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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
iv

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
b
AusAID Financed 7.6 7.6 15.2 29.7 8.6 5.1 13.7 39.5
a
Total 21.5 29.6 51.1 100.0 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.
v

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
a
Name of Mission Date Persons Person-Days of Members
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.
119o00'E 125o00'E
Babuyan Channel
o
122 00'E

o o
PHILIPPINES
21 00'N 21 00'N

Itbayat INTEGRATED COMMUNITY


Basco
BATANES
APAYAO
HEALTH SERVICES PROJECT
Kabugao
Sabtang
(as completed)
o
122 00'E
Bangued
KALINGA REGION II
REGION I
ABRA
CAR Cagayan Valley
Tabuk
Ilocos
MT. PROVINCE
Bontoc

South China Sea IFUGAO


Lagawe
BENGUET N
La Trinidad
Baguio

0 50 100 150
16o00'N 16o00'N

Kilometers

REGION III
Central Luzon
PACIFIC OCEAN
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 Philippine Sea
Regional Boundary
ORIENTAL Sibuyan Sea
Boundaries are not necessarily authoritative. MINDORO

REGION IV-B
MIMAROPA REGION VIII
Eastern Visayas

Borongan
Roxas EASTERN
Visayan
SAMAR
CAPIZ Sea
ANTIQUE

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

REGION X
Northern Mindanao
Prosperidad
AGUSAN
DEL SUR

8 o00'N DAVAO 8 o00'N


REGION IX DEL
Zamboanga Peninsula NORTE
Sulu Sea
Tagum

NCR- National Capital Region Isabela Moro Gulf


ARMM- Autonomous Region in Muslim Mindanao REGION XI
Davao Region
CALABARZON- Cavite, Laguna, Batangas, Rizal, Quezon BASILAN ARMM 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
Celebes Sea
TAWI-TAWI
119o00'E 125o00'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.
2

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).
3

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.
10
For 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 Sigla 11 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.
7

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.
8

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
9

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.
11

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.
13

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).
14

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

Appendix 1
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

Appendix 1
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

Appendix 1
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

Appendix 1
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.

Appendix 1
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

Appendix 1
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

Appendix 1
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
b
Order 205, 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

Appendix 1
(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
25
26
Table A1.1: Incidence of Selected Diseases by Project Province

Appendix 1
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

Appendix 1
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

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.
28
Table A1.2: Budget Allocation and Expenditures for Health in the Pilot Provinces
1999–2005 (Philippine Pesos)
Project Sites 1999 2000 2001 2002 2003 2004 2005

Appendix 1
Apayaoa
Total LGU Budget 173,203,557 190,356,455 217,903,578 222,955,409 245,153,306 258,100,000 274,304,722
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
% 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.
30
Table A1.4: Utilization Rates of Selected Hospitals Constructed or Renovated/Expanded

Appendix 1
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

Appendix 1
79.2 84.7 85.3 80.1 86 80.2 66.5 73.4 83.7 86 86.3 86
toilet

31
32
Kalinga Palawan
Indicators
1999 2000 2001 2002 2003 2004 1999 2000 2001 2002 2003 2004
Maternal Care

Appendix 1
% 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

Appendix 3
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.
PROJECT IMPLEMENTATION SCHEDULE

Project Milestones 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7 Year 8

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 1 2 3 4
Loan Approval
Loan Signing
Loan Effectivity
Project Launching
Establishment/Operations of
Project Management Office
Implementation
Consultancy Services:
Evaluation, Start of Services
Project Components
Civil Works
- Site Inspection
- Design
- Construction

Procurement
- Equipment and Furniture

- Medical Equipment

- Drugs

Telecommunications

Health Management
Systems Development and
Documentation
Health Management
Systems Implementation
Health Promotion/Social
marketing
Benefit Monitoring and

Appendix 4
Evaluation
Replication

Project Loan Closing

Planned

35
Actual
36
Appendix 5
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 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 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
a b
Project Manager Gonzales Devanadera Canda 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.
44 Appendix 8
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.

Appendix 8
45
46 Appendix 8
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;
a
recently did the F1 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
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.

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