ASIAN DEVELOPMENT BANK PCR:PHI 27010

PROJECT COMPLETION REPORT

ON THE

WOMEN’S HEALTH AND SAFE MOTHERHOOD PROJECT (Loan 1331-PHI)

IN THE

PHILIPPINES

June 2004

CURRENCY EQUIVALENTS

Currency Unit – Peso (P)

At Appraisal At Program Completion (12 Oct 1994) (1 Sep 2003)

P1.00 = $0.04 $0.0182 $1.00 = P25.57 P55.045

ABBREVIATIONS

ADB – Asian Development Bank AKAP – awareness, knowledge, attitudes, and practice BHS – barangay health station BME – benefit monitoring and evaluation DOH – Department of Health FHSIS – field health services information system GIS – geographic information system HBMR – Home-based mother record IDD – iodine deficiency disorder IEC – information, education, and communication LBW – low birth weight LCA – life cycle approach LGU – local government unit LIC – lying-in-clinic MIS – management information system MMR – maternal mortality ratio MWH – maternity waiting home NNM – neonatal mortality PCPD – Philippine Center for Population and Development PMO project management office PNC – prenatal care PPH – postpartum hemorrhage QA – quality assurance RHU – rural health unit RRP – report and recommendation of the President SMP – Safe Motherhood Program TBA – traditional birth attendant TT – tetanus toxoid WHDP – Women’s Health and Development Program WHSMP – Women’s Health and Safe Motherhood Program

NOTE

In this report, "$" refers to US dollars.

CONTENTS Page

BASIC DATA iii

MAP ix

I. PROJECT DESCRIPTION 1

II. EVALUATION OF DESIGN AND IMPLEMENTATION 2

A. Relevance of Design and Formulation 2 B. Project Outputs 3 C. Project Costs 6 D. Disbursements 6 E. Project Schedule 7 F. Implementation Arrangements 7 G. Conditions and Covenants 7 H. Consultant Recruitment and Procurement 8 I. Performance of Consultants, Contractors, and Suppliers 8 J. Performance of Borrower and the Executing Agency 9 K. Performance of the Asian Development Bank 9

III. EVALUATION OF PERFORMANCE 10

A. Relevance 10 B. Efficacy in Achievement of Purpose 10 C. Efficiency in Achievement of Outputs and Purpose 11 D. Preliminary Assessment of Sustainability 11 E. Environmental, Sociocultural, and Other Impacts 12

IV. Overall Assessment and Recommendations 12

A. Overall Assessment 12 B. Lessons Learned 12 C. Recommendations 13

APPENDIXES 1. Summary of Civil Works 15 2. Complete List of Civil Works by Province 16 3. Summary of Project Commodities 18 4. Major Technical Outputs 19 5. Implementation Schedule 20 6. Project Management Structure 21 7. Status of Compliance with Loan Covenants 22 8. Assessment of Overall Project Performance 25

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BASIC DATA

A. Loan Identification

1. Country 2. Loan Number 3. Project Title 4. Borrower 5. Executing Agency 6. Amount of Loan 7. Project Completion Report Number

Philippines 1331-PHI (SF) Women’s Health and Safe Motherhood Project Republic of the Philippines Department of Health SDR 36.80 million PCR:PHI 758

B. Loan Data 1. Appraisal – Date Started – Date Completed

2. Loan Negotiations – Date Started – Date Completed

3. Date of Board Approval

4. Date of Loan Agreement

5. Date of Loan Effectiveness – In Loan Agreement – Actual – Number of Extensions

6. Closing Date – In Loan Agreement – Actual – Number of Extensions 7. Terms of Loan – Interest Rate – Maturity (number of years) – Grace Period (number of years) 8. Terms of Relending (if any) – Interest Rate – Maturity (number of years) – Grace Period (number of years) – Second-Step Borrower

6 June 1994 24 June 1994 10 October 1994 11 October 1994 10 November 1994 20 January 1995 20 April 1995 19 May 1995 1 30 June 2001 16 October 2002 2 1% per annum 35 years 10 years Not applicable Not applicable Not applicable Not applicable

9. Disbursements

a. Dates

Initial Disbursement 22 August 1995

Final Disbursement 16 October 2002

Time Interval 85 months and 18 days

Effective Date 19 May 1995

Original Closing Date 30 June 2001

Time Interval 73 months and 11 days

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b. Amount ($)

Original Allocation Category SDR US$a

Last Revised

Allocation

Amount

Cancelledb

Net Amount

Available

Amount

Disbursed

Undisbursed

Balance

Civil Works 4,780,000 7,012,260 10,067,681 (150,000) 10,067,681 9,370,914 826,142 Equipment 750,000 1,100,250 3,138,586 — 3,138,586 2,299,791 923,846 Medical Supplies 17,105,000 25,093,035 9,834,642 (12,145,210) 9,834,642 8,742,034 1,291,934 Consulting Services 310,000 454,770 2,842,939 — 2,842,939 2,914,500 (52,043) Local Expenditures (i) Civil Works (ii) Equipment (iii) Medical Supplies (iv) IEC Materials and Activities (v) Consulting Services (vi) Project Management Office Support (vii) Unallocated

520,000 340,000 880,000

4,290,000

1,660,000 660,000

1,180,000

762,840 498,780

1,290,960 6,293,430

2,435,220

968,220

1,731,060

― — —

4,686,018

— 886,655

—

― — —

(1,104,790)

— —

—

― — —

4,686,018

— 886,655

—

― — —

4,322,242

— 831,452

—

― — —

477,697

— 69,446

—

Service Charge during Construction

1,165,000 1,709,055 626,898 (850,000) 626,898 589,787 51,285

Unallocated 3,160,000 4,635,720 677,331 (1,250,000) 677,331 — 751,013 Total 36,800,000 53,985,600 32,760,750 (15,500,000) 32,760,750 29,070,720 4,339,320 — = not available. a As of appraisal, SDR rate = $1.467. b 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 26 April 1999, SDR rate = $0.7354, while during the second partial cancellation of the loan on 17 May 2001, SDR rate = $0.7937. The SDR rate during the final cancellation on 16 October 2002 was $0.7382.

10. Local Costs (Financed) - Amount ($ million) $9.65 million - Percentage of Local Cost 68.98% - Percentage of Total Cost 28.89% C. Project Data

1. Project Cost ($ million)

Appraisal Estimate Actual Cost

Amount % Amount %

Foreign Exchange Cost 40.02 59.3 19.41 58.1 Local Currency Cost 27.48 40.7 13.99 41.9

Total 67.50 100.0 33.40 100.0

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2. Financing Plan ($ million)

Appraisal Estimate Actual Cost Foreign

Exchange Local

CurrencyTotal Cost

% Foreign Exchange

Local Currency

Total Cost

%

Implementation Costs

Borrower-Financed 13.50 13.50 20 4.34 4.34 13

Appraisal Estimate Actual Amount % Amount %

ADB-Financed 40.02 13.98 54.00 80 19.41 9.65 29.06 87

Total 40.02a 27.48 67.50 100 19.41 13.99 33.40 100

IDC Costs

Borrower-Financed — — — — — — — —

ADB-Financed 1.71 1.71 100 0.59 0.59 100

Total 1.71 1.71 100 0.59 0.59 100 — = not available. ADB = Asian Development Bank, IDC = interest during construction. a Inclusive of taxes and duties, physical and price contingencies, and service charge equivalent to $11.23 million. 3. Cost Breakdown by Project Component ($ million)

Appraisal Estimate Actual Component Foreign

ExchangeLocal

CurrencyTotal Cost

Foreign Exchange

Local Currency

Total Cost

Maternal Care

Civil Works 7.02 2.71 9.73 8.19 3.31 11.50 Equipment and Supplies 26.20 6.67 32.87 10.63 1.08 11.71 Training 0.00 1.78 1.78 0.00 0.00 0.00 Consultant Services 0.45 2.70 3.15 0.00 3.27 3.27 Operation and Maintenance 0.00 1.34 1.34 0.00 0.00 —

Institutional Development

Information, Education, and Communication

0.00 6.30 6.30 0.00 4.95 4.95

Project Management 0.00 1.10 1.10 0.00 1.38 1.38

Total Base Cost 33.67 22.60 56.27 18.82 13.99 32.81 Taxes and Duties 0.00 1.51 1.51 0.00 0.00 0.00 Contingencies 4.64 3.37 8.01 0.00 0.00 0.00 Service Charge During

Implementation 1.71 0.00 1.71 0.59 0.00 0.59

Total Project Cost 40.02 27.48 67.50 19.41 13.99 33.40

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4. Project Schedule

Item Appraisal Estimate Actual

Date of Contract with Consultant Project Management Specialist (individual) Philippine Center for Population Development (firm)

July 1995 July 1995

1 September 1995

24 April 1996 Civil Works Contracta First Contract Awarded July 1995 6 October 1997 Last Contract Completed December 1999 December 2001 Equipment First Procurement Awarded January 1997 18 May 1998 Last Procurement Completed December 1999 Nov 2001

Item

Appraisal Estimate

Actual

Supplies

First Procurement Awarded July 1995 10 September 1996 Last Procurement Completed December 2000 31 August 2002 Other Milestones Partial Cancellation First - $10.0 million Second - $ 5.5 million

26 April 1999 17 May 2001

Loan Closing Date Extension First Second

31 December 2001

30 June 2002

a Fourteen civil works contracts covering 523 health facilities were awarded during project implementation.

5. Project Performance Report Ratings Ratings

Implementation Period Development Objectives

Implementation Progress

Project Administration Committee (PAC) Notesa 1. From 1 June 1995 to 31 December 1995 — AAA 2. From 1 January 1996 to 31 December 1996 — AAA 3. From 1 January 1997 to 31 December 2001 — AAA Project Performance Report (PPR) 4. From 1 November 1998 to 31 December 1998 U U 5. From 1 January 1999 to 31 January 1999 U U 6. From 1 February 1999 to 31 October 1999 S U 7. From 1 November 1999 to 31 December 1999 S S 8. From 1 January 2000 to 31 December 2000 S S 9. From 1 January 2001 to 31 January 2001 S HS 10. From 1 February 2001 to 28 February 2001 S S 11. From 1 March 2001 to 31 May 2001 S HS 12. From 1 June 2001 to 31 December 2001 S S 13. From 31 January 2002 to 31 December 2002 S S

— = not applicable. a Rating used in project administration committee notes: first letter – rating for implementation delay; second letter –

rating for cost overrun; third letter – compliance with covenants (A = Satisfactory; B = Partly Satisfactory; C = Unsatisfactory).

Rating used in PPR: HS = Highly Satisfactory; S = Satisfactory; U = Unsatisfactory.

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D. Data on Asian Development Bank Missions

Name of Mission

Dates

No. of Persons

No. of Person-Days

Specialization of Membersa

Fact-Finding 7 to 23 Feb 94 5 85 a, b, g Pre-Appraisalb 6 to 24 Jun 94 1 19 a Inception 22 to 27 Jun 94 2 12 a, d Review-1 19 to 26 Feb 96 1 8 d Review-2 24 Sep to 4 Oct 96 2 24 c, d Review-3 3 to 12 Mar 97 1 10 c

Name of Mission

Dates

No. of

Persons

No. of

Person-Days

Review-4 16 to 23 Sep 97 1 8 c Review-5 18 to 29 May 1998 2 16 c, j Midterm Review 25 Nov to 11 Dec 98 4 41 c, g, h Special Loan Administration-1 11 to 23 Mar 99 1 13 c Special Loan Administration-2 2 to 13 Aug 99 2 30 c, h Disbursement 26 Aug 99 2 2 e, f Special Loan Administration-3 4 to 5 Nov 99 1 2 c Review-6 13 to 21 Mar 00 2 18 a, c Review-7 27 Sep to 11 Oct 00 2 30 a, h Review-8 19 to 30 Apr 01 1 8 h Review-9 8 to 16 Oct 01 2 18 b, h Review -10 12 to 15 Feb 02 2 8 b, i

Subtotal During Project Implementation

28 248

Project Completion Reviewc 18 Aug to 7 Sep 03 4 82 b, g, i

a a = health specialist, b = senior project specialist, c = project specialist, d = project economist, e = control officer, f = disbursement analyst, g = consultant, h = associate project analyst, i = assistant project analyst, j = general services staff.

b Mission was upgraded from pre-appraisal to appraisal on 8 July 1994. c Mission comprised H.Y. Zhai, senior project specialist/mission leader; M.T.R. Valenzuela, assistant project analyst;

M.A. Belsey, evaluation specialist/staff consultant; and E. Gonzaga, health specialist/staff consultant.

I. PROJECT DESCRIPTION

1. When the Government of the Philippines requested the Asian Development Bank’s (ADB) support for a project on women’s health and safe motherhood in 1992, the health status of women in the Philippines was poor. The maternal mortality ratio (MMR)1 was estimated at 209 per 100,000 live births.2 An estimated 65% of pregnant women and 52% of lactating mothers were suffering from iron deficiency anemia. The leading causes of maternal mortality at that time were post-partum hemorrhage and hypertensive complications of pregnancy, conditions that are related to inadequate prenatal care, poor obstetric care, inadequate management of obstetric emergencies, and weak referral systems.3

2. The project goals were to improve the health status of women—in particular those of reproductive age—and to support the country’s long-term goal of reducing fertility, female morbidity, and maternal mortality. The project aimed to improve maternal care services, to improve the referral system, and to strengthen the national safe motherhood program. The Department of Health (DOH) was the executing agency.

3. The project had three components: (i) maternal care; (ii) information, education, and communication (IEC); and (iii) project management. Maternal care support focused on improving the provision of maternal care services and the referral systems in 40 provinces, as well as strengthening the national safe motherhood programs. The IEC component sought to develop and utilize an integrated communication strategy to (i) make women more conscious of their health needs and (ii) encourage them to seek health information and health services during and after pregnancy. The project management component financed the establishment and operation of a project management office (PMO).

4. The five quantifiable objectives for the maternal care services component were to (i) reduce the MMR by 25%, (ii) reduce the incidence of low birth weight by 10%, (iii) increase prenatal care coverage to 100%; (iv) increase the rate of deliveries supervised by trained attendants to 100%, and (v) provide referral services for all high-risk pregnancies and obstetric emergencies. The project supported three national safe motherhood program objectives to (i) decrease by 50% the prevalence of iron deficiency anemia and iodine deficiency disorders (IDD) in women of reproductive age, (ii) decrease by 50% the prevalence of vitamin A deficiency among children under 1 year of age, and (iii) provide tetanus toxoid (TT) vaccinations to all pregnant women.

5. The project was implemented against the background of devolution of responsibility for public health care. As devolution unfolded, care delivery fragmented and quality of local health care services deteriorated. Health care referral systems in the poorest, most inaccessible communities became dysfunctional.

1 The number of women dying of childbirth per 100,000 live births per year. 2 In comparison with Thailand (140), Viet Nam (140), Malaysia (59) and PRC (49). 3 ADB. 1994. Report and Recommendation of the President to the Board of Directors on a Proposed Loan to the

Republic of the Philippines for the Women’s Health and Safe Motherhood Project. Manila.

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II. EVALUATION OF DESIGN AND IMPLEMENTATION

A. Relevance of Design and Formulation

6. The government endorsed the Plan of Action of the International Conference on Population and Development in 1994, giving higher priority to women’s health. This commitment stemmed from a recognition of (i) women’s health as a critical element of social and economic development, (ii) the lopsided focus of maternal and child health services on the child to the neglect of the mother, and (iii) the persistent high levels of maternal mortality and morbidity that can only be reduced if women have access to high-quality health services. The DOH prepared a national Women’s Health and Safe Motherhood Program (WHSMP), which defined the women’s essential health needs and identified the broad strategies to meet them. National women’s groups strongly supported the WHSMP. It was fully consistent with ADB’s policies for the health sector in the Philippines. The project was a key element of the implementation of the WHSMP.4

7. The project preparation began in 1993 when implementation of health sector devolution just started. Neither DOH nor ADB fully anticipated the impact that devolution would have on the project in terms of health sector management structure, functions, and financing of the health services. Particularly dramatic was the loss of coordination and health information flow between central, provincial, and municipal governments. In hindsight, the project’s geographical coverage of 40 provinces was overly ambitious.

8. Prior to devolution, hardly any budget was allocated for renovating or repairing government-operated hospitals and other health facilities. After devolution, the poor condition of health facilities was further aggravated by local government units’ (LGU) inability to provide funds for repairing and maintaining health facilities and equipment. The project provided a timely stimulus for improvements of physical facilities, equipment, and supplies for maternal health, as well as essential and emergency obstetric care. The project’s IEC orientation for health workers and LGU executives promoted sensitivity regarding women’s privacy and dignity. The project was particularly appealing to and clearly mobilized political commitment of LGU executives as it provided resources and technical support for improving women’s health during the difficult initial period of devolution.

9. The project’s technical design accurately reflected the strategy to reduce the cause-specific maternal mortality and morbidity rates by promoting (i) a system for identifying risk (use of home-based mother record and IEC), (ii) an awareness of the signs of obstetric emergency (IEC), and (iii) a system of timely transport (community-based referral) to facilities capable of providing appropriate clinical management and emergency care based on upgraded capacities of health facilities.

10. The project appropriately addressed key issues in improving provision of women’s health services. It focused on all levels of referral linkages within the maternal health systems and emphasized IEC and advocacy. Advocacy focused on increasing awareness of community health workers, pregnant women, and their families on the need for women’s health services and on motivating women to use them. It contributed to improving the quality of the health facilities, thus making them more acceptable to women.

4 Implementation of WHSMP was jointly funded, on a parallel basis, by ADB, Australian Agency for International

Development, European Union, Kreditanstalt für Wideraufbau of Germany, and World Bank.

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11. Project formulation could have been improved in terms of setting better quantitative targets. For example, the target of a 25% reduction of MMR was inappropriate for an implementation period of 5 years as reductions in the MMR are not linear, and visible improvement takes several years while (i) essential elements and conditions are put in place, (ii) women and their families become aware of the services and perceive them as acceptable, and (iii) women and their families understand maternal risk and the need to seek appropriate and timely care.

12. The PMO was an ad hoc structure created to ensure a functional reinforcement of management and coordination of project activities by authorities at both national and community levels. The inherent implementation risk of this type of structure was that it lacked an institutional anchor within DOH that would have ensured timely implementation.

B. Project Outputs

13. In addition to upgrading health facilities—including innovations such as maternity waiting homes (MWHs) and lying-in-clinics (LICs)—the project supported three critical capacity-building elements: (i) an IEC component based on well-established methodologies and approaches; (ii) a life cycle approach (LCA) in involving the community in managing reproductive health; and (iii) quality assurance as a problem-solving management system for maternal health services. Physical targets to improve the referral system were achieved, and capacity-building objectives were largely achieved. Appendixes 1-4 summarize the project’s expected and achieved quantitative outputs.

1. Maternal Care: Strengthening the Referral System

14. Under the project, 36 provincial hospitals, 56 district hospitals, 163 rural health units (RHUs), and 270 barangay (village) health stations (BHSs) were upgraded or built. In addition, 10 LICs and 15 MWHs were constructed. LICs and MWHs were constructed in selected project sites as a test of innovative approaches to improve safe motherhood and effective referral. During implementation, adjustments were made to the number of health facilities in response to emerging needs. Civil works encountered considerable delays because of (i) delays in hiring consultants, resulting in a 1-year delay in civil works design; (ii) poor coordination among engineers at the regions, provinces, and municipalities in reviewing and approving schematic drawings, architectural plans, and engineering designs; (iii) slow hiring of contractors at DOH regional health offices; and (iv) corrections of technical flaws in the architectural and engineering designs.

15. The delays in civil works in turn delayed the provision of equipment and supplies. LICs and MWHs were not completed until late in implementation, leaving insufficient time for evaluating their effectiveness, efficiency, or acceptability.

16. Equipment and medical supplies were provided to selected health facilities as an integral part of the effort to strengthening the referral system. Under the project, 88 anesthesia machines, 270 gynecological examination couches, 92 blood bank refrigerators, 48 laboratory refrigerators, and various furniture and fixtures were procured. Each recipient of the equipment was provided with guidelines for inspection, acceptance, utilization, and maintenance.

17. The supplies for treating obstetrical emergencies were provided for use in provincial hospitals, district hospitals, RHUs, and BHSs. Obstetrical supplies to promote safe deliveries at home were also provided. These supplies were part of a special intervention to reduce maternal

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mortality and morbidity arising from post-partum infection. Guidelines were prepared on the acceptance, distribution, and utilization of supplies to ensure proper use. The roles and responsibilities of the health providers who administer the supplies were also clarified.

18. Seven packages of supplies were procured for obstetrical emergencies, reproductive health, and safe home delivery. The total cost was estimated at $4.25 million. Many of these supplies were only procured and distributed near the end of implementation.

19. Major problems encountered during procurement were (i) difficulty in preparing and finalizing specifications and (ii) lengthy procurement processes within DOH, particularly evaluation of bids, resolutions to award contracts, and contract reviews. To overcome the lengthy procurement process, ADB agreed that DOH entered into a memorandum of understanding with the United Nations Children’s Fund (UNICEF) to accelerate the procurement of various goods. However, UNICEF procurement also took longer than expected.

20. The project supported a pilot test of LCA to managing health service delivery at the community level. The pilot focused on (i) identifying clients who are currently or potentially most at risk; (ii) developing continuous care relationships between clients and service providers; and (iii) integrating delivery of service interventions. The results of the pilot confirmed LCA as an innovative approach to improving women’s health and promoting safe motherhood. The approach responds to the health needs not only of women but of the whole community. The pilot tests have established community health systems that may be adopted in other communities. DOH recognized the benefit of the LCA and is considering mainstreaming the approach into the health care delivery system.

2. Maternal Care: Strengthening the National Safe Motherhood Program (SMP)

21. The project supported strengthening the national SMP by providing micronutrient supplementation such as vitamin A capsules, iodine capsules, and ferrous sulfate (iron) tablets. This initiative was intended to help eliminate vitamin A deficiency, iron deficiency anemia, and IDD among pregnant and lactating women. Micronutrients worth of $3.75 million were procured and distributed. Again, procurement and distribution of micronutrients were completed later in the project.

22. Home-based mother records (HBMR) were used as an innovative approach to reducing maternal mortality and morbidity. HBMR was given to pregnant women when they first sought prenatal care. The same record would be brought back to the health facility for every subsequent prenatal visit. Over 5 million HBMRs were printed— in English and Filipino, as well as dialects such as Ilonggo, Visaya, and Ilocano—and distributed in the project provinces.

23. The quality assurance subcomponent was an initiative to support quality maternal care services at hospital and primary health care levels. A quality assurance manual was developed to facilitate learning and to serve as the operations manual during the pilot test. Quality assurance teams were organized and mobilized in each pilot health facility to implement, monitor, and evaluate the quality assurance process. Reinforcement activities were also undertaken to ensure that the basic principles, objectives, and plans were implemented. An assessment and evaluation of the effectiveness of the quality assurance techniques, methods, and strategies was also undertaken.

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24. The quality assurance subcomponent was successfully pilot-tested. It became a major part of the DOH’s Strategic Framework of the Sentrong Sigla Movement, a national quality assurance program for public health facilities.

25. Most of the expected outputs in support of the national SMP were achieved, albeit late in implementation. Although the HBMR and the safe home delivery kits were successfully distributed, the HBMR was not always accompanied by locally adapted training in its use, and the latter was not supported by resupply and/or supervision.

26. Two very important additions to the SMP during implementation were the materials, manuals, and guidelines for maternal death review, and the development of a maternal geographic information system (GIS) database. With further development, adaptation, and training in their application, both additions have the potential to contribute to achieving project goals in the future.

3. Information, Education, and Communication

27. The IEC component was a priority initiative to change women’s health-seeking behavior through a comprehensive national communication campaign to promote women’s health and women’s rights. Strategies and interventions were developed to make IEC more responsive to the national women’s health program and to fully realize its potential as a cost-effective approach to improving women’s health. A distinctive feature of the IEC activities was an effort to articulate gender perspectives. Social marketing activities were also intended to be tied into the IEC component to avoid gross overlaps and provide better integration with the empowerment strategy.

28. The IEC component had four strategies: (i) research, (ii) national advocacy, (iii) creative development of IEC materials, and (iv) reproduction and adaptation of these materials to the local cultural setting and needs. Research determined the levels of awareness, knowledge, attitudes, and practices (AKAP) on women’s health. National advocacy focused on raising the consciousness of LGU executives, civic groups, and communities on women’s concerns. Creative development involved conceptualizing and developing integrated, cost-effective, and gender-sensitive communication messages. The prototype messages were then translated into English and local dialects and distributed in the project provinces.

29. Other IEC activities included the development of a safe motherhood website, a midwives’ manual on maternal care, an obstetrical emergency calendar, and a monthly ribbon advocacy activity.5 The social marketing initiative concentrated on marketing the use of MWHs, LICs, safe home delivery kits, and micronutrient supplements.

30. Most IEC activities had generated some research work, but the quality of this work varied significantly. Some write-ups were incomplete and successful IEC processes were not fully documented. There were few links between advocacy and other outputs, like quality assurance, IEC creative campaigns, social marketing, and gender sensitivity training. More significantly, the human and technical resources were not available to integrate these outputs and the existing survey data to establish a more targeted community-level interpersonal communications strategy.

5 The campaign entailed focusing one women’s health issue every month and was symbolized by a colored ribbon to

be worn by health personnel.

6

31. IEC implementation was significantly delayed by consultants’ poor quality of work, termination of the consultant’s service contract, and rehiring of new consultants. Most IEC activities were completed just before the loan closing date.

4. Project Management

32. The PMO was created to ensure that the project was managed and implemented in an efficient and timely manner. It was tasked to coordinate planning and implementation of project activities and to provide technical assistance, training, information, logistical, and financial support to implementation. It carried out its tasks through a network of DOH staff representing concerned DOH work units, consultants, and contractual staff.

33. Initially, the PMO lacked authority to fully carry out its functions because it lacked support from DOH leadership and coordination was poor between the different technical programs/services. These factors were aggravated by the challenges of coordination and communications in a newly devolved health care system. DOH instituted a number of changes in response to recommendations from the midterm review. One notable measure was the establishment of a Women’s Health and Development Program (WHDP) unit within the DOH. It was given a full mandate to plan and coordinate all activities related to women’s health. This unit then became the PMO’s institutional base to carry out day-to-day administration of the project and monitoring of project progress and performance. Project implementation and performance strengthened markedly.

C. Project Costs

34. Project cost estimated at appraisal was $54 million equivalent, inclusive of contingencies and service charges during construction. Total actual project cost amounted to $29 million equivalent. The decrease in project cost was primarily due to the depreciation of the Philippine peso from about P25.57 to $1.00 at appraisal to about P55 to $1.00 at the close of the project. As a result, the actual local costs of goods and services fell substantially compared to those anticipated at appraisal.6 The quantities of micronutrients were reduced to reflect actual needs, and DOH to procure the tetanus toxoid vaccine from its own budget, further lowering actual project cost. A summary of the project’s appraisal and actual financing plans and costs is provided in the Basic Data section of this report.

D. Disbursements

35. The first disbursement was made on 22 August 1995 and the final disbursement on 16 October 2002. Disbursement was slow in the first 3 years of project implementation (9.2% had been disbursed by the midterm review in November 1998 although 60% of the project life had elapsed). Disbursement improved markedly since 2000 because project activities increased. Of the $32.76 million net amount available for disbursement after the last revised allocation, $4.30 million remained undisbursed and were canceled when the loan account was closed. Most of the loan proceeds were disbursed through the special account. The imprest account was particularly effective for activities implemented at the regional, provincial, and district levels. Direct payment was adopted for major import contracts at the central level.

6 A total of $15.50 million was cancelled in two installments: one in April 1999 and one in May 2001.

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E. Project Schedule

36. ADB approved the project on 10 November 1994. The loan became effective on 19 May 1995, one month later than the target date. The project encountered considerable and repeated delays in civil works and in the procurement of medical equipment and supplies. Implementation of IEC activities was also significantly delayed (Appendix 5). ADB twice approved the government’s requests to extend loan closing date by a total of 12 months (30 June 2001 to 31 December 2001 and 31 December 2001 to 30 June 2002) to complete planned activities. Loan accounts were kept open until 16 October 2002 to accommodate submission and processing of eligible withdrawal applications.

F. Implementation Arrangements

37. In compliance with the loan agreement, a project steering committee was created at the national level to provide overall policy guidance for project implementation. The DOH secretary served as project director and an assistant secretary was the project coordinator. A PMO was set up to manage the day-to-day administration of the project and to monitor its performance and evaluate its results. The PMO was staffed by consultants and contractual project staff and supported by a network of anchor personnel representing concerned units within DOH. The DOH regional offices provided assistance to LGUs and undertook implementation of region-wide activities. DOH and the LGUs entered into project implementation agreements, and project resources were allocated to participating LGUs on the basis of need and under variable cost-sharing arrangements (Appendix 6).

38. Although high-level involvement could be considered an advantage in ensuring political commitment and policy leadership, the project spanned three presidents and six DOH secretaries with differing perspectives, commitments, and involvement in project implementation. There were also competing demands and unclear lines of responsibility and authority among concerned DOH units.

39. After the midterm review, the newly structured DOH leadership made serious efforts to salvage the project given the largely dysfunctional pre-midterm review phase. DOH Administrative Order No. 26-A, s. 1999 set out the reforms instituted to better respond to the project’s needs. Among the administrative changes made was the creation of a WHDP unit within DOH.7 The WHDP was empowered to plan and coordinate all women’s health-related activities and its manager was designated as project coordinator. The PMO was then anchored with the WHDP unit. Two undersecretaries were designated project directors, one for administration and the other for planning and programming. Contracts with several poorly performing contracting firms and consultants were terminated. New consultant teams were contracted to continue the project. The adjusted arrangements after the midterm review markedly improved project implementation. The post-midterm review phase represented a complete turnaround for project performance.

G. Conditions and Covenants

40. The Philippine government complied with nearly all of the loan covenants set out at appraisal (Appendix 7). Separate accounts were maintained and audited for the loan and

7 ADB. 1999. Administrative Order No. 26-A, s. Administrative Orders. Manila. Available at LNADBG1.

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government counterpart funds. The covenant on civil works and use of equipment8 was complied with, but the level of maintenance was minimal. A weakness in the formulation of the covenant was related to benefit monitoring and evaluation (BME). The covenant should have emphasized the need for collection of data at inception followed by regular data collection during implementation to effectively evaluate project benefits and achievements. BME had only been partially completed at project close.

H. Consultant Recruitment and Procurement

41. The project used 14 person-months of international consulting services and 387 person-months of domestic consulting services. DOH internationally recruited a consulting firm—the Philippine Center for Population and Development (PCPD)—to provide technical support according to ADB’s Guidelines on the Use of Consultants. However, recruitment took 1 year from shortlisting to final notice to proceed. The delay was primarily due to repeated reviews of the contract documents by DOH concerned offices, disputes over the provision of taxes, and concerns over DOH’s authority to enter into a multiple-year contract without full budget appropriations. The consultant finally commenced work in May 1996.

42. DOH terminated the services of PCPD’s civil works team in February 1999 for poor performance. In May 1999, the entire PCPD contract was terminated because the quality of outputs from most of its experts was unacceptable. DOH hired individual consultants, with ADB endorsement, to replace PCPD. Individual consultants were engaged according to procedures acceptable to ADB.

43. Goods were procured according to ADB’s Guidelines on Procurement, following the mode of procurement prescribed in the loan documents. ADB approved DOH’s request to engage UNICEF as its procurement agent for some micronutrients and medical supplies in an effort to overcome DOH’s lengthy procurement process (para. 22).

I. Performance of Consultants, Contractors, and Suppliers

44. The performance of PCPD consultants fell short of expectations. Most of their outputs were inappropriate to DOH’s health reforms. Overall performance of the civil works subcontractors was poor. PCPD clearly lacked the technical expertise and experience to judge the capacity or manage the performance of its civil works team.

45. PCPD’s evaluation consultant—engaged to develop the baseline survey and BME program—was a well-qualified economist with wide experience in population policy and health economics. However, there was a large discrepancy between the consultant’s qualifications and outputs. The consultant for quality assurance was initially recruited by PCPD. When PCPD’s contract was cancelled, DOH recruited the consultant directly. Despite the delays, the quality assurance activities were a high point in implementation. The quality assurance models and tools were well developed and successfully tested and documented. PCPD was initially involved and satisfactorily produced the design and terms of reference for the two LCA pilot studies. PCPD’s performance in the first and second pilot studies was satisfactory and provided useful information and experience for future community-based health development work.

8 Loan Agreement Article IV, Section 4.09 which states that “the Borrower shall ensure that the project facilities are

operated, maintained, and repaired in accordance with sound administrative, financial, engineering, environmental, health care, and maintenance and operational practices.”

9

46. PCPD undertook the initial AKAP studies from which the IEC strategies and messages were developed. After PCPD’s contract was terminated, several nongovernment organizations were contracted for different elements of the revised IEC strategies. Despite delays, they satisfactorily undertook and completed the work, although at times on a more limited basis than originally envisaged. PCPD satisfactorily undertook an initial AKAP study that served as a starting point for the advocacy element of the revised IEC plan in 2000. The subsequent consultant—Woman Health Philippines Inc., a known pioneer in women’s advocacy—then developed an implementation strategy and carried out the advocacy activities.

47. Other individual consultants that DOH hired performed satisfactorily and were able to complete their assignments.

48. The performance of a few contractors was unsatisfactory. Oversight by DOH was insufficient in cases when contractors were unable to meet the product specifications or comply with delivery requirements.

J. Performance of the Borrower and the Executing Agency

49. The assessment of DOH’s performance can be split into two phases: before and after the midterm review. By most indicators, performance before the midterm review was less than satisfactory. The apparent lack of leadership, commitment, and involvement, as well as the absence of an institutional anchor for the PMO, contributed to significant delays in mapping out effective implementation strategies, recruiting consultants, and procuring both technical services and goods in the first 3 years of implementation.

50. DOH’s performance in implementation greatly improved after the midterm review. The institutional and managerial changes introduced by DOH provided continuity of managerial and technical leadership and resulted in an appropriate division of responsibilities. As a result, implementation accelerated and quality of outputs improved. Post-midterm review implementation was much closer to the planned schedule of activities—albeit realistically scaled back—and was productive in terms of advancing the project’s goals, objectives, and approaches.

K. Performance of the Asian Development Bank

51. The project was reviewed twice a year during implementation. ADB maintained a good relationship with DOH throughout implementation. ADB made serious efforts in working with DOH to address implementation problems and was responsive to needs that arose during implementation. However, ADB’s efforts to ensure proper implementation of the BME program were less successful. The overall performance of ADB is rated satisfactory.

52. Some weaknesses in the preparation of the project were noted. An epidemiologically oriented health systems management specialist would have been a beneficial addition to the project preparatory team, particularly in recognition of DOH’s weaknesses in field health services information systems (FHSIS). The loan document could have included appropriate specifications of project-supported equipment and contents of the emergency and obstetric supplies. Broader, more in-depth involvement of stakeholders during project design may have resulted in earlier recognition of the extensive technical and administrative difficulties in managing the civil works and procurement, given the highly ambitious project coverage.

10

III. EVALUATION OF PERFORMANCE

A. Relevance

53. The project supported the government’s national WHSMP and was a key element in its implementation. The project’s thrust was fully consistent with ADB policies for the Philippines’ health sector. Project design accurately reflected the strategy to reduce cause-specific maternal mortality and morbidity rates and provided much-needed support to achieving the objectives of the WHSMP. The project’s interventions to improve the provision of maternal care services and the referral system, and to strengthen the national safe motherhood program, proved critical and timely in the context of devolution.

54. The project provided a solid foundation for improving women’s health. The achievements of the project could be improved by further integrating (i) the quality assurance as locally relevant management tools; (ii) LCA as a community-based health management strategy; (iii) maternal GIS, together with reinforced FHSIS and the maternal death reviews as a management information system (MIS); and (iv) linkages between advocacy, IEC participatory research, social marketing, and interpersonal communications.

55. After extensive delays, the midterm review put the project back on track. Efforts made to adjust implementation arrangements, and mainstreaming the project’s interventions into DOH regular work programs, proved fruitful to advancing the project’s objectives and facilitating the project’s sustainability within DOH. The project is rated highly relevant.

B. Efficacy in Achievement of Purpose

56. The project clearly achieved its immediate objectives of improving maternal care services, improving the referral system, and strengthening the national SMP. All project facilities that the project completion report mission visited were operational. Staffing was generally adequate and essential supplies were available.

57. The capacities of project-improved health facilities have been greatly enhanced to provide better maternal care services. These health facilities have become the critical referral network within each project province. The micronutrients procured and distributed under the project provided direct input and contributed to the national SMP. The project has successfully pilot tested and established the essential groundwork for achieving specific objectives to improve women’s health and safe motherhood. For example, several very useful MIS tools and methods were established or adapted on a pilot basis, including the women’s health website, the GIS for maternal health, the maternal death review, and the barangay-based household data board. The IEC initiatives, to a large measure, raised consciousness of women’s health concerns among women, as well as LGU executives, civic groups, and communities.

58. The 25% reduction of MMR and other quantifiable project objectives can only be considered aspirations since they do not appear to be derived from nationally relevant epidemiological, behavioral, or health system analyses as to what could be realistically achieved with project inputs in the project timeframe.9

9 A decline in MMR is rarely linear, but is curvilinear with a lag phase as the required inputs to achieve change are

put in place. For a 5-year project while the outputs of hospital deliveries and PNC may increase rapidly, there is a lag in the decline of MMR since those at greatest risk are least likely to use the services.

11

59. An assessment of efficacy is difficult because DOH was unable to implement a full BME program. A more successful BME program would have facilitated the improvement of the FHSIS and provided a better base for benefits evaluation. The project produced tangible positive effects, despite the fact that many necessary outputs were not realized until very late in implementation and there was little time for them to have affected the MMR or other quantitative indicators. The Project is rated efficacious.

C. Efficiency in Achievement of Outputs and Purpose

60. The project’s capacity-building outputs—including the number of improved health facilities—were modified to respond to emerging needs. The quantities of micronutrients provided were adjusted based on actual yearly demand. The project was completed 12 months after the original loan closing date because of delays encountered during the first 3 years of implementation.

61. Despite delays, most of the project’s quantitative and qualitative targets were achieved. Major achievements in the maternal care component included (i) 550 upgraded and better equipped health facilities at four different service levels; (ii) a well developed LCA, for community-based health management; (iii) high quality outputs on quality assurance models, assessment tools, and implementation strategies; (iv) maternal GIS and maternal death review initiatives; (v) provision of HBMR, emergency obstetric kits, and safe home delivery kits; and (vi) much needed supplies of micronutrients. A wealth of creative IEC and social marketing materials were developed, distributed, and used by the target beneficiaries.

62. Health workers and women using the health care services gave positive feedback about facility upgrades despite the delays in civil works. Anecdotal evidence showed that attendance for the different maternal health services, particularly at BHS level, increased after the upgrades. The attending women expressed satisfaction over improved facilities that gave greater respect for privacy. Gender sensitivity was also reinforced through the IEC campaign, LGU advocacy, and health worker training.

63. The most significant factors causing the less-than-satisfactory project performance and negative impact before the midterm review were the absence of visible and forceful DOH leadership and the lack of an institutional base within DOH. These problems were rectified at the time of the midterm review.

64. It is too early to assess the project’s internal or external efficiency as there is extensive time lag in declines of MMR and other indicators. The project is rated less efficient given inefficient project management in the first 4 years and late achievement of positive effects.

D. Preliminary Assessment of Sustainability

65. Sustainability of project impacts at the central level depends largely on mobilizing adequate national resources to continue the initiatives pilot-tested under the project. DOH began a consultative process in mid-2000 to develop strategies and activities for sustaining the project outputs and initiatives. Particular emphasis was placed on obtaining commitments from the LGUs to continue to provide annual adequate budget for operations and maintenance of health facilities. To promote the SMP, DOH issued Administrative Order No. 79, s.2000, which stipulates that the gender and development budget (estimated at 5% of the total DOH budget) shall be used for safe motherhood implementation at all levels. DOH regional offices are also

12

expected to allocate budget for technical and financial assistance to LGUs to support women’s health and safe motherhood.

66. Secondly, sustainability requires further strengthening of the institutional capacities of DOH, its regional offices, and the provincial health offices for program development, implementation, and evaluation. Addressing these concerns is an integral part of ongoing DOH health sector reforms.

67. Thirdly, sustainability depends on LGUs’ ability to mobilize resources and use the methodologies and management tools developed under the project. LGUs have developed several mechanisms to establish and maintain systems for cost recovery—such as retention of hospital income and trust funds—which would likely help sustain project achievements. However, managing the health system is a relatively new mandate for LGUs, and they essentially lack a managerial approach to public health in general and to maternal health in particular. They also face tough decisions in allocating adequate annual budget for health given limited financial resources. The sustainability of the project is rated as likely.

E. Environmental, Sociocultural, and Other Impacts

68. The environmental impact of the physical infrastructure funded by the project was negligible. Poverty was identified as an underlying factor in women’s health, but there were no activities specifically directed at poverty alleviation aside from the fact that the project was directed at poor areas. The project had a significant impact on the LGUs and LGU executives concerned in terms of helping them assume the devolved mandate of managing health services, and overcoming the uncertainties associated with the evolving devolution. Gender sensitivity training has been useful and efficient in mobilizing support from local authorities, many of which not only welcomed the material support of the project but also made commitments regarding the use of local resources.

IV. OVERALL ASSESSMENT AND RECOMMENDATIONS

A. Overall Assessment

69. The project’s overall assessment is successful (Appendix 8). This is despite a very slow and difficult start of the project. Remedial measures taken by ADB and DOH after midterm review were able to effectively resolve the problems, which facilitated project implementation in the subsequent phase. In broad terms, the project was implemented as conceived and achieved most of its physical targets. The project succeeded in reducing MMR, established a much improved referral system in 40 provinces, and provided critical inputs to carry forward the country’s national safe motherhood program. The project’s qualitative benefits, e.g., a community-based LCA, quality assurance systems, maternal death review, maternal GIS, IEC strategies, themes and messages, had only began to yield results towards the end of the project but they have created the critical building blocks for further improvements by DOH.

B. Lessons Learned

70. The following key lessons were learned from the project:

(i) Preparation of a complex and large-scale project, particularly in the context of devolution of health services and associated institutional reforms should entail more in-depth analysis of the potential risks affecting implementation.

13

(ii) Project coverage extending to one half of the country was too ambitious. This resulted in thin spreading of resources and capacities. Reduced project coverage, coupled with more extensive and comprehensive support within a project province, could have created the critical mass of health facilities for a better functioning, sustainable referral system.

(iii) Top management support is critical to implementation. This was clearly the case during the latter part of implementation. A system of accountability must be clearly defined for all parties involved and effective mechanisms should be in place to ensure compliance.

(iv) A PMO anchored in an appropriate organic unit of the executing agency is more effective than a stand-alone structure.

(v) Effective monitoring and evaluation requires that a simple set of indicators and guidelines for collection be designed at appraisal and made operational at the beginning of project implementation. The number of indicators selected at appraisal was too large, assumed data sources were inappropriate, and major surveys were left to government financing (subject to availability of budget). Baseline data was made partly available only after the midterm review.

(vi) Clear and detailed terms of reference, essential qualifications, technical competency, and relevant experience should be specified for consultants. Technical and managerial capacities for consulting firms should be clearly defined.

(vii) Project design should envisage adjustment to emerging needs, making projects more relevant, efficient, and effective.

C. Recommendations

1. General

71. There is an urgent need for stronger support and political commitment for family planning, given the growth rate of 2.3% per annum. Family planning should become an integral part of the women’s health and development program.

72. Any proposal for a follow-up project should include a component on the systematic strengthening of MIS for women’s health and safe motherhood. The MIS needs at each level must be defined in relation to management needs, focusing on problem identification and problem solving. The management-relevant elements of LCA, quality assurance, neonatal death review, HBMR, and maternal GIS should all be parts of an integrated package.

2. Project-Related

a. Management and Benefit Monitoring Systems

73. DOH should complete the BME requirements of the project by the end of 2005. Completion will affect the assessment of project sustainability. A “blind” maternal death review should be undertaken for a suitably sized barangay sample of maternal deaths for 2002. The

14

sample should include project and nonproject barangays and be analyzed in terms of project/nonproject variables.

74. There is an urgent need to develop a system of functional coordination and a seamless flow of patients, information, and supportive supervision between the different levels of health facilities. Such a system needs to be developed with the involvement of all stakeholders, critically tested, evaluated, adapted, and ultimately extended nationwide.

75. Mainstreaming or extending LCA should be a priority at the community level. This requires a set of clear policy guidelines from DOH.

b. Technology Development and Adaptation

76. Development should be continued on the adaptation and field-testing of the walking blood bank. Guidelines, suitable manuals, and training materials should be developed and appropriately adapted to local needs.

77. Neonatal mortality (NNM) is likely to be a more sensitive indicator of maternal care when maternal deaths are rare among a small group of women. DOH should consider setting up a sentinel reporting system for NNM rather than depending on reports that are highly variable in quality. DOH should also consider including the World Health Organization (WHO) paper chest circumference tape in the safe home delivery kit as a means to judge approximate weight.

78. DOH should further extend the work on maternal GIS as a planning, management, and evaluation tool. This should include within the GIS database a number of additional variables: individual maternal death by place of residence and death, location of health facilities, density of population by barangay, etc. The maternal GIS should also be used as an educational and advocacy tool for communities, health workers, and decision makers. Full capacity for operating and interpreting the maternal GIS should be placed at DOH regional offices, while the research and development functions for application of the GIS remain at the central level.

15

SUMMARY OF CIVIL WORKS

Health Facilities Planned Actual

Provincial Hospitals 40 36

District Hospitals 54 56

Rural Health Units 160 163

Barangay Health Stations 280 270

Maternal Waiting Home 15 15

Lying-in Clinic 10 10

Total 559 550

Source: Department of Health.

16 Appendix 2

COMPLETE LIST OF CIVIL WORKS BY PROVINCE

Number of Health Facilities Constructed/Renovated

Region

Province Provincial Hospital

District Hospital

Rural Health

Unit

Barangay Health Station

Maternity Waiting Home

Lying-in Clinic

2 Batanes 1 1 4 7 Cagayan 1 1 4 7 Quirino 1 1 4 7 CAR Abra 1 1 4 7 Apayao 1 3 2 4 1 1 Benguet 1 1 4 7 1 Kalinga 1 2 3 1 Ifugao 1 2 4 7 1 Mountain Province 1 1 4 7 1 1 4 Aurora 1 1 4 7 Occidental Mindoro 1 1 4 7 Oriental Mindoro 1 1 4 7 1 Quezon 1 3 4 7 Romblon 1 1 4 7 Palawan 1 2 4 7 1 1 5 Camarines Sur 2 6 4 Catanduanes 1 1 4 7 Masbate 1 1 4 7 1 Sorsogon 1 1 4 7 1 6 Antique 1 1 4 7 Capiz 1 1 4 7 Guimaras 1 5 5 Negros Occidental 1 2 4 7 7 Negros Oriental 1 2 4 7 8 Biliran 1 4 7 1 Eastern Samar 1 1 4 7 1 1 Northern Samar 1 1 4 7 Southern Leyte 1 2 4 7 Northern Leyte 1 2 4 7 Western Samar 1 1 4 7 9 Zamboanga del Norte 1 1 4 7 Zamboanga del Sur 1 1 4 7 1 1 Basilan 1 2 4 6 1

Appendix 2 17

Number of Health Facilities Constructed/Renovated

Region

Province Provincial Hospital

District Hospital

Rural Health

Unit

Barangay Health Station

Maternity Waiting Home

Lying-in Clinic

Caraga Agusan del Sur 1 1 4 7 Surigao del Norte 3 4 7 1 Surigao del Sur 1 4 7 12 North Cotabato 1 1 4 7 1 ARMM Lanao del Sur 3 4 7 Sulu 1 1 4 3 1 Tawi-Tawi 1 2 4 7 1 1 Maguindanao 1 1 4 7 1 1 Total 36 56 163 270 15 10 ARMM = Autonomous Region of Muslim Mindanao, CAR = Cordillera Administrative Region. Source: Department of Health.

18 Appendix 3

SUMMARY OF PROJECT COMMODITIES

Project Commodity Total Quantity 1. Vitamin A

• 100,000 IU 3,000,000 capsules • 10,000 IU 130,000,000 capsules • 200,000 IU 13803,100 capsules

2. IOC 11,872,353 capsules 3. Ferrous Sulfate 6,000,000 tablets 4. Safe Home Delivery Kits 1,386,000 kits 5. Emergency Obstetric Supplies Various items

• Dextrose • Water for Injection • Diazepam • Oxytocin • Infusion Set • Disposable Syringe • Hydralazine • Methelyrgometrine • Magnesium Sulfate

6. Reproductive Health Supplies Various items • Epinephrine 358 bottles • Atrophine Sulfate 9,826 bottles • Surgical Gloves 142,156 pairs • D5W 37,265 bottles • Infusion Administration set 39,153 pcs • Cherries 68,166 • Gauze 63,937 pads • Syringes 68,166 pcs • Hypodermic 124,990 • Surgical blade 46,711 • Lidocaine 7,749.44 • Glutaraldehyde 358 gallons • Cotton Balls 100,348 • Gauze 51,070 pads • Meperidine • Diazepam 37,335 • Winged Infusion Set 39,153 sets • Suture chronic cat gut 39,153 • Naloxone 778

7. Anesthesia Machine 88 8. Blood Bank Refrigerator 92 9. Laboratory Refrigerator 48 10. Gynecological Examining Couch 270 11. HBMR 5,110,662

HBMR = home=based mother record, IOC = iodine oil capsule, IU = international units, pcs = pieces. Source: Department of Health.

Appendix 4 19

MAJOR TECHNICAL OUTPUTS

1. Comprehensive Emergency Obstetric Manual

2. Maternal Care Manual for Midwives and Hilots1

3. Obstetric Emergency (Table Calendar Type)

4. Maternal Death Review Manual

5. Women and Chemical Exposure

6. Manual for Trained Hilots

7. Maternal Geographic Information System

8. Maternal Health Modeling

9. Maternal Health Website

10. Home-Based Mother Records

11. Quality Assurance Framework, Methodologies, and Monitoring and Assessment tools

12. Quality Assurance Training Manuals

13. Life Cycle Approach Concept Paper, Management Framework, Implementation Documentation, Assessment Reports, and Recommendations for Further Action

14. National Advocacy Campaigns on Women’s Health and Safe Motherhood

15. Creative Information, Education, and Communication Messages and Materials for Women’s Health and Safe Motherhood

16. Social Marketing Campaign

1 Hilot is a local term for traditional birth attendant.

20

Appendix 5

IMPLEMENTATION SCHEDULE

Activities 1994 1995 1996 1997 1998 1999 2000 2001 2002J A S O N D J F M A M J J A SONDJ F MAMJ J A S ONDJ F MA MJ J A S ONDJ F MA MJ J AS ON D J F M A M J J A S ONDJ F MA MJ J A SONDJ F MAMJ J AS ONDJ F MA M J

Loan Approval *

Loan Effective * *

Civil Works

Design Electronic Upgrade

Bidding and Contract Award Additional Works, exclude Variation O d Construction/Improvements

Procurement Deliver Annually

Medical Equipment Specifications Contract

Initial Medical Supplies Contract

Emergency Transport Facilities Specifications Contract

Information, Education, and Communication

Life Cycle Approach

Social Marketing

Consultant Services Project Management and Technical Support

Selection

Selection Philippine Center for Population and Development Individual consultants hired Design and Supervision

Selection Selection Philippine Center for Population and Development/DCCD Individual consultant-engineers hired

Legend Target schedule per Appraisal

Actual implementation schedule

Appendix 6 21

PROJECT MANAGEMENT STRUCTURE

Project Manager

Finance

Administrative

Consultants

M&E

ADB / AusAID Desk

WB / EU / KfW Desk

Undersecretary Office for Standards,

Regulations and Health Facilities

Project Director (DOH Secretary)

In

Steer

Project Coordinator

Assistant Secretary for Finance and Administration

Procurement and Logistics Service

Center for Health Development

Provincial LGU

Civil Works Contractors

Provincial HealOffices

Municipal LGU

ADB = Asian Development Bank, AusAID = Australian Agency for International DevelopmDepartment of Health, EU = European Union, KfW = Kreditanstalt für Wiederaufbau, LGU = locaunit, M&E = monitoring and evaluation, WB = World Bank.

Finance Service

Health frastructure Service

Project ing Committee

s

th

s

ent, DOH =l government

22 Appendix 7

STATUS OF COMPLIANCE WITH LOAN COVENANTS Covenant

Reference in Loan Agreement

Status of Compliance

1. Engagement of consultants for project management and technical support team. Selection and engagement of consultants shall be made without any restrictions against, or preference for, any particular consultants or any particular class of consultants except as otherwise in this Schedule.

2. Department of Health (DOH), as the

project executing agency, shall have the overall responsibility for carrying out the project. The undersecretary/chief of staff of DOH shall be the project director, responsible for overall project supervision. The DOH’s Office of Special Concerns (OSC) shall be responsible for project implementation. The assistant secretary of OSC shall be the project coordinator, assisted by the project management office (PMO).

3. DOH shall establish a project steering

committee (PSC), which shall provide policy guidance 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 further include senior representatives of concerned offices in DOH, and representatives of National Economic and Development Authority (NEDA), Department of Finance (DOF), Department of Budget Management (DBM), project implementing agencies, and nongovernment organizations. The PMO shall serve as secretariat to the PSC. The PSC shall meet within one month of the loan effective date and subsequently at least once every quarter.

4. The PMO shall establish within the OSC,

headed by a full-time project manager acceptable to ADB, shall be responsible for the day-to-day project implementation including preparation of project reports,

Loan Agreement (LA), Schedule 5, paras. 1and 3 LA, Schedule 6, para. 1 LA, Schedule 6, para. 2 LA, Schedule 6, para. 3

Complied with. DOH took more than 1 year to complete recruitment. Complied with. Complied with. Complied with. After the midterm review mission, the PMO was based in the WHDP, which resulted in

Appendix 7 23

Covenant

Reference in Loan Agreement

Status of Compliance

maintenance of project records and accounts, recruitment and engagement of consultants, and procurement activities.

5. The regional field office (RFO) under the

direction of the PMO shall be responsible for coordination of project implementation in their respective regions.

6. DOH shall execute the project

implementation agreements (PIAs) with each project provinces, which shall include arrangements for the implementation in the concerned project province of the respective project components.

7. DOH shall ensure that all civil works

carried out in provincial and district hospitals under the project are inspected and approved by the PMO before the final contract payments are made.

8. The Borrower shall ensure that the project

facilities are operated, maintained, and repaired in accordance with sound administrative, financial, engineering, environmental, health care, and maintenance and operational practices.

9. DOH shall adopt a BME plan satisfactory

to ADB. DOH shall, with the assistance of the consultant provided under the project for the purpose, be responsible for carrying out baseline and benefit evaluation surveys, pilot studies, and benefit and monitoring activities in accordance with the BME plan. The RFOs shall assist in carrying out BME activities in their respective regions.

10. DOH shall ensure that the local

government units (LGUs) shall recruit and engage, for the duration of the project and beyond, midwives for the 25 project

LA, Schedule 6, para. 4 (a) LA, Schedule 6, para. 5 LA, Schedule 6, para. 8 LA, Article IV, Section 4.09 LA, Schedule 6, para. 9 LA Schedule 6, para. 10

marked improvement in project implementation. Complied with. Complied with. Due to the large number of LGUs involved, completion of PIAs took longer than planned. Complied with. But due diligence process at DOH needs improvement. The process used in designing and confirming the final civil works designs proved unsatisfactory. Complied with. Due to resource constraint, maintenance was at the minimal level. Complied with. Routine monitoring activities undertaken. Baseline data was only partially completed by midterm review. Major surveys not conducted. Only facility-based surveys undertaken. Partially complied. The actual ratio varied from province to province.

24 Appendix 7

Covenant

Reference in Loan Agreement

Status of Compliance

provinces to the extent necessary to establish a ratio of one midwife per 5,000 women aged 15-50.

11. DOH shall ensure timely provision of

doctors on a temporary basis to replace each of the doctors undergoing training for the duration of the training.

12. DOH shall cause the project provinces to

ensure that the doctors to be trained under the project undertake to return to their hospitals upon completion of the training and will remain in service with such hospitals for a period in accordance with the applicable regulations of the borrower.

13. The borrower and ADB shall conduct a

midterm review of all aspects of the project, including assessment of progress made and problems encountered.

14. DOH shall conduct an inventory of

obstetric and gynecological equipment in all hospitals identified for upgrading under the project and inform ADB of its findings.

15. The borrower shall furnish to ADB

(semiannual reports) quarterly progress reports on the carrying out of the Project and on the operation and management of project facilities.

LA Schedule 6, para. 11 (a) LA Schedule 6, para. 11 (b) LA, Schedule 6, para. 12 LA, Schedule 6, para. 13 LA, Section 4.07 (b)

Complied with. Complied with. Complied. Completed in November 1999. Complied with. Generally complied with.

Appendix 8 25

ASSESSMENT OF OVERALL PROJECT PERFORMANCE

Criterion Weight Assessment Rating Value

Weighted Rating

(A) (B) (C) (D) (B x D) 1. Relevance 20% Highly Relevant 3 0.60 Relevant 2 Partly Relevant 1 Irrelevant 0 2. Efficacy 25% Highly Efficacious 3 Efficacious 2 0.50 Less Efficacious 1 Inefficacious 0 3. Efficiency 20% Highly Efficient 3 Efficient 2 Less Efficient 1 0.20 Inefficient 0 4. Sustainability 20% Most Likely 3 Likely 2 0.40 Less Likely 1 Unlikely 0 5. Institutional Development 15% Substantial 3

Significant 2 0.30 Moderate 1 Negligible 0 Overall ratinga 2.00

and other impacts

a Sum of the weighted ratings. Notes: Highly Successful (HS): Overall weighted average (OWA) is >2.5 and none of the 5 criteria has a score of less

than 2; otherwise, the rating would be downgraded by one level. Successful (5): OWA is between 1 .6 ≤S ≤2.5 and none of the 5 criteria has a score of less than 1; otherwise

the rating would be downgraded by one level. Partly Successful (PS): OWA is between 0.6 ≤LS ≤1 .6 and number of criteria receiving a rating of less than 1

should not exceed 2; otherwise the lowest rating would be given. Unsuccessful (U): OWA is <0.6. Source: Department of Health.