health promotion and outreach activities were undertaken at the activity local level, including puppet shows, films shown at community

Performance Monitoring Design Summary Assumptions and Risks Indicators/Targets Mechanisms assemblies, and distribution of brochures in local dialects. PHOs and RHUs received health promotion equipment (e.g., sound systems, video cameras, computers, and LCD screens). At the national level, three social marketing workshops distilled lessons learned, documented best practices, and identified measures to sustain initiatives.

Table A1.6 summarizes health indicators in the four provinces.

3.1.E. Provinces appropriately Project activities undertaken in Project progress Project activities were not implemented as scheduled. The managing investment time frame reports installation of the subsystems was highly dependent on the pace of work of the consultants and DOH. The planning system took time to be finalized. Only a few of the civil works were completed on time. The telecommunications systems were installed quite late while the social marketing activities were implemented toward the end of the Project. Project implementation suffered delays as a result of staff turnover.

3.2 Essential health subsystems The following systems are Facility surveys The IHPS was installed and applied by the pilot provinces in developed, tested, and developed, tested, implemented, 1–2 annual cycle planning sessions. modeled and documented: Health worker • health services planning surveys and focus Under the health management information system, 2 HOMIS • health finance group discussions modules were institutionalized in several hospitals. The RHU-MIS • HMIS was simplified and installed in selected RHUs in Surigao del Norte, • HOMIS Project progress South Cotabato, and Kalinga. • human resources reports development Four of seven subsystems of the HHRMDS were completed, • community mobilization Systems modules, including: (i) performance management system, (ii) job-related monographs, user recruitment and selection system, (iii) human resource planning, manuals, and other and (iv) training development and needs assessment. documentation Two manuals were developed for hospital operations and management: (i) the referral manual, and (ii) the hospital

operations manual. The latter became part of the licensing 1 Appendix requirements for hospitals.

Four workable systems (IHPS, HOMIS, the referral system, and health care financing schemes) were replicated in 7 provinces. The IHPS was adopted and introduced nationwide through Executive Order 205,b while the referral system was adopted in ILHZ

provinces. 23

24 Performance Monitoring Design Summary Assumptions and Risks Indicators/Targets Mechanisms

The Project established 5 ILHZs in 4 provinces: 2 in Apayao 1 Appendix (Pudtol-Luna ILHZ and Flora-Marcela ILHZ), 2 in Kalinga (Chico River Basin ILHZ and Balabalan ILHZ), and 1 in Palawan (BusCoCuLin ILHZ).

3.3 DOH capacity to support National and regional staff Project progress National and regional staff were trained on the subsystems comprehensive health services trained and equipped to support reports on training developed under the Project. Training was provided to all regions delivery is strengthened LGUs in implementation of and procurement/ on integrated health planning and the referral system. Regional subsystems other inputs, and staff were trained on HOMIS, enabling them to support the midterm evaluation installation and follow-up. Several CHD and national DOH staff attended training on health management at the Asian Institute of National staff trained in planning Management, participated in observation tours to other provinces, and implementing investment and were sent to international conferences and training events. projects targeted at priority needs Provincial level focal persons were trained in data collection, analysis, and reporting for BME, but its importance was not fully Implementation of effective BME appreciated by the LGUs. Outcome indicators and benefits of the system for the Project project interventions were not systematically recorded, and monitoring of project benefits ceased with loan closure. Utilization of the project investments, continued application of the management systems, and the deployment of trained staff is therefore no longer tracked.

4. Activities Financing: 4.1 Delivery of comprehensive services strengthened ADB ($17.6 million) AusAID ($13.7 million) A. Management and financing subsystems operationalized in the project provinces: Government ($3.3 million) • Technical training undertaken • Monitoring and evaluation system put into action Inputs: • Management and financing subsystems implemented in hospitals and health Civil works ($9.3 million) management offices Equipment and medical supplies ($6.1 million) Vehicles (($0.5 million) B. Referral systems improved: Training, fellowships, • Communications systems installed Workshops ($3.9 million) • Physical infrastructure at provincial, municipal, and barangay levels improved and Consulting services ($11.4 million) rehabilitated Monitoring and evaluation ($0.3 million) • Medical equipment and ambulances provided and/or installed Replication activities ($0.4 million) Health promotion ($0.8 million) C. Communities and NGOs mobilized for health promotion: Studies and surveys ($0.1 million) • Community resource centers established Project management ($1.4 million) • Rotating funds for motorcycle purchase by midwives established

Performance Monitoring Design Summary Assumptions and Risks Indicators/Targets Mechanisms • Community grants process established and providing grants

D. Priority programs emphasized: • Health promotion activities undertaken • Drugs, kits, and training for priority programs provided

E. Provincial project implementation office established

4.2 Health subsystems: • Subsystems developed • Subsystems replicated

4.3 DOH support to comprehensive health services delivery strengthened: • DOH staff trained in implementation and monitoring of subsystems • ICHS project management unit established and functioning

ARI = acute respiratory infection; AusAID = Australian Agency for International Development; BHS = barangay health station; BHW = barangay health worker; BME = benefit monitoring and evaluation; BOR = bed occupancy rate; BusCoCuLin = Busuanga, Coron, Cullion, and Linapacan; CHD = Center for Health and Development; DOH = Department of Health; HHRMDS = Health Human Resources Management and Development System; HMIS = Health Management Information System; HOMIS = Health Operation Management Information System; HRD = human resources development; HSRA = Health Sector Reform Agenda; ICHSP = Integrated Community Health Services Project; ILHZ = inter-local health zone; IPHS = Integrated Health Planning System; LGU = local government unit; NGO = nongovernment organization; PHO = provincial health office; PMO = project management office; PO = people’s organizations; RHU = rural health unit; PhilHealth = Philippine Health Insurance Corporation; TB = tuberculosis; TB-DOTS = Tuberculosis Directly-Observed Treatment Short-course. a A premier government corporation that ensures sustainable, affordable, and progressive social health insurance that endeavors to influence the delivery of accessible quality health care for all Filipinos. b Issued January 2000 mandating establishment of Inter-Local Health Zones and Integrated (inter-Local Government Unit [LGU]) Health Planning, designed to encourage and facilitate inter-LGU cooperation and innovative strategies and approaches for basic health services delivery.

Appendix 1 1 Appendix 25

Table A1.1: Incidence of Selected Diseases by Project Province 1 Appendix 1999–2004 Apayao Guimaras Indicators 1999 2000 2001 2002 2003 2004 1999 2000 2001 2002 2003 2004

Number of diarrhea cases below 5 years old 1,258 1,054 1,041 1,104 817 846 879 900 635 496 422 184

Rate of diarrhea below 5 years old per 100 population 95.2 78.1 75.7 78.8 57.2 58.2 44.6 44.9 31.1 23.9 20.0 8.6

Rate of diarrhea, all ages per 100,000 population 2,104 1,848 1,796 2,017.4 1,470.9 1,322.9 1,026.6 1,041.6 741.4 538.8 418.5 177.4

Number of measles cases below 5 years old 4 13 5 4 26 22 9 12 47 6 12 3

Rate of measles, all ages per 100,000 population 5.5 17.2 7.4 9.3 55.9 61.9 21.3 18.1 88.8 9.1 21.3 7.4

Number of tetanus neonatorum cases 2.2 0 1.1 0 0 0 0 0 0 0 0 0

Number of ARI/ pneumonia less than 5 years old 591 484 553 1,917 738 1,170 1,180 838 894 1,193 1,295 677

Rate of ARI/ pneumonia less than 5 years old per 1,000 population 44.7 35.9 40.2 136.8 51.7 80.5 59.9 41.8 43.8 57.4 61.3 31.5

Rate of ARI/ pneumonia, all ages per 100,000 population 953.5 738.1 726.3 3,894.1 1,329.7 2,045.2 1,416.7 1,176.7 1,020.5 150.1 1,666.6 587.7

Rate of malaria, all ages per 100,000 population 4,649 3,064 2,893 3,872.4 2,819.9 1,354.8 0 0.7 0 0.7 0 0

Rate of tuberculosis/ respiratory cases, all ages per 100,000 population 376.4 262.1 382.6 110.7 114.8 136.7 482.0 459.0 446.0 245.0 127.6 132.2

Schistosomiasis, all ages — — — — — — — — — — — —

Table A1.1: Incidence of Selected Diseases by Project Province 1999–2004 Kalinga Palawan Indicators 1999 2000 2001 2002 2003 2004 1999 2000 2001 2002 2003 2004 Number of diarrhea cases below 5 years old 2,578 2,057 2,074 1,845 1,678 1,420 5,082 6,396 5,043 5,043 2,795 2,338

Rate of diarrhea below 5 years old per 100 population 106.3 83.1 82.3 71.9 64.2 53.4 62.0 75.9 58.4 57.0 30.9 25.2

Rate of diarrhea, all ages per 100,000 population 3,193 1,990.2 2,058.4 1,707.8 1,443.5 1,289.2 1,761.5 1,681.3 1,361.6 1,329.5 763.2 558

Number of measles cases below 5 years old 2 12 14 30 85 18 22 41 417 417 248 18

Rate of measles, all ages per 100,000 population 3.6 24 24.7 24.3 77.1 31.1 14.7 23.2 139.2 135.9 76.5 4.1

Number of tetanus neonatorum cases 0.6 0 0 0.6 0 0 0 0 0.2 0.2 0 0

Number of ARI/ pneumonia less than 5 years old 2,279 1,826 1,756 2,119 2,431 2,795 2,733 2,599 2,346 2,348 1,170 1,086

Rate of ARI/ pneumonia less than 5 years old per 1,000 population 94.0 73.8 69.6 82.5 93.0 105.1 33.3 30.8 27.2 26.5 12.9 11.7

Rate of ARI/ pneumonia, all ages per 100,000 population 2,384.5 1,371 1,475.8 1,615.2 1,998.3 2,485.7 695.1 634.6 592.7 578.7 320.9 288.7

Rate of malaria, all ages per 100,000 population 1,822.8 924.5 665.4 592.4 499.8 302.5 4,171.4 3,846.3 1,576.5 1,539.3 1,647 1,128.3 1 Appendix

Rate of tuberculosis/ respiratory cases, all ages per 100,000 population 291.1 157.0 234.1 102.2 73.8 118.8 103.3 191.6 122.7 119.8 98.1 137.4

27 Schistosomiasis, all ages — — — — — — — — — — — — — = not available. ARI = acute respiratory infection. Source: Annual Accomplishment Reports, Field Health Services Information System, 1999-2004.

2 8

Table A1.2: Budget Allocation and Expenditures for Health in the Pilot Provinces 1999–2005 (Philippine Pesos) A

Project Sites 1999 2000 2001 2002 2003 2004 2005 ppe Apayaoa n

Total LGU Budget 173,203,557 190,356,455 217,903,578 222,955,409 245,153,306 258,100,000 274,304,722 d Amount Allocated for Health 37,619,483 39,281,621 42,377,402 51,625,709 51,343,714 53,637,819 42,666,075 ix 1 % Allocated for Health 21.7 20.6 19.4 23.2 20.9 20.8 15.6 Total LGU Expenditures 158,259,581 193,404,027 198,375,637 240,283,014 209,030,469 256,795,343 312,795,661 Amount of Expenditures for Health 29,418,351 34,488,770 37,034,973 42,699,699 26,722,705 39,979,712 33,960,773 % of Expenditures for Health 18.6 17.8 18.7 17.8 12.8 15.6 10.9

Kalingab Total LGU Budget 186,748,378 238,912,326 247,517,793 228,003,211 292,922,405 299,549,717 299,567,568 Amount Allocated for Health 66,898,294 72,832,047 81,190,820 85,137,809 91,925,695 88,074,109 90,562,693 % Allocated for Health 35.8 30.5 32.8 37.3 31.4 29.4 30.2 Total LGU Expenditures 167,463,471 222,724,288 221,855,107 243,539,298 242,475,902 253,423,665 274,280,643 Amount of Expenditures for Health 64,640,514 79,524,531 77,990,822 79,066,434 80,803,571 85,053,523 489,226,116 % of Expenditures for Health 38.6 35.7 35.2 32.5 33.3 33.6 32.5

Palawanc Total LGU Budget 501,268,489 663,856,276 744,777,431 782,678,180 853,989,489 867,319,583 836,351,914 Amount Allocated for Health 92,884,039 101,606,110 134,154,353 119,299,635 134,989,424 128,149,040 120,818,158 % Allocated for Health 18.5 15.3 18.0 15.2 15.8 14.8 14.4 Total LGU Expenditures 505,268,489 682,706,276 744,777,423 747,655,921 853,909,489 864,319,583 863,351,914 Amount of Expenditures for Health 92,623,631 101,551,574 121,681,452 119,299,635 127,989,424 116,789,040 108,053,905 % of Expenditures for Health 18.3 14.9 16.3 16.0 15.0 13.5 12.5

Guimarasd Total LGU Budget 109,387,102 129,957,140 135,951,359 158,780,261 177,381,686 174,404,289 186,396,306 Amount Allocated for Health 23,306,367 30,179,980 32,560,462 31,332,447 35,088,667 40,439,162 44,262,284 % Allocated for Health 21.3 23.2 24.0 19.7 19.8 23.2 23.7 Total LGU Expenditures 96,203,490 115,369,127 130,902,433 146,217,896 186,811,858 196,021,473 200,290,605 Amount of Expenditures for Health 23,365,771 26,652,430 27,296,967 27,709,145 34,298,917 31,577,650 42,313,917 % of Expenditures for Health 24.3 23.1 20.9 19.0 18.4 16.1 21.1 LGU = local government unit. Sources: a Certified Statement of Income and Expenditures, Apayao Province, 1999–2005. b Kalinga Budget, 1999–2005. Health budget includes share from LGU resources ( the “20% Development Fund”.) c Palawan Budget, 1999–2005. Health budget includes share from LGU resources (the “20% Development Fund”). d Guimaras Budget, 1999–2005. Health budget includes share from LGU resources (the “20% Development Fund”).

Appendix 1 29

Table A1.3: Status of Barangaysa with Barangay Health Station per Pilot Province, 1999–2004

Provinces 1999 2004 Number of Number of % Number of Number of % Barangays BHS Barangays BHS Apayao 131 44 33.6 134 68 50.7

Guimaras 96 46 47.9 98 69 70.4

Kalinga 150 78 52.0 152 115 75.7

Palawan 356 171 48.0 366 178 48.6

Total 733 339 46.2 750 430 57.3 BHS = barangay health station. a the smallest political division in the Philippines, usually consisting of one or more villages with an average population of 5,000 persons. Sources: Department of Health (DOH). 1999. Field Health Information System Report. Manila. DOH. 2004. Integrated Community Health Services Project Completion Report. Manila.

Table A1.4: Utilization Rates of Selected Hospitals Constructed or Renovated/Expanded Appendix 1 Appendix Under the Integrated Community Health Services Project

Completion Amount Category/ No. of Authorized Bed Occupancy Rate Based on Authorized Beds Hospital Civil Works Period (Pesos) Classification Hospital Beds 2000 2001 2002 2003 2004 2005 Apayao Apayao Provincial Renovation/ Feb 2002– 6,872,907 Infirmary 25 34.1 32.6 20.3 17.9 16.1 12.0 Hospital (Kabugao) Upgrading Oct 2003 Amma Jadsac DH Renovation/ Feb 2002– 4,954,929 Infirmary 25 33.9 20.2 25.6 17.2 23.7 22.8 Pudtol) Upgrading Sep 2003 Apayao DH Renovation/ Feb 2002– 3,191,052 Infirmary 25 5.8 6.4 16.4 12.6 8.5 n.a. (Calanasan) Upgrading Nov 2002 Kalinga Kalinga Provincial New construction Jan 2003– 89,162,825 First level 100 52.3 62.4 59.5 71.7 83.9 82.6 Hospital Sep 2003 referral Rizal DH Renovation May 2000– 4,199,302 Infirmary 25 25.7 22.0 18.2 26.3 32.6 28.2 (Juan Duyan) Nov 2001 Western Kalinga DH Renovation July 2001– 4,891,914 Infirmary 25 29.8 28.2 23.0 22.3 33.9 26.8 (Balbalan) Mar 2003 Kalinga DH Renovation May 2000– 3,631,963 Infirmary 25 29.5 24.4 30.9 29.4 32.7 19.8 (Lubuagan) Jun 2004 Pinukpuk DH New construction May 2002– 6,795,022 Infirmary 25 31.9 35.6 40.0 37.8 31.2 36.4 Mar 2003 Guimaras Guimaras Provincial Renovation Jan 2002– 16,502,187 First level 50 — — — — — — Hospital Mar 2003 referral Nueva Valencia DH New construction Dec 2001– 14,718,896 Infirmary 50 — 18.0 Feb 2002 Palawan Narra Medicare DH Renovation May 2001– 5,313,337 First level 103.9 54.1 25 — 66.7 45.3 64.2 Aug 2003 referral Coron DH Renovation July 2001– 4,443,036 First level 25 35.3 28.5 42.0 48.4 42.4 58.9 Dec 2002 referral Quezon Medicare DH Renovation Dec 2001– 1,267,389 Infirmary 10 — 68.5 79.6 52.4 51.1 nd Sep 2002 Roxas DH New construction Aug 2002– 11,505,161 Infirmary 15 — 49.1 73.2 61.2 62.1 44.8 Jan 2003 Aborlan DH Renovation Dec 2001– 5,500,714 Infirmary — 15 40.5 49.5 51.5 72.2 47.0 Aug 2003 Taytay DH Renovation Aug 2002– 5,627,505 First level — 25 86.0 59.6 61.0 67.0 80.0 Jan 2003 referral Cuyo DH Renovation Aug 2002– 6,709,226 First level — 50 78.0 78.0 79.0 59.0 76.0 Jan 2003 referral n.a. = not available; DH = district hospital. Sources: Hospital statistics reports, 2001–2005 by province; and Department of Health–Integrated Community Health Services project completion reports.

Table A1.5: Selected Indicators of Program Coverage by Pilot Province, 1999–2004

Apayao Guimaras Indicators 1999 2000 2001 2002 2003 2004 1999 2000 2001 2002 2003 2004 Maternal Care % of pregnant women with 60.6 62.7 55.3 61.5 62.6 60.9 67.0 68.8 62.7 66.4 59.4 60.6 3 or more prenatal visits % of pregnant women given 52.4 58.9 53.7 54.8 55.8 54.4 39.6 58.5 52.4 55.6 58.0 58.9 tetanus toxoid 2 % of postpartum women with 74.8 77.8 71.2 70.9 72.5 73.2 64.3 58.2 66.7 67.9 60.4 62.6 at least 1 postpartum visit % of lactating mothers given 71.1 76.1 67.8 70.9 71.1 73.2 55.7 70.5 61.0 63.0 49.7 61.3 vitamin A % of deliveries attended by 91.3 88.4 92.5 96.0 95.8 97.3 95.5 96.4 97.3 98.2 97.8 98.4 health professionals % of deliveries in health 11.5 10.8 16.4 15.7 17.1 22.8 32.1 31.3 31 31.9 34.7 41.8 facilities Child Care % of fully immunized children 84.1 84.8 82.1 87.2 83.8 80.6 76.6 80.5 77.7 79.4 79.8 80.2 % of 0–59 month old children 23.7 19.4 16.7 22.8 18.4 14.6 11.8 12.9 13.3 8.1 8.2 4.8 with diarrhea given ORS % of 0–59 month old children with pneumonia given 99.6 94.1 98.2 98.9 99.2 99.2 93.6 99.5 99.2 98 100 99.5 treatment % of 12–59 month old 99.9 82.5 27.3 4.5 35.7 17.9 60.5 206.7 36.6 103.3 77.1 130.6 children given vitamin A Tuberculosis Rate of new sputum + initiated treatment per 113.0 101.0 103.2 124.1 72.1 99.8 104.5 133.0 78.8 91.4 81.7 87.7 100,000 population Rate of tuberculosis cases 282.0 215.9 289.9 246.2 138.1 137.7 209.0 235.6 184.6 245.0 212.7 140.3 per 100,000 population Malaria 0.7 0.7 1.1 2.7 2.5 1.1 — — — — 0.001 — % of confirmed cases Environmental health % of households with access 64.7 76.6 76.4 67 71.9 76.2 69.1 69 70.3 81.7 81.7 82.9 to safe water supply % households with sanitary 1 Appendix 79.2 84.7 85.3 80.1 86 80.2 66.5 73.4 83.7 86 86.3 86 toilet

32 Kalinga Palawan Indicators 1999 2000 2001 2002 2003 2004 1999 2000 2001 2002 2003 2004

Maternal Care 1 Appendix % of pregnant women with 57.7 56.4 50.1 44.3 50.3 48.8 82.3 80.9 80.7 72.4 71.9 78.6 3 or more prenatal visits % of pregnant women given 49.8 50.8 46 43.8 46.8 34.7 56.8 61.2 40.1 39.2 56.4 67.6 tetanus toxoid 2 % of postpartum women with 71.8 76.1 71.8 72.1 69.9 65 76.7 80.9 82.7 68.3 73.5 72.8 at least 1 postpartum visit % of lactating mothers given 66.5 70.4 60.1 66.2 67.8 61.7 68.4 64.5 78.9 49.1 64.6 62 vitamin A % of deliveries attended by 90.6 90.6 91.8 92.3 91.4 96.1 82.9 83.4 84.5 84.5 83.2 83.8 health professionals % of deliveries in health 16.3 20.3 18.3 21.7 20.9 36.3 9 8.2 12.2 12.2 6.4 6.1 facilities Child Care % of fully immunized children 79.2 75.5 81.1 66.2 71.9 78.4 83.9 81.9 63.6 72.3 91.2 87.6 % of 0–59 month old children 33.6 31.5 24.9 22.4 21.9 19 25.9 26.9 23.8 17.8 17.4 13.7 with diarrhea given ORS % of 0–59 month old children with pneumonia given 94 97 93.5 88.5 96.9 93.1 88.8 98.1 97.1 98.4 98.9 99.9 treatment % of 12–59 month old 13.1 104.7 131.5 104.8 140 105.2 130.9 60.8 155 54.9 156.4 165.1 children given vitamin A Tuberculosis Rate of new sputum + initiated treatment per 123.2 115.4 76.5 78.5 74.9 98.1 72.4 93.6 177.1 61.5 62.3 66.5 100,000 population Rate of tuberculosis cases 223.6 235.5 201.9 223.1 238 163.5 303.1 318.2 301.8 163.9 139.5 160.6 per 100,000 population Malaria 0.4 0.3 0.2 0.5 0.5 0.4 1.8 1.4 2.9 1.3 2 2.3 % of confirmed cases Environmental health % of households with access 77.7 75.3 78.1 90.6 92.4 88.9 32.3 28.5 93.1 93.1 93.8 76.5 to safe water supply % households with sanitary 38.6 44.7 43 49.6 51.8 51.2 38 36.9 74.6 74.6 100 78.5 toilet Source: Department of Health. Field Health Information System Reports. 1999–2004.

Appendix 2 33

STATUS OF SENTRONG SIGLA CERTIFIED RURAL HEALTH UNITS CONSTRUCTED/RENOVATED UNDER THE PROJECT

Type of Assistance Sentrong Siglaa Rural Health Unit New Construction Renovation Certification Status

Apayao Flora / / Sta. Marcela / / Calanasan / / Pudtol / / Kabugao / x Luna / /

Guimaras Jordan / / Nueva Valencia / / San Lorenzo / / Sibunag / / Buenavista / x

Kalinga Pinukpuk / x Tinglayan / / Balbalan / / Tanudan / x Pasil / x

Palawan Cuyo / / Taytay / / Araceli / x Brooke’s Point / / Sofronio Espanola / x Quezon / / Rizal / x Cullion / x Busuanga / x Linapacan / / Roxas / / Magsaysay / / Dumaran / / Cagayancillo / / Balabac / x Agutaya / x Total 22 10 20/32 = 62.5% / = done; x = not done. a Sentrong Sigla Movement is a joint effort of the Department of Health and the local government units. It aims at promoting availability of quality health services in health centers and hospitals, and at making these services accessible to every Filipino. Its main component is the certification and recognition program that develops and promotes standards for health facilities. Source: Department of Health Status Report on Sentrong Sigla Certification as of December 2005.

34 PROJECT COST BY EXPENDITURE CATEGORY Project Component Estimated Cost at Actual Cost Disbursed Deviation of Remarks Appraisal ($ million) Actual ($ million) Disbursement 3 Appendix ADB Govt Total ADB Govt Total % of Total from Cost at Cost Appraisal Disbursed ($ million)

Civil Works 4.80 0.85 5.65 5.49 1.08 6.57 31.80 +0.92 Mainly because of increase in the cost of Kalinga Provincial Hospital and change in the scope of work for some facilities from renovation to new construction or replacement Equipment 2.88 0.32 3.20 3.23 0.67 3.90 18.90 +0.7 Increase was mainly caused by the increase in the communication equipment Vehicles 0.86 0.04 0.90 0.46 0.09 0.55 2.70 -0.35 Training and 2.27 0.57 2.84 1.90 0.35 2.25 10.90 -0.59 Workshops Consulting Services 2.92 0.52 3.44 3.65 0.66 4.31 20.9 +0.87 The increase was mainly caused by the pretermination of consultancy services of Coffey Philippines, Inc., which required hiring new consultants to complete the work. Monitoring and 0.17 0.00 0.17 0.39 0.07 0.46 2.20 +2.03 Evaluation Replication Activities 4.27 0.73 5.00 0.34 0.07 0.41 2.00 -3.0 Actual amounts decreased because of the delayed Health Promotion 1.39 0.00 1.39 0.62 0.13 0.75 3.60 -0.75 implementation of these activities Studies and Surveys 0.12 0.03 0.15 0.02 0.00 0.02 0.10 -0.05 Community Projects 0.00 0.00 0.00 0.00 0.00 0.00 0.00 — Operations and 0.00 0.00 0.00 0.00 0.00 0.00 0.00 — Maintenance Project Management 0.82 0.25 1.07 1.20 0.23 1.43 6.90 +0.36 Subtotal 20.50 3.31 23.81 17.30 3.35 20.65 100.0 -3.16 Taxes and duties .00 0.61 0.61 -0.61 Base Cost 20.50 3.92 24.42 17.30 3.35 20.65 100.0 -3.77 Price Contingency 3.27 0.21 3.48 -3.48 Physical 1.45 0.21 1.66 -1.66 Contingency Service Charges 0.69 0.00 0.69 0.30 — 0.30 -0.39 Total Project Cost 25.91 4.33 30.24 17.60 3.35 20.95 -9.29 ADB = Asian Development Bank, Govt = Government of the Philippines. Note: Numbers may not add up because of rounding. Original Amount of Loan: $25.91 million Original Govt Counterpart: $4.33 million Partial Loan Cancellation: $5.6 million Actual Amount Disbursed: $3.35 million Amount after Cancellation: $20.31 million % of Utilization: 77.4 Actual Amount Disbursed: $17.60 million % of Utilization: 86.6 Source: Department of Health, ICHSP Project Completion Report.

Appendix 4 35

2004 Year 8

2003

Year 7

2002

Year 6

2001

Year 5

2000

Year 4

1999

Year 3

1998 Year 2

PROJECT IMPLEMENTATION SCHEDULE

Year 1

1996 1997 1996 1997

1 2 3 4 2 1 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

- Site Inspection - Design - Construction - Equipment and Furniture - Medical Equipment - Drugs Planned Actual Project Milestones Loan Approval 1995 Loan Signing Loan Effectivity Project Launching Establishment/Operations of Project Management Office Implementation Consultancy Services: Evaluation, Start of Services Project Components Civil Works Procurement Telecommunications Health Management DevelopmentSystems and Documentation Health Management ImplementationSystems Health Promotion/Social marketing Benefit Monitoring and Evaluation Replication Project Loan Closing 36 Appendix 5 Appendix SUMMARY OF TRANSITIONS IN PROJECT LEADERSHIP 1997–2004

No. of 1997 1998 1999 2000 2001 2002 2003 2004 Transitions 1 2 3 4 1 2 3 4 123412 3 4 1 2 3 4 12341234 1 2 Department of Health Secretary Reodica Estrella Romualdez Dayrit 4 Project Director Gaco Fernandez Lopez Padilla 4 Project Coordinator Bonoan Perez de Bernardo Ala 5 Guzman Project Manager Gonzales Devanadera Canda a b Magtibay 6 Apayao - Governor Laoat Bulot 2 - PHO Domingo Dangao 2 - PIU Sebastian Banaga Malingan 3 Kalinga - Governor Wacnang Belac Duguiang 3 - PHO 0 - PIU Saguilot 0 Guimaras - Governor Lopez Nava 2 - PHO Lozarita Gumarin Lozarita 3 - PIU Liguid Gotico Piccio 3 Palawan - Governor Socrates Reyes 2 - PHO Socrates Palanca 2 - PIU Tejares 0 PHO = public health office; PIU = project implementation unit. a Pangilinan. b Baldago. Source: Field interviews.

Appendix 6 37

STATUS OF COMPLIANCE WITH LOAN COVENANTS

Reference in Loan Status of Covenant Agreement Compliance Conditions of Effectiveness

1. A safe 90 days after the date of this Loan Agreement Article VI Complied with is specified for the effectiveness of the Loan Agreement for the purposes of Section 9.04 of the Loan Regulations

Conditions of Disbursement

Standard Covenants

2. Maintenance and audit of separate accounts for the Section 4.06(b) Complied with Bank-financed components of the Project; unaudited project accounts to be furnished not later than six (6) months after the end of each fiscal year; audited accounts and auditors report not later than nine (9) months after the end of fiscal year

3. Quarterly progress reports on the carrying out of the Section 4.07(b) Complied with Project and on the operation and management of the Project Facilities to be submitted

4. PCR to be prepared and furnished not later than Section 4.07(c) Complied with three (3) months after physical completion of the Project

Project Specific Covenants I. General Implementation Arrangements

Project Executing Agency

5. DOH, as the Project Executing Agency, shall have Schedule 6, para. 1 Complied with the overall responsibility for the implementation of the Project. The Undersecretary/Chief of Staff of DOH shall be the Project Director, responsible for overall supervision of the Project. The service Chief of the Community Health Service (CHS) within DOH shall be the Project Coordinator, assisted by the Project Management Office referred to in paragraph 3 of this schedule.

Project Steering Committee (PSC)

6. DOH shall establish a PSC which shall provide policy Schedule 6, para. 2 Complied with advice and direction on the implementation of the Project and approve the annual implementation plans in conjunction with the annual budget. The PSC shall be chaired by the Project Director and shall include senior representatives of concerned offices within DOH, the Governors of the Project provinces (or their designates), NGOs. The PMO shall serve as a secretariat to the PSC. The PSC shall meet promptly after the Effective Date and thereafter at least twice a year.

38 Appendix 6

Reference in Loan Status of Covenant Agreement Compliance Project Management Office (PMO)

7. The PMO established within OMS, headed by a full- Schedule 6, para. 3 Complied with time Project Manager acceptable to the bank, shall be responsible for the day-to-day implementation of the Project including preparation of Project reports, maintenance of Project records and accounts, recruitments and engagement of consultants and procurement activities.

Implementation at Regional and Provincial Levels

8. (a) Under the direction of the PMO, the Regional Schedule 6, para. 4 Complied with Field Office (ROS) of DOH shall be responsible for coordination of Project implementation within their respective regions, including coordination of financial and other reporting at the regional level

(b) In each Project Province, the Governor shall serve as the Provincial Project Director to ensure provincial commitment to the project. A Provincial Project Coordinator, appointed by the Governor from the Provincial Health Office (PHO) staff, shall be responsible for the day-to-day implementation of the Project in the relevant project province. The provincial project coordinator shall be supported by a Project Implementation Unit (PIU) consisting of an Assistant Project Coordinator, up to four contractual staff and counterparts from the relevant PHO. The PIU shall be responsible for coordination of project activities with concerned LGUs, Monitoring of the project implementation within the project province, and financial and other reporting at the provincial level.

II. Project Implementation Arrangements

9. DOH shall execute a Project Implementation Schedule 6, para. 5 Complied with Agreement (PIA) with each Project Province, which shall serve as an Annex to the Comprehensive Health Care Agreement (CHCA) negotiated between DOH and such Province, and which shall include arrangements for the implementation in such province of the relevant Project components, and in particular.

(i) an undertaking by such province to execute, within 3 months after execution of the PIA by DOH and such province, a Memorandum of Agreement (MOA) acceptable to DOH and the Bank with each municipality located within such province (which MOA shall specify the respective responsibilities, contributions and ongoing commitments of the parties thereto relating to the project); and (ii) an agreement between DOH and such province that no Project activities will be undertaken in a municipality until

Appendix 6 39

Reference in Loan Status of Covenant Agreement Compliance such MOA has been executed by such Province and such Municipality; detailed descriptions of project components to be implemented in such province and the respective responsibilities of DOH and such Province.

Funds to be allocated from the proceeds of the Loan and the AusAID Grant, from the resources of the Borrower, and from the contributions to be made by such Province and other LGUs, for project activities within such province; undertaking by such province (and undertaking to be obtained from other concerned LGUs within such province) with respect to (i) the high budgetary priority to be given to the project throughout its implementation, and (ii) financing of recurrent expenses, including staffing, operation and maintenance of vehicles and equipment, and replenishment of medical kits and hospital supplies financed under the project; assurances with respect to the release of health personnel to participate in training activities under the project, appropriate staffing arrangements to ensure efficient and effective Project implementation and appropriate reassignment of health personnel following training; and establishment of benchmarks and evaluation of performance on a yearly basis, with provisions for reducing, suspending or canceling of Project activities in such Province (or in any LGU within such province) in the event that such province (or any such LGU) fails to achieve these benchmarks or otherwise fails to satisfy its obligations under the relevant PIA (or the relevant MOA, in the case of failure of any such LGU).

10. Each PIA shall pertain to the entire Project period Schedule 6, para. 6 Complied with and shall provide Province-specific implementation schedules and corresponding financing arrangements on an annual basis. Each year, during the negotiation of the CHCAs, DOH shall confirm the implementation schedules and financing arrangements, as provided in each PIA, for the following year. Any material adjustments to the PIAs shall be subjected to prior approval of the bank. Upon execution of a PIA and any amendments thereto, DOH shall furnish a copy to the bank.

11. The borrower, through DOH, shall furnish the bank as Schedule 6, para. 7 Complied with promptly as possible with a copy of each MOA entered into by a Project Province and a municipality, and shall ensure that, except as otherwise agreed by DOH and the Bank, no Project activities will be undertaken in a municipality until a MOA acceptable to DOH and the Bank has been executed by such municipality and Project Province in which the municipality is located.

40 Appendix 6

Reference in Loan Status of Covenant Agreement Compliance III. Other matters

Strategic Health Service Plans

12. The Borrower, through DOH, shall ensure that each Schedule 6, para. 8 Complied with Project Province prepares a strategic health service plan. Incorporating a provincial training program and participation of the private sector, within 3 months after execution of the PIA between DOH and such province. DOH shall prepare criteria acceptable to the bank for selection of training courses and participants in such courses.

Benefit Monitoring and Evaluation (BME)

13. The borrower shall ensure that, within three months Schedule 6, para. 9 Complied with after the Effective Date, DOH shall adopt a BME plan acceptable to the bank, under which DOH shall, with the assistance of the BME consultant(s) for the project and the involvement of RFOs in the Project Provinces, carry out appropriate baseline and evaluation surveys, pilot studies and benefit monitoring activities. The Borrower shall ensure that the Project Provinces and other LGUs participating in the project maintain accurate and complete health statistics necessary for BME, and that they make such statistics available to DOH on a timely basis.

Performance Indicators

14. The Borrower shall ensure that, under each PIA Schedule 6, para.10 Complied with entered into with a Project Province, DOH shall establish yearly benchmarks for performance by such Province and LGUs within such Province, that such performance shall be evaluated by DOH at least on a yearly basis, and that the results of such evaluation shall be taken into consideration in allocating Project funds to such Province for each succeeding year

Mid-Project Evaluation

15. Within 3 years after the effective date, the Borrower, Schedule 6, para. 11 Complied with the bank and AusAID shall conduct a mid-Project evaluation of the Project, which shall evaluate the achievement of Project objectives, identify problems in implementation and propose solutions. Such mid- project evaluation shall also identify successful health sub-systems developed under the project for replication in other provinces included in the Borrower’s Social Reform Agenda during the remaining implementation period.

Appendix 6 41

Reference in Loan Status of Covenant Agreement Compliance Coordination with Women’s health and Safe Motherhood (WHSM) Project

16. To maximize coordination between the Project and Schedule 6, para. 12 Complied with WHSM Project, the Borrower, through DOH, shall ensure that WHSM Project is implemented on a priority basis in each Project Province (other than the Province of South Cotabato) commencing 1995.

Provincial Implementation and Financing

17. The Borrower, through DOH, shall ensure that, in Schedule 6, para. 12 Complied with each Project Province, the Provincial Project Coordinator is delegated appropriate responsibility to implement the Project, and that the PIU in such Province is provided with adequate staff and support.

18. The Borrower, through DOH, shall ensure that, each Schedule 6, para. 14 Complied with Project Province provides, over the life of the Project, increasing levels of financial support for the Project activities and adequate staff financing to operate and maintain the Project facilities and programs during and after Project implementation.

Selection Criteria for Upgrading of District Hospitals

19. The Borrower, through DOH, shall ensure that each Schedule 6, para. 15 Complied with district hospital to be upgraded under the Project (a) is geographically accessible for referrals from RHUs and BHSs within the relevant district and serves a majority of the population in that district; (b) has adequate staff and access to water and electricity; (c) owns or can acquire the necessary land for any extension planned under the Project; and (d) is at least two hours travel time from the nearest other hospital (including district, provincial and regional hospitals).

Environmental and Other Requirements

20. The Borrower, through DOH, shall ensure that all civil Schedule 6, para. 17 Complied with works carried out under the Project are in compliance with all applicable environmental and zoning laws and regulations and that all necessary licenses and permits are obtained prior to the commencement of such works. The Borrower, through DOH, shall also ensure that all health facilities constructed or renovated under the Project comply with applicable laws and regulations relating to the disposal of medical waste, and shall ensure that such disposal is appropriately monitored.

42 Appendix 6

Reference in Loan Status of Covenant Agreement Compliance Quality of Civil Works

21. The Borrower shall ensure that DOH monitors the Schedule 6, para. 17 Complied with quality of all civil works carried out under the Project and that, before final payment is made to any contractor under the Project, staff of the PMO inspect and commission the construction or renovation work performed by such contractor.

Community Health Resource Centers

22. The Borrower, through DOH, shall ensure that NGOs Schedule 6, para. 18 Complied with and local communities have ample access to each community health resource center established under the Project.

AusAid = Australian Agency for International Development; BHS = barangay health station; DOH = Department of Health; LGU = local government unit; MOA = memorandum of agreement; NGO = nongovernment organization; PIA = project implementing agency; PCR = project completion report; PMO = project management office; RHU = rural health unit; WHSM = Women’s health and Safe Motherhood.

Appendix 7 43

UTILIZATION STATUS OF THE INTEGRATED HEALTH PLANNING SYSTEM BY REGION

Center for Health Development Utilization Status Not all LGUs are utilizing the system; irregular Cordillera submission of annual plans

Ilocos Utilized by the LGUs

Cagayan Valley ILHZs are using the system

Central Luzon Utilized by some LGUs

CALABARZON Utilized by the LGUs

MIMAROPA Utilized by the LGUs

Bicol Utilized by the LGUs in their annual health planning

Western Visayas Utilized by the LGUs; they are submitting their annual health plans regularly

Central Visayas Used only by the organized ILHZ

Zamboanga Peninsula Not utilized by the LGUs

Davao Utilized by the LGUs down to the barangaya level; all SS Certified RHUs are using the IHPS

SOCCSKARGEN Almost all provinces are using the IHPS except for South Cotabato – about 30% RHUs are utilizing the unit-based planning system introduced by AusAID

Metro Manila Not utilized by LGUs; only 2–3 municipalities submitted their annual plan for the last 2 years AusAID = Australian Agency for International Development; CALABARZON = Cavite, Laguna, Batangas, Rizal, and Quezon; IHPS = integrated health planning system; ILHZ = inter-local health zone; LGU = local government unit; MIMAROPA = Occidental Mindoro, Oriental Mindoro, Marinduque, Romblon, and Palawan; RHU = rural health unit; SOCCSKARGEN = South Cotabato, Cotabato, Sultan Kudarat, Sarangani and General Santos City; SS = Sentrong Sigla. a The smallest political division in the Philippines, usually consisting of one or more villages with an average population of 5,000 persons. Note: No report for eastern Visayas, northern Mindanao, CARAGA (an Administrative Region in northeastern Mindanao composed of 4 provinces: Agusan del Norte and del Sur; Surigao del Norte and del Sur), and Autonomous Region in Muslim Mindanao (ARMM). Source: Report on Integrated Health Planning System Utilization, Health Policy Development and Planning Bureau- Department of Health. December 2005.

8 Appendix

STATUS OF SYSTEMS INSTALLATION IN PILOT AND REPLICATION AREAS

Health Apayao Guimaras Kalinga Palawan Ifugao Mountain Province Systems Integrated Formulated strategic Prepared 2000–2004 Developed the Integrated Prepared integrated Had strategic plan Health planning Health plan for 2000–2004 provincial health plan provincial health plan for health plan in 2001, which until 2004 practiced already at Planning 2000–2004 included the plans of the municipal and district Prepared annual Continue to do annual 6 ILHZs Participation of local levels plans from 2001 to planning but not using Continue to do annual stake-holders in 2004 the IHPS planning but not using the Continue to do annual planning process IHPS planning but not using the established and Continue to do annual IHPS institutionalized planning but not using ILHZ in Tinglayan the IHPS continues to prepare IHPS plan Health Cooperative Guimaras Health Ambigatton Multipurpose BusCoCuLin District Project strengthened Sagada Health Financing pharmacy Insurance Program Cooperative organized in Health Insurance Program operations of already Insurance Program Schemes implemented in three continues to operate 2002; now on its 6th year existing cooperative receives P150,000 a hospitals of operation BusCoCuLin health pharmacies in year from municipal Nueva Valencia financing adopted by the Mayoyao and government Several RHUs Medical Assistance Peso for Health southern district of Aguinaldo collecting users’ fees Fund established established in Tabuk, Palawan Basao Og0Ogbo Pinukpuk, and Balbalan insurance program Three RHUs already Cooperative pharmacies set up for Besao under PhilHealth OPB Bumilgan Cooperative continue to operate District Pharmacy organized User fees formalized Kalinga Medical Assistance Fund started in Parallel drug importation 2001 Contribution of province of Tinglayan established its P2 million per year own paluwagan (an indigenous scheme where money is pooled without being tied to specific needs or emergencies)

Health HOMIS installed in HOMIS installed in HOMIS installed in Kalinga HOMIS installed in Ospital LAN installed in 2003, LAN installed in 2003 Manage- Apayao Provincial Guimaras Provincial Provincial Hospital, and ng Palawan, after which HOMIS at Besao Sagada ment Hospital and Flora Hospital Pinukpuk and Rizal district Narra District Hospital, was also installed; District Hospital, Information District Hospital hospitals Coron District Hospital, system fully after which HOMIS

System As of PCR, HOMIS is As of PCR, HOMIS and Brooke’s Point District operational was also installed; As of PCR, HOMIS is not functional Hospital system fully

Health Apayao Guimaras Kalinga Palawan Ifugao Mountain Province Systems not functional operational in Kalinga operational Provincial Hospital but HOMIS not functional in further assistance required Narra but continues to to generate tables; HOMIS operate in Coron District not functional in Rizal Hospital District Hospital

Health Utilization of hospital Guimaras health Hospital operations Ospital ng Palawan using Hospital procedures Hospital procedures Operations procedure manuals in referral system manual and health referral the hospital procedures manual prepared and manual developed and 2001 manual prepared by manual distributed in 2003 manual; referral system adopted in Mayoyao and now utilized Manage- province in 2003 formalized and District Hospital ment Referral system Assessment tools strengthened with the Health referral system Systems implemented in 2003 Return referral not developed are now used Project Health referral system developed and now working in provincial and district developed and implemented Two-way referral hospitals Two-way referral system implemented system not working (a Developed the clinic not working system where the management protocol Developed database for lower level refers the BenchBook (the patient to a higher quality improvement level for treatment, manual for hospitals) and then refers back to the lower level after treatment)

Human Implemented HRM system PMS and JRRSS PMS/JRRSS accepted Resources subsystems were patterned after implemented and used 2000–2001; Manage- PMS, JRRSS, HRPS, existing CSC systems HRPS and TDNA ment and and TDNA and further modified accepted in 2002; HRMO Develop- in the Project established as a separate ment Human resources unit under PHO System management and Committee on Health development unit Selection and established in 2001 Recruitment established BusCoCuLin= Busuanga, Coron, Culion, and Linapacan; CSC = Civil Service Commission; HOMIS = Hospital Operation Management Information System; HRM = human resource management ; HRMD = human resource management and development; HRMO = human resource management office; HRPS = human resource planning system ; IHPS = Integrated Health Planning System; ILHZ = inter-local health zone; JRRSS = Job-Related Recruitment and Selection System; LAN = local area network; OPB = outpatient benefit; PCR = project completion review; PHO = provincial health office; PMS = performance management system; RHU = rural health unit; TDNA = training development and needs assessment.

8 Appendix

45 46

8 Appendix

Health Systems Mindoro Oriental Capiz Antique Davao del Norte Agusan del Sur Integrated Health Integrated health planning now Integrated health planning Integrated health planning Integrated health planning Integrated health Planning institutionalized now institutionalized in all now institutionalized in all now institutionalized in the planning now levels levels province institutionalized in the province Continue to do IHPS; recently did the F1a plan; started to integrated barangayb planning

Health Financing Oriental Mindoro Provincial User’s fee and PDI PhilHealth only scheme Botika ng Barangay ( a HCF options now Schemes Consumers Cooperative adopted adopted by provincial and village level pharmacy) and implemented are: organized with initial municipal LGUs PhilHealth adopted hospital revolving fund, membership of 140 and capital User’s fee gradually hospital income of P21,600 implemented in Roxas retention, LGU cost Memorial Provincial sharing mechanism PhilHealth now Hospital and other district from hospital operations institutionalized through hospitals and user’s fee; provincial government, which provincial governor also implemented user’s fee approved Provincial Hospital Revolving Trust Fund; 3 of 5 RHUs are recipients of PhilHealth capitation funds for indigents Health Management LAN installed in 2003 after LAN installed in 2003 after LAN installed in 2003 after LAN installed in 2003 after LAN installed in 2003 Information System which HOMIS was also which HOMIS was also which HOMIS was also which HOMIS was also after which HOMIS was installed; system fully installed; system fully installed; system fully installed; system fully also installed; system operational operational operational operational fully operational

HOMIS operational in Roxas memorial Provincial Hospital with some difficulties in generating PhilHealth requirements Health Operations and Hospital procedures manual Hospital procedures Hospital procedures manual Hospital procedures manual Hospital procedures Management Systems developed and now utilized manual prepared and specific to SAHA prepared developed and adopted manual adopted and adopted now implemented Health referral system Health referral system Health referral system, developed and now Health referral system established in SAHA area including clinic protocols and Health referral system, implemented established in replication guidelines, developed and including clinic protocols area; now replicated in now implemented and guidelines, other zones developed and now

Health Systems Mindoro Oriental Capiz Antique Davao del Norte Agusan del Sur implemented Referral functional in Bailan District Hospital Human Resources Management and Development System F1 = Fourmula 1; HCF = health care financing; HOMIS = Hospital Operation Management Information System; IHPS = Integrated Health Planning System; LAN = local area network; PhilHealth = Philippine Health Insurance Corporation; RHU = rural health unit; SAHA = San Jose, Hamtic, and Anini-y. a FOURmula 1 for Health is the implementation framework for health sector reforms in the Philippines for the medium term, 2005–2010. The components of FOURmula- One are (i) health care finance reform, (ii) health service delivery strengthening, (iii) governance reform and (iv) regulatory reform. b The smallest political division in the Philippines, usually consisting of one or more villages with an average population of 5,000 persons. Source: Department of Health, ICHSP Project Completion Report; field interviews.

Appendix 8 Appendix

47 48 Appendix 9

STATUS OF PHILHEALTH ACCREDITATION

Province/Health Facilities Inpatient Outpatient TB-DOTS Maternity Benefit Benefit Benefit Packagec Package Packagesa Packageb Apayao Rural Health Units Calanasan /(I) X X Conner X X X Flora /(R X X Kabugao X(I) X X Luna /(I) X X Pudtol /(I) X X Sta. Marcela /(I) X X Hospitals Calanasan District Hospital / / Conner national-retained / / Flora District Hospital / / Apayao Provincial Hospital / / Luna District Hospital / / Pudtol District Hospital / / Sta. Marcela Medicare / / Hospital

Guimaras Rural Health Units Buenavista /(R) X X Jordan /(R) X(E) X Nueva Valencia X(E) Ongoing X accreditation San Lorenzo /(R) Ongoing X accreditation Sibunag /(R) Ongoing X accreditation Hospitals Buenavista Community X X Hospital Nueva Valencia District / / Hospital Guimaras Provincial Hospital / /

Kalinga Rural Health Units Balbalan /(I) / X Lubuagan /(I) / X Pasil X X Pinukpuk X X Rizal X X Tabuk (3) /(3R) / X Tinglayan Ongoing X accreditation Tanudan X X

Hospitals

Appendix 9 49

Province/Health Facilities Inpatient Outpatient TB-DOTS Maternity Benefit Benefit Benefit Packagec Package Packagesa Packageb Kalinga Provincial Hospital / Juan M. Duyan District / Hospital Western Kalinga District / Hospital Kalinga District Hospital / Pinukpuk District Hospital / Tanudan District Hospital /

Palawan Rural Health Units Aborlan X X Agutaya X X Araceli X X Balabac X X Bataraza X X Brooke’s Point /(R) X Busuanga X X Cagayancillo X X Coron X X Cuyo / X Dumaran X X El Nido /(R) X Espanola X X Kalayaan X X Linapakan X X Magsaysay x X Narra /(I) X Quezon X X Rizal X X Roxas X X San Vicente X X Taytay X X

Hospitals Aborlan Medicare Hospital / Brooke’s Point District / Hospital Coron District Hospital / Cuyo District Hospital / Quezon Medicare Hospital / Taytay District Hospital / / = accredited; x = not accredited; I = initial accreditation; R = renewed accreditation; E = expired accreditation. PhilHealth = Philippine Health Insurance Corporation, TB-DOTS = Tuberculosis Directly Observed Treatment Short-course. a Source: PhilHealth Masterlist of OPB Providers, as of April 2006. b Source: National TB Program Data Base on TB-DOTS Accredited Facilities as of December 2005. c Source: PhilHealth Masterlist of Maternity Package Providers as of December 2005.

50 Appendix 10

HOSPITAL OPERATIONS AND MANAGEMENT INFORMATION SYSTEM IMPLEMENTATION STATUS (as of 19 May 2006)

Hospital Location Modules Status Installed

Original ICHSP Sites (18 hospitals) 1 1 Amma Jadsac District Hospital Apayao Module 1 For follow-up and evaluation 2 2 Apayao Provincial Hospital Apayao Module 1 For follow-up and evaluation 3 3 Flora District Hospital Apayao Module 1 For follow-up and evaluation 4 4 Juan M. Duyan District Hospital Kalinga Module 1 For follow-up and evaluation 5 5 Kalinga Provincial Hospital Kalinga Module 2 For follow-up and evaluation 6 6 Pinukpuk District Hospital Kalinga Module 1 For follow-up and evaluation 7 7 Calanasan District Hospital Apayao Module 1 For follow-up and evaluation 8 8 Guimaras Provincial Hospital Guimaras Module 1 For follow-up and evaluation 9 9 Nueva Valencia District Hospital Guimaras Module 1 For follow-up and evaluation 10 10 Siargao District Hospital Siargao Module 1 For follow-up and evaluation 11 11 South Cotabato Provincial Hospital South Cotabato Module 2 For follow-up and evaluation 12 12 Lake Sebu District Hospital South Cotabato Module 1 For follow-up and evaluation 13 13 Norala District Hospital South Cotabato Module 1 For follow-up and evaluation 14 14 Polomolok District Hospital South Cotabato Module 1 For follow-up and evaluation 15 15 Ospital ng Palawan Palawan Module 1 For follow-up and evaluation 16 16 Narra District Hospital Palawan Module 1 For follow-up and evaluation 17 17 Brooke’s Point District Hospital Palawan Module 1 For follow-up and evaluation 18 18 Coron District Hospital Palawan Module 1 For follow-up and evaluation

ICHSP Replication Sites (7 hospitals) 19 1 Mayoyao District Hospital Ifugao Module 1 For follow-up and evaluation 20 2 Besao District Hospital Mountain Module 1 For follow-up and Province evaluation 21 3 Oriental Mindoro Provincial Hospital Oriental Mindoro Module 1 and part of Module 2 Updated the system 22 4 Angel Salazar Memorial General Antique Module 1 For follow-up and Hospital evaluation 23 5 Roxas Memorial Hospital Capiz Module 1 For follow-up and evaluation 24 6 Kapalong District Hospital Davao del Norte Module 1 For follow-up and evaluation 25 7 Democrito Plaza Memorial Hospital Agusan del Sur Module 1 For follow-up and evaluation

Appendix 10 51

Hospital Location Modules Status Installed

NCHFD Pilot Sites (19 hospitals) 26 1 Gov. Celestino Gallares Memorial Bohol Module 1 For upgrade to Hospital Module 2 27 2 Paulino J. Garcia Memorial Research Nueva Ecija Module 1 For follow-up and and Medical Center evaluation 28 3 Davao Medical Center Davao Module 1 Being implemented in mental hospital 29 4 Ilocos Training and Regional Medical La Union Module 2 Awaiting new server Center 30 5 Jose R. Reyes Memorial Medical Manila Module 1 Awaiting new server Center 31 6 Baguio General Hospital Baguio Module 2 For follow-up and evaluation 32 7 Fairview General Hospital Quezon City Module 1 Not operational; awaiting hardware upgrade 33 8 Las Piñas District Hospital Las Piñas Module 1 Not operational; awaiting completion of building construction 34 9 Valenzuela General Hospital Valenzuela Module 1 Updated the system 35 10 Mariano Marcos Memorial Hospital Batac, Ilocos Module 1 For upgrade to Norte Module 2 36 11 Quirino Memorial Medical Center Quezon City Module 1 Module 2 to be implemented 37 12 Mayor Hilarion A. Ramiro Sr. Training Ozamis City Module 1 For upgrade to and Teaching Hospital Module 2 38 13 Northern Mindanao Medical Center Cagayan de Oro Module 1 Updated the system 39 14 Tondo Medical Center Manila Module 1 IHOMP room under construction 40 15 Cagayan Valley Medical Center Tuguegarao Module 1 Stopped using the system 41 16 Cotabato Regional and Medical Cotabato City Module 1 Needs updating of the Center system 42 17 Bicol Medical Center Legazpi, Albay Module 1 For upgrade to Module 2 43 18 Davao Regional Hospital Tagum, Davao Module 1 Updated the system 44 19 San Lazaro Hospital Manila Module 1 Updated the system 45 20 National Kidney and Transplant Quezon City Pulled out HOMIS Institute 46 21 Capitol Medical Center Quezon City Pulled out HOMIS

Future Installations (8 hospitals) 1 Vicente Sotto Memorial Medical Cebu City Center 2 Zamboanga City Medical Center Zamboanga City 3 St. Anthony Mother and Child Cebu City Hospital 4 Eversly Child Sanitarium Mandaue City 5 Western Visayas Medical Center Iloilo City 6 Batangas Regional Hospital Batangas City 7 Veterans Regional Hospital Bayombong, Nueva Vizcaya 8 Tabiana District Hospital Iloilo City Module 1 HOMIS = Hospital Operation Management Information System, ICHSP = Integrated Community Health Services Project, NCHFD = National Center for Health Facilities Development. Source: Department of Health Information Service Report, 2006.