Document of The World Bank FOR OFFICIAL USE ONLY lteport No. 7665-PH STAFF APPRAISAL REPORT PHILIPPINES HEALTH DEVELOPMENT PROJECT MAY 25, 1989 Country Department II Asia Regional Office This document has a restricted distribution and may be used by recipients only In the perfonnance of 2 A -, I P It. . . a . . . I CURRENCY EQUIVALENTS Currency Unit - Philippine Peso (P) US$1.00 - P21 (November 1988) FISCAL YEAR January 1 - December 31 ABBREVIATIONS API - Annual Parasite Incidence ARI - Acute Respiratory Infection CBR = Crude Birth Rate CDR - Crude Death Rate BHS - Barangay Health Station CHS = Community Health Service COA = Commission on Audit DBM = Department of Budget and Management DOH = Department of Health GIS = Geographic Information System GOP = Government of the Philippines HIS - Health Information System IEC = Information, Education and Communication IMR = Infant Mortality Rate MCH = Maternal and Child Health MCP = Malaria Control Program MIS - Management Information System MMR - Maternal Mortality Rate NEDA = National Economic Development Authority NGO m Non-governmental Organization NNC - National Nutrition Council PHC - Primary Health Care POPCOM = Population Commission RHU = Rural Health Unit SCP = Schistosomiasis Control Program TCP = Tuberculosis Control Program TFR = Total Fertility Rate UNFPA = United Nations Fund for Population Activities UNICEF - United Nations Children's Fund USATD = United States Agency for International Development WHO = World Health Organization VO OUVIIAL UK ONLY PHILIPPINES SUZLTE DEVELOEPINT PROJECT Table of Contents Page No. LOAN AND PROJECT SUMMARY .... . iv DEFINITIONS ................................................ vii I. INTRODUCTION ......................................... 1 11. HEALTH, NUTRITION AND POPULATION SECTOR . . 2 A. ProĢile ........................................... 2 B. Health Sector Organization, Services, Expenditures and Financing ...................... 5 C. Sectoral Issues ................................... 9 D. Government Policies and Strategies .... ........... 12 E. Bank Group Role and Strategy ...................... 12 III. THE PROJECT .......................................... 14 A. Project Objectives ................................ 14 B. Project Description ..................... 14 C. Detailed Project Description ...................... 16 Strengthening Health Impact Programs .............. 16 Institutional Strengthening of DOH ................ 21 Community Health Development ...................... 25 Policy Development ................................ 27 IV. PROJECT COST AND FINANCING ........................... 27 A. Costs ............................................. 27 B. Financing .......... 27 C. Procurement ....................................... 29 D. Disbursement ...................................... 31 E. Accounts, Audit and Reporting ..................... 31 This report is based on the findings of an appraisal mission which visited the Philippines ir, November 1988. Mission members were: S. Scheyer (Mission Leader), B. Liese, C. Fogle, L. Salmen and D. Conrad. The report was prepared by S. Scheyer and C. Fogle. This document has a restricted distribution and may be used by recipients only in the performancee of their official duties. Its contents may not otherwise be disckoso without World Bankc authorization. - ii - Page No. VI. PROJECT IMPLEMTATION ............................... 32 A. Status of Project Preparation ... 32 b. Organization and MHanag_nt . . 32 C. louitoring and lvaluation . . 33 VI. PROJECT UUEITS AND RISKS ....... ... 34 . Benefits... 35 S. Risks ............................................. 35 C. Impact on Women ................................... 35 D. Environmental Aspects ............................. 35 VII. AGREEMENTS REACHED AND RECOMMENDATION ................ 36 TABLES IN THE TEXT 1. Project Costs .......................................... 28 2. Procurement Arrangements ...............................3 0 ANNEXS 1. Comparative Socio-Economic Indicators ................. 38 2. Total Population Size, Crude Birth and Death Rates and Total Fertility Rates for Selected Years ........ 39 3. Trends in Infant, Child arnd Maternal Mortality and Life Expectancy, 1930-1985 ...................... 40 4. Trends in Causes of Mortality, 1946-1984 .............. 41 5. Trends in Leading Causes of Morbidity, 1978-1984 ...... 42 6. Trends in Malnutrition, by Region and Targeted Areas, 1976 and 1979 ................................ 43 7. Projections for Budgetary Allocations for the Sector, 1988-1992 ................................... 44 8. Targets as Outlined in Midterm Development Plan, 1988-1992 ........................................... 45 9. Project Costs by Year ........................ 46 10. Project Cost Sunumary .................................. 47 11. Summary Account by Project Component .................. 48 12. Estimated Schedule of Disbursements ................... 49 13. Implementation Schedule ............................... 50 14. Implementation Responsibilities ....................... 57 15. Evaluation Tasks ...................................... 65 16. Proposed Project Monitoring Schedule .................. 67 17. Selected Documents and Data Available in the Project File ........................................ 68 _ iii - Pazn No. CHARTS 1. MWlaria Morbidity and Mortality Trends ................ 69 2. Organization Structure of the Department of Health 70 3. DOd Regional and Provincial Structure. 71 4. DON lnfornatio Comunication Sytm.. 72 5. DOE Packet Radio Diagram ...... ..................... 7' 6. DOB Desktop Publishing Diagram . .74 7. DOE Data File Managemnt Diagram . . 75 S. DOB Information, Sducation and Communication Diagram 76 9. DOH Audio-Visual Diagram ..77 10. DOH Training Diagram ..78 11. Organization Structure of the Community Health Development Component ..79 MAPS IBRD 21389 Philippines - Distribution of Malaria IBRD 21388 Philippines - Known Endemic Areas for Schistosomiasis - iv - PHILIPINES HEALTH DKZVLOPMENT PROJECT Loan and Proiect Sainary Borrowers Republic of the Philippines Amounts US$70.1 million equivalent Terms: Repayable in 20 years, including 5 years of grace, at the Bank's standard variable interest rate. Cofinancing: Government of Italy, US$8.1 million equivalent Government of Japan, US$4.3 million equivalent Proiect Description: The project would help the Goverrment to meet its objectives to expand and improve public and primary health care, especially for high-risk groups; strengthen the efficiency and effectiveness of the Department of Health (DOH); promote collabcration among the Government, local communities and non-governmental organizations (NGOs) in meeting community health needs; and establish improved mechanisms for future policy development. Specifically, the project would support: (a) four priority prog,-ams for improvements in the control of major communicable diseases (malaria, tuberculosis and schistosomiasis) and in maternal and child health; (b) institutional strengthening of DOH through improvements in managcment information systems, planning and budgeting procedures, central laboratory support, service delivery capability, communications, training and evaluation mechanisms; (c) establishment of a program for provision of grants for organizing and implementing provincial-level partnerships among DOH, local governments and NGOs for community health projects; and (d) establishment of & national health policy committee and a secretariat within DOH and provision for studies. To carry out these activities, drugs, pesticides, equipment, vehicles, materials, community health grants, training, and technical assistance would be financed under the project. Benefits and Rikes: The project would: (a) reduce the prevalence of *alaria, tuberculosis and schistosomiasis in high-risk areas; (b) reduce the mortality risk to womn and children in high-risk communities and encourage the lowering of fertilityl (c) improve DOS'. capacity to identify and monitor high-risk households vithin comunities which would increase equity and efficiency of services; (d) mobilize counity resources through partnerships of local governments and NGOO with DOH to meet critical comunity health needs; (e) improve the in3titutional capacity of DOH in planning, management, communication, support and evaluation, leading to more effective and efficient delivery of services; and (f) enhance future sector policy analysis. One major risk is that communities with a high prevalence of malaria, tuberculosis and schistosomiasis as well as high maternal and infant mortality levels may be in areas of potential instability, and efforts to reach these communities could be affected by future political developments. Sufficient flexibility exists in DOH's selection of communities to be supported by the project to overcome the risk that such developments might affect project scope, although some deserving communities might not receive support under these circumstances. There is also a risk of slow Implementation due to delays in counterpart funding and weak administrative capacity. These risks would be minimized through an annual review with the Bank of project performance and financial requirements and through the establishment of a Project Coordinating Unit (see pp. 24 and 32) and the designation of individuals responsible for monitoring and problem-solving in each of the implementing units of DOH. - vi - Estimated Costs La Local Foreign Total (USS million) Strematheni&E DON Isect Program Malaria Control Program 9.2 10.6 19.8 Tuberculosis Control Program 7.6 7.3 14.9 Schistosomiasis Control Program 4.8 3.5 8.3 Maternal and Child Health 0.7 2.3 3.0 Subtotal 22.3 23.7 46.0 Strengthening DOH Institutional CaRacity DOH Information Systems 1.7 2.1 3.8 Regional/Provincial Health Planning 1.6 - 1.6 Field Services 9.5 7.3 16.8 Central Laboratory 0.6 1.7 2.3 Project Management 0.7 0.1 0.8 Informatior. Education & Communication 1.8 0.3 2.1 Training of DOH Staff 6.7 0.1 6.8 Evaluation 1.3 - 1.3 Project Preparation/Start-up 1.7 1.2 2.9 Subtotal 25.6 12.8 38.4 Comnunity Health Development Community Health Development Fund 7.4 - 7.4 Community Health Systems Support 1.2 0.3 1.5 Subtotal 8.6 0.3 8.9 Policy Development Subtotal 0.6 - 0.6 Total Base Costs 57.1 36.8 93.9 Price Contingencies 10.7 3.8 14.5 Total Project Costs la 67.8 40.6 108.4 Financing Plan Government of the Philippines 25.9 -- 25.9 Goverrnent of Japan 2.5 1.8 4.3 Government of Italy 0.2 7.9 8.1 World Bank 39.2 30.9 70.1 Total 67.8 40.6 108.4 Estimated Disbursements: Bank FY 1990 1991 1992 1993 1994 1995 1996 Annual 5.0 7.0 9.4 16.2 12.4 12.0 8.1 Cumulative 5.0 12.0 21.4 37.6 50.0 62.0 70.1 Economic Rate of Return: Not Applicable - vii - PHILIPPINES HEALTH DEVELOPMENT PROJECT Definitions Annual Parasite Number of people with positive blood Incidence (API): slides collected over a one-year period per 1,000 population. Barangay: The smallest political division in the Philippines, usually consisting of one or more villages for an average population of about 5,000 persons. Crude Birth Rate: Number of live births per year per 1,000 population. Crude Death Rate: Number of deaths per year per 1,000 population. Infant Mortality Annual number of deaths of infants under Rate: 1 year per 1,000 live births during the same year. * .Life Expectancy: Average number of years childre:, born in the same year can expect to live if mortality rates for each age/sex group remain the same in the future. Maternal The number of deaths to women who die * Mortality Rate: due to pregnancy and child bearing complications in a given year per 1,000 live births in that year. Morbidity: The frequency of disease and illness in a population. Prevalence Rate: The number of persons having a particular disease at a given point in time per population at risk. Usually expressed per 1,000 persons per year. Rate of Population Rate of natural increase adjusted for Growth: (net) migration expressed as a percentage of the total population in a given year. Total Fertility The average number of children that would Rate: be born alive to a woman during her lifetime if she were to pass through her childbearing years conforming to the age- specific fertility rates of a given year. PHILIPPINES MEALTH DEVELOPMENT PROJECT l. INTRODUCTION 1.1 The Government of the Philippines (GOP) achieved an impressive performance in the 1970s in improving the health and nutrition status of its people. During the same period, it also achieved some success, although more limited, in reducing population growth. The progress in both areas began to slow down in the early 1980s, however, as a result of the economic crisis and consequent severe reductions in public expenditures (see Annex 1). The continuation of the economic crisis into the mid-1980s, combined with the change in administration in early 1986 and subsequent governmental reorganization, further weakened the Government's ability to reverse these negative trends. The World Bank report, The Poverty Challenge in the Philippines (Report No. 7144-PH, October 1988) notes that, as total expenditures declined, a larger share of the declining public health resources have been devoted to urban-based curative services, and rural preventive services have suffered in the process. 1.2 As the economy moves toward recovery, the new administration has taken important steps to improve resource allocations to the health sector. In 1987 and 1988, an increased share of total government resources in nominal terms were allocated to health (from 3.72 in 1986, to 5.4Z in 1987, 5.72 in 1988 and 5.82 for 1989). In addition, the Government has moved to extend the effect of its limited resources available for health through a revised community health str&tegy designed to minimize regional disparities and to focus priority preventive and prima:y health services on the groups and geographic areas of greatest need. As part of that strategy, the Targeted Area Development Programs of the Department of Health (DOH) provide for additional resource allocations to areas where the health and nutrition status of the population is nelow the national average. In addition, the DOH Impact Programs focus resources on priority health problems. Besides targeting services to groups and areas of greater need, both of these programs seek more effective health outcomes and sustainability through greater community self-reliance in undertaking projects to reduce health risk to their own people. An essential part of this process is the effort being made to facilitate partnerships between the DOH and provincial-based non-governmental organizatinns (NGOs) to initiate and support the implementation of community health development projects. II. HEALTH. NUTRITION AND POPULATION STATUS A. Profile 2.1 Health. Although the health of the Philippine population improved significantly during the 1970s, progress towards mortality reduction in the 1980s has slowed. The crude death rate leclinod from 12 per 1,000 in 1970 to 7.9 per 1,000 in 1985. Life expoctancy at birth increased from 58 years in 1970 to 63.1 years in 1985; and the infant mortality rate declined from 75 per 1.000 live births in 1975 to 52.9 per 1,000 live births in 1988. (UNICEF's State of the World's Children 1988, however, shows the IMR for the Philippines as 76.) (See Annexes 2 to 6.) Infant mortality, however, still represents over 20Z of the crude death rate. Forty-one percent of infant deaths occur during the first 27 days of life. Maternal mortality and morbidity, while poorly recorded, have been on the increase in the Philippines since ;980. DOH reports that for every 10,000 births reported, nine mothers die of pregnancy-related causes, mainly due to hemorrhage and hypertensive complications. The leading causes of death for all ages are still infectious and communicable diseases, although degenerative diseases are slowly gaining prominence. Health statistics for 1978-85 indicate that acute respiratory infections and diarrhea continue to be the major causes of death among infants and preschool-aged children, with pneumonia the leading cause of infant deaths. 2.2 There have also been major increases in the incidence of communicable diseases in the past several years, and especially in the number of cases of malaria and tuberculosis. Malaria is the most important tropical parasitic disease in the Philippines and now ranks as the sixth cause of morbidity and tenth as a cause of mortality. In the period since 1959, there have twice been attempts to decentralize the malaria control program; in both cases there was a strong resurgence of the disease. The second attempt coincided with the integration and decentralization of DOH services in 1983. During that period, the country wide prevalence of malaria tripled and the total number of reported cases rose from about 70,000 to about 180,000. Chart 1 provides malaria morbidity and mortality trends over time, and Map 21389 identifies the incidence levels of malaria across the country. 2.3 Tuberculosis also continues to be a major public health problem, affecting an estimated 82 of the Philippine population. Over the past decade, tuberculosis has become one of the ten leading causes of morbidity and mortality and has caused ten percent of the total deaths due to infectious diseases over the past five years. With the Philippines among the five countries with the highest tuberculosis prevalence for which reliable data exist, tuberculosis in the Philippines in 1984 ranked fifth as a cause of morbidity and third as a cause of mortality with an overall prevalence of about 6.6 persons per 1,000 population. A national tuberculosis survey conducted in 1983 shows that prevalence rates vary by region, with the Western Visayas, all of Mindanao and the National Capital Region/Manila showing higher rates than the national average. Highly urbanized areas and cities exhibit higher prevalence rates than rural areas. Shortagps of tuberculosis drugs and trained personnel have limited the number of cases under treatment to 602 of those diagnosed positive for tuberculosis. 2.4 For schistosomiasis, prevalence surveys show that about 500,000 persons in 150 municipalities and 22 provinces are infected and about 4 million persons are at risk of the disease. Data for this and other infoctious diseases indicate that morbidity an0 mortality rates from preventable causes have stabilised at high levels or are even increasing. Map IBRD 21388 indicates the known prevalence areas for schistosomiasis. 2.5 Children aged 0-6 years comprise 201 of the Philippine population, or about 11.7 million persons in )988. Deaths to children under 5 years accounted for over 30Z of all reported deaths in 1985, with infant deaths accounting for over 202 of total deaths. The infant mortality rate (IDR) was estimated at 56.6 deaths per 1,000 live births in 1985 and 52.9 in 1988; the rates vary greatly, with depressed areas such as Sulu and Tawi-Tawi registering levels of 133 per 1,000. Child mortality rates are also high, with acute respiratory infections (ARIs) and diarrhea as the major causes of death among infants and children. ARIs have overtaken diarrhea as the major cause of childhood death and illness. Fifty-five percent of the total under-five mortality is now due to the six ARI-related diseases of pneumonia, measles, bronchitis, influenza, pertussis and diphtheria. The 1981-85 average incidence of ARI-related diseases among the 0-4 year age group was 59 cases per 1000 population, while the mortality rate was about 5 per 1,000 population. There are greater numbers of ARI cases in remote areas such as Mindanao and in crowded urban poor communities. High levels of malnutrition compound the problem of preventing ARI, as the relationship between infection and malnutrition is a synergistic one in which malnutrition reduces resistance to infection and infection, in turn, worsens nutritional status. This relationship is demonstrated in the greater frequency and severity of ARI cases among undernourished children and low birth- weight infants. Pneumonia persists as the single most impcrtant cause of infant death, with 27Z of infant deaths and 452 of child deaths due to pneumonia in 1985, or 35Z of total under-five mortality. 2.6 The provision of maternal and child health (MCH) services has been on the decline throughout the 1980s. Annually, approximately two million women in the Philippines become pregnant; 9 out of every 10.000 women die each year of pregnancy-related causes. Deaths are maiiLly due to hemorrhage (37Z) and hypertensive complications of pregnancy (282). Over the 1981-83 period, survey data indicated that provision of prenatal care declined by about 38Z, childbirth attendance by around 292 and post-natal care by 852. Although DOH reports show that around 702 of pregnant women are seen at least once in a prenatal clinic, hospital and city-based data indicate that of the urban women delivered in hospitals, around 652 are admitted as emergencies with no proper antenatal care. Maternal illnesses such as anemia and undernutrition affect almost half of all pregnant women. These conditions have been correlated with high fetal loss. The foregoing conditions of high maternal mortality and morbidity are closely associated with multiparity and infrequent and low quality of antenatal care. 2.7 Nutrition. Nutritional problems in the Philippines are primarily those of dietary/nutrient inadequacies among preschool children and pregnant and nursing mothers. Despite survey data indicating improvements in the early 1980s, the nutrition situation appears to have worsened steadily since the late 1970s when the economic downturn began to accelerate. Preschool children constitute about 201 of the population and have been identified as the population group most likely to be affected by malnutrition and most likely to suffer from its consequences. A 1988 UNICEF Report states that the Philippires is among those Asian countries with the highest percentage of infants with low birth weight and the highest percentage of children under five suffering from malnutrition. In 1978, the proportion of children below weight-for-height standards was 14Z; this number declined to around 1OZ in 1982, but rose again to 14Z in 1985. 2.8 Population. There has been a major increase in the population of the Philippines over the past two decades. The population grew from 27 million in 1960 to 55 million in 1985, representing an average growth rate of 3.02 in the 1960s and 2.7Z in the 1970s. Between 1960 and 1975, the crude birth rate has actually risen slightly, reflecting an increase in the number of women in childbearing years, earlier age of marriage, adoption by the family planning program of less effective contraceptive methods (such as rhythm) and a slow decline in female fertility. The total fertility rate declined from about 7.0 in the 1960s to around 4.96 in 1980, and has declined slightly more to 4.84 in 1984. Based on the 1983 and 1986 demographic surveys, the current population growth rate is estimated to be 2.4Z, one of the highest in Asia. The 1988 World Development Report estimates that for the period 1986-2000 the average growth rate will decline only 0.1 Z, to 2.3Z. If present trends continue, and only a slight decline in fertility takes place during the next 20 years, the population will almost double during this period. A recent review of family planning statistics condtucted by the National Census Office indicates that from an all-time high of 417,971 family planning acceptors in FY1975-76, the count had dwindled to 144,658 by 1985. Most available projections for the Philippines indicate a substantial increase in its population for the rest of the century. 2.9 Family planning services were first offered in the Philippines in the 1950s by NGOs, and their activities expanded in the 1960s with external assistance. The national ftmily planning program began in 1970 with the Population Commission (POPCOM) as coordinating body for agencies engaged in population and family planning activities. Since the 1986 change in Government, there has been a Dignificant national debate about the Government's population policy and family planning program. In 1987, the Government adopted a new population policy that endorses family planning for family welfare. While ruling out abortion, the policy endorses the right of women to choose for themselves the means to control their fertility among medically safe methods. A five-year population program has since been developed for 1989-1993 that sets overall objectives and scope of activities but is deficient in not specifying agency-specific programs or resource requirements. -5- 2.10 Recently, it was decided to make DOE the lead agency for family planning service delivery and to remove operational responsibility from the Population Commission. The Commission will in the future function as a policy coordination and monitoring and evaluation agency. The DOH has adopted a set uf guidelines to implement this transfer of operational responsibility and is finalizing an intersectoral plan for the national family planning program. Substantial assistance on grant terms for the five-year family plannlng program is expected to be provided by the United States Agency for International Development (USAID) and the United Nations Fund for Population Activities (UNFPA). NGOs are expected to play significant roles in service delivery supported by the Department of Health. The proposed Bank-assisted project would support the program through its support for a substantial increase in the number of midwives, who are the major suppliers of community-level family planning services. B. Health Sector Organization, Services, Exyenditures and Financing 2.11 Organization. The DOH is the principal health policy-making and implementing agency of the Government. It has five organizational levels: (a) the central level, comprising DOH headquarters; (b) the regional level, including offices of the regional directors of health and general and special hospitals; (c) the provincial level, including offices of the provincial health officers and provincial and district hospitals; (d) the level which includes the municipal health officer; and (e) Rural Health Units, (RHUs) including midwives and Barangay (village) Health Stations (BHSs). At DOH are five major offices headed by Undersecretaries of Health, with an Executive Committee to decide program policies and priorities. A reorganization in 1988 streamlined DOH management in order to improve the efficiency and effectiveness of health service delivery. The 1988 reorganization transferred responsibility for the operational budget to the provincial level, expanded the physical coverage of the public health care system, particularly to the barangay level, and helped clarify responsibilities at each level of the health-care delivery system (see Charts 2 and 3 on DOH's organization). 2.12 Services. Health services are provided by DOH and by other government and non-government agencies. In 1986, there were 1,949 hospitals, about 702 private and 302 public. Of the total number of hospitals, half were for primary care and were mostly owned by the private sector. Most of the private facilities are relatively small hospitais, located mainly in urban areas, with limited diagnostic and treatment capabilities. Their rapid growth in the 19709 was partially erncouraged by a government policy that provided credits for their finaicing. The public and for-profit private health-care facilities are supplemented by various NGOs, which provide mainly primary care services, including maternal and child health, family planning and nutrition services. Most NGOs focus on the depressed areas of the country and their services represent only a small part of the total Philippine service capacity. A majority of the rural population continues to rely upon the services of traditional health practitioners, especially for pregnancy and childbirth care. 2.13 Realizing that it had no effective strategy for reaching families in their communities and households, the Government in the early 1980s adopted a national comunity-bas3d Primary Health Care (PHC) program, with support from the Bank-assisted Second Population Project (Cr. 923-PH). The PHC system was adopted as the framework for servLce delivery to the rural poor in their communities and by 1985 had been introduced in most of the country. The program drew on the experience of many large-and small-scale PHC experiments which had been underway in the Philippines for years. The strategy expanded services by making use of voluntary community and barangay-level workers, decentralized program management and budgeting and encouraged the integration of preventive and curative services at the provincial level and below. Local government involvement and pL ticipation were expanded. Evaluations of program effectiveness are mixed. 2.14 At the same time that DOH adopted the PHC program, it also decentralized its health program activities and health service administration. This included (a) decentralization of central level responsibility for planning, programming and budgeting to the provincial level and below; (b) integration of curative and preventive health services in the provincial health office and district hospital; and (c) development o. a community outreach program through the training of volunteer community health workers. 2.15 In addition, special categorical disease control programs for malaria, tuberculosis, etc., which were formerly vertically organized from the central to the barangay level, were largely dismantled in the expectation that program activities would be taken over bv the new primary care approach. This expectation was not fulfilled due to the technical complexity and administrative and logistical control required for effective implementation of these programs. With decentralization and the redeployment of program workers to carry out the range of activities related to the primary health care program, technical supervision of disease control efforts significantly deteriorated, as did management of materials and supplies. The new reliance on volunteer workers, who often lacked the specialized skills to carry out the categorical programs, and cortinuous shortages of important supplies for the programs due to budget limitations and the diversion of transport vehicles, resulted in high dropout rates from the programs and increased incidence of the diseases addressed under the programs. 2.16 The DOH has now reevaluated its community-based health development policy and recently formulated a new approach which includes NGO participation as a partner. This strategy includes some elements of the earlier PHC program, but is designed to remedy the technical deficiencies noted above by reconstituting the vertical disease-control programs. The strategy alters the highly structured, top-down prescriptive approach to delivery of community-based health services carried out mainly by DOH personnel, to a partnership among the DOH, local governments, NGOs and other governmental institutions. The goal is to retain the technicai skill advantage of the vertically organized programs, while assuring their integration, where appropriate, with existing horizontal programs to help ensure efficient use of common resources. The Government and DOH recognize -7- that even the availability of greatly expanded resources for the health sector cannot fill existing needs without major support from the communities being served and from NGO or private organizations active in providing similar services. 2.17 Recently the DOE has undertaken an extensive re-evaluation of its fragmented MCI and family planning services. The new MCB/family planning approach integrates health services at the peripheral level (R1U and barangay). The new approach focusses on modifying risk to women and children, with priority placed on identLfying and reaching communities (barangays and households) where the women and children are at highest risk. Modifying child risk would involve integrating jimunization treatment of acute respiratory illness, oral rehydration, linkage of food supplementation to nutritional deficiences and provision of micro-nutrient supplementation. Modification of maternal risk will focus on early identification, appropriate referral and monitoring of high risk pregnancies, family planning and pre- and post-natal care. Vitamins, iron and other micro-nutrient supplementatiorn would be provided women in the childbearing years. USAID and UNFPA are now adapting their DOH support mechanisms, in order to provide direct budget support to the DOH's integrated MCH/family planning program. 2.18 DOH service delivery is also constrained by a shortage of midwives in many areas of the country. Deployed first as DOH staff in the early 19709, midwives have proved to be effective and relatively low-cost providers of health care within the community. At the time of the first Bank-assisted Population Project (Ln. 1035-PH) in the early 19709, the role of midwives focussed on the care of normal childbearing women through pregnancy and the first months of their child's life. The Population I project provided resources for the extension of the family planning program to small towns and rural arear and included resources for the retraining of midwives to expedite this process. The Population II project (Cr. 923-PH) provided resources for the construction of over 1000 BHSs, (the health facility base for midwives) and for their continued training. With the cou4ng of PHC, however, the role of the midwives was greatly expanded to include the provision of services in many of DOH's vertical programs and major community organization responsibilities. Inevitably, the focus on maternal care and family planning was diluted as major new responsibilities were added to those already handled by the midwives. The number of midwives in the field remains sharply inadequate in light of the Government's commitment to improved health care, especially to high-risk households and communities. The Government has recently approved the reduction of the current 5000:1 population-to-midwife ratio to 3000:1 for underserved areas. 2.19 Expenditures. A significant fall in the GNP in real terms in the period 1983-85 led to an even greater decline in total health expenditure, which fell from 2.9Z of GNP in 1983 to 2.42 in 1985. At constant prices, total health expenditure decreased by 192 in the two- year period. The decline in aggregate health expenditure was greater in the public than in the private sector. Thus, while the public sector accounted for 382 of total health expenditure in 1983, it accounted for only 262 of the smaller total in 1985. 2.20 The reduction in health expenditure in the public sector reflected an overall decrease in Government expenditure as a percentage of GNP. Reductions in Government health expenditure were greater than were the general cutbacks in total Government expenditure. Accordingly, the health share of central Government expenditure declined from 4.42 in 1983 to 3.6Z in 1985. During this period, outlays at constant prices by the public sector on health declined by 452, and those in the private sector by only 42. In view of the emphasis on curative care in the private sector and the more substantial input into preventive services in the public sector, these cutbacks in public health expenditure placed great pressure on the availability of funds for preventive services, resulting in DOH preventive services budget reductions of nearly 502 at current prices. 2.21 These trends in public expenditure continued in 1986. A real and substantial increase in GNP in 1987 and 1988 and greater priority given to the public sector resulted in an increase in Government expenditure as a percentage of GNP to 122 in 1988, which is still below that in 1983. The health share of central Government expenditure in 1988 was 3.42 of the total, a substantial improvement on 2.62 in 1987, but still well below the 4.42 for 1983. It is also below the average of 42 for the lower-middle-income countries. Present plans are for the health share of central Government expenditure to increase gradually from the annual average of 3.9? in the period 1976-85, to an E4erage of 6.3Z in the period 1987-92, to 9.62 in 1992. The planned increaseL in real health expenditure by the public sector places great emphasis on increasing the capacity of preventive and other outreach services related to priority public health problems, such as malaria, tuberculosis, schistosomiasis, diarrheal diseases and maternal and child health. 2.22 DOH Recurrent Costs. DOH annual recurrent expenditure declined by 332 between 1983 and 1985, in constant terms although the recurrent expenditure budgeted increased by 532 in the two-year period 1985-87, also at constant prices. The level of DOH capital expenditure has changed by as much as 802 in a single year at constant prices; accordingly, the recurrent/capital cost ratio has changed from 9.5 in 1983 to 17.4 in 1985 and 13.1 in 1987. The varying rates of change in recurrent and capital expenditures are reflected in the proportion of recurrent to total DOH expenditure. Changes in the proportion of recurrent to total DOH expenditure show an inverse relationship to the growth in DOH total expenditure at constant prices. Thus, the proportion of recurrent expenditure increased from 912 of the total in 1983 to 952 in 1985, as total expenditure declined at constant prices, and declined to 932 in 1987, as expenditure increased at constant prices. 2.23 Funding Sources. Most of the financial resources used by DOH come from central Government general funds. User charges and other operating income have been estimated to contribute the equivalent of 42 of funds used, and are paid into the goverr sent's general revenue funds. Foreign loans and grants have played a minor financial role in funding health services (42 of total public health spending in 1983), but their contribution increased to 72 as central Government expenditure declined at constant prices in 1983-85. The planned growth in DOH expenditure in the period 1989-1992 is to be funded by a significant increase in the taxation effort of the central Government from a growing GNP. This appears to be realistic if present efforts are sustained: central Government tax revenue has increased from 11.51 of GNP in 1985 to 14.7S in 1987. The forecast rate for 1992 is 14.72 of a larger GNP. C. Sectoral Issues 2.24 Increasing Incidence of Major Communicable Diseases. The combination of past organizational and structural changes in national disease control programs and reduced financial resources has resulted in weak and ineffective programs and an alarming increase in the incidence of disease. Management of the control programs suffered greatly in the early 1980s from the rapid decentralization of responsibility which occurred without adequate provision for continued technical supervision, from dependence on untrained multipurpose field personnel as program staff and from sharp declines in supplies of drugs and other program materials. Vector control efforts for many prograwn diminished sharply with the new reliance on voluntary (and usually unskilled) workers to carry out complex and sometimes unpleasant program tasks. Inadequate transport and storage arrangements led to shortages in all types of program materials. There were also no mechanisms under the decentralized system to readjust specific intervention strategies when such strategies became inappropriate over time, as when certain drugs lost their usefulness due to parasite resistance. 2.25 Weak Maternal and Child Health Services. Maternal and child health activities within DOH have been highly fragmented in the past. Unlike the categorical disease programs, which typically have clear geographical foci, single chains of institutional command within the DOH, employ uni-purpose workers and receive funding from a single external source, DOH's MCH activities overlap with those of many other health programs and have suffered from the lack of a clear integrating strategy at the service delivery level. The situation for child health services has improved somewhat in recent years, as major donors such as USAID and UNICEF have provided support for a range of child survival activities. Services to minimize the risks associated with pregnancy and childbearing have not received similar levels of support. 2.26 DOH's Institutional Weakness. Structural weakness in DOH management systems was partially addressed by the recently completed reorganization. As a result, more focussed targeting of services to clients is being undertaken, and critical operating systems such as procurement and budgeting are being streamlined. WHO and USAID supported development of a health information system and the Population II Project (Cr. 923-PH) provided the DOH with microcomputer and radio communication equipment at central and regional levels. Much, however, remains to be done to overcome past institutional neglect and deterioration of assets. Basic health systems at the field level have received little upgrading for years while field personnel skills now lag behind the demands placed upon them. - 10 _ 2.27 Many of the institutional weaknesses of DOH can be traced to the failure of the health system to expand its resources to match increases in population size and changing service demand patterns. When resources have been available, their impact was often diminished through wasteful duplication of effort in areas such as training; information, education and comiuncation (IZC); and evaluation. Although substantial amounts of government and external support have been used in these three areas, in particular, the impact of these investments has been limited. 2.28 One of the major policy changes initiated by DOH in the early 1980s was the attempt to decentralize the administration of health services (see para. 2.14). The attempted decentralization is generally viewed as having been implemented too fast and by fiat vithout adequate preparation. As DOH has moved ahead of other Government agencies in implementing decentralized activities, it has had to develop wholly new policies to deal with new administrative situations. Each level of the DOH system, beginning with the RHUs and moving upward through district, provincial, regional and central levels, was confronted with policy and procedural demands new to it. Planning, budgeting, procurement and financial responsibilities, formerly exclusively the domain of the central and regional DOH, were given to lower levels, but these levels were poorly prepared to handle the new management responsibilities. 2.29 Limited DOH Capacity to P'an, Monitor and Evaluate the Health System. Further efforts to decentralize DOH are likely to flounder without substantial upgrading of existing systems for budgeting, accounting and auditing of DOH programs, for collecting and processing data on health status and health management, and for strengthening procurement and logistics. At present, Government budgeting systems make it very difficult for line agencies to track program inputs against desired outputs. Funds allocated to DOH for a given program and spent at the center can be monitored with reasonable certainty, but health activities implemented at the provincial level or below are financed from a lump-sum allocation provided to the provincial health officer. As a result, despite guidelines from the center regarding relative priorities and targeting among various health programs as well as between preventive and curative health functions, the DOH has had difficulty in determining whether such expenditures adhere to department priorities. 2.30 Health statistics and health management data systems have been weakened by a variety of problems, including lack of uniformity in reporting by geographical region, large amounts of health provider time required for report preparation, significant loss of data during transfer from one level of DOH to another, inefficient manual processing of data and inadequate standardization of format, content and management of health records. These systems moved data upwards through the health system to fill its multiple requirements but did not allow for data analysis, with the result that lcier levels of the system received little or no feedback. Over the past decade, substantial amounts of external assistance, notably from the Bank Group, USAID and WHO, have gone into the development of DOH health and management information systems. - 11 - 2.31 Need to Reach Impoverished Communities. The DOH has designated about 452 of the country's barangays as *hardship areas for which the standard health service delivery mechanisms are inadequate. Innovative and integrated approaches to commnity health development are required to raise the health status levels of these communities to the existing national average, thus reducing current marked regional health disparities. The mobilization of latent communit7 resources for health will be needed if major improvements in health status are to be achieved and sustained. To this end, the DOH has recognized the need to forge viable partnerships with MGOs and local government units in order to address the needs of commnities for which the standard interventions have not succeeded. The partnership arrangement is expected to enhance the flexibility of existing DOH programs and supplement its technical resources with the community development skills of the NGOs. 2.32 Inequitable Distribution of Health Services. The Governament spends most of its health resources on curative care, and since 1982 the proportion. spent for preventive care has been declining. Between 1981 and 1985 the proportion of Government spending for preventive care fell from 372 to 282; in contrast, the proportion of Government spending for curative care rose from 54Z in 1982 to 63Z in 1985. A large part of public spending on curative care went to support public hospitals: such expenditures rose from 552 of total DOH expenditures in 1981 to 71? in 1985. 2.33 The distribution of facilities for curative care is also skewed, as private hospitals are largely concentrated in the urban areas of the country. The National Capital Region accounted for nearly one third of the total number of hospital beds (90,000) in 1985 and had a bed-to-population ratio of 1:234, which is significantly less than the national average of 1:607. All the other regions were above the national average. Health providers also tend to be concentrated in urban areas. For example, DOH doctors are highly concentrated in Luzon, while continuing vacancies exist for rural health physicians. Regional per capita health expenditures reflect the regional/urban bias, with only the National Capital Region and kegion II (northwest Luzon) consistently having per capita expenditures above the national average during 1981-1985. 2.34 Policy Research Needs in Health. Policy development in health has traditionally been undertaken by the DOH in response to requests from outside, either from possible external funding agencies or as part of an upcominig national development plan. Only rarely have these analyses been applied to ongoing programs or used as the basis for the development of new ones. Now, however, as demand for health services grows in tandem with population increases, and continuing resource constraints place limits on the services that can realistically be provided, DOH needs to be guided by clear policies and priorities in its provision of services. Furthermore, since various agencies can ultimately affect the outcome of health and nutrition programs, a mechanism is needed by which DOH and other concerned agencies can jointly formulate sound policies; at present, no such mechanism exists. - 12 - D. Government Policies and Strategies 2.35 Government Policy and Objectives. The Government's Medium- Term Development Plan (1987-1992), updated in July 1988, articulates a health development policy which aims to: (a) expand and improve comnmuicable disease control, with emphasis on the targeting of areas with the greatest needs; (b) strengthen decentralization of the health network and collaboration among DON, local governments, private providers of health services and NGOa in the development of effective coemunity-based services: (cc strengthen planning, management, coanmication and evaluation capacities of the health sector; (d) strengthen the regulatory functions of the Government and balance public and private sector roles in the provision of curative care; (e) expand investments in the health sector and broaden the mechanisms for financing health services; and (f) promote responsible parenthood and strengthening of family planning. Annex 8 summarizes the goals of the plan. In 1987, a new family planning policy was adopted that promotes responsible parenthood and individual choice in controlling fertility among medically safe methods, except for abortion. The policy assigns DOH the responsibility for the delivery of family planning services, including support to NGOs and other government agencies. 2.36 To address the broad range of issues facing the sector, the Government's strategy is to allocate increased resources to the sector while seeking efficiency improvements, and to emphasize improvements in public and primary health care in the near term, while laying the groundwork for improvements in curative care service delivery and financing in the longer term. Already, the new administration has taken important initial steps toward these ends. Since 1987, an increasing share of government expenditures has been allocated to health, and this trend would continue in the 1989 budget (para. 2.21). A new drug policy has been adopted that is expected to improve significantly cost-efficiency in drug use and procurement. A new Health Information System (HIS) has been developed with assistance from USAID and WHO, and DOH has made substantial progress in designing and testing a new program budgeting system and in revising the design of its Management Information Systeni (MIS). The DOH has increased immiunization coverage, improved program performance in diarrheal disease control and launched a program for the control of acute respiratory infections. To extend the effect of the still very limited resources available for health, DOH has also developed a new, revised community health strategy designed to minimize regional disparities and to focus priority preventive health resources on groups and geographic areas of greatest needs (para. 1.2). E. Bank Group Role and Strategy 2.37 Experience with Previous Projects. The Bank Group's health sector project work in the Philippines began over a decade ago with a first Population Project (Ln. 1035-PH), followed in 1979 by a second Population Project (Cr. 923-PH). The most significant activity under the first Population Project was DOH's hiring, training and utilizing of midwives under a restructured health care delivery system: this component helped improve the quality and availability of health - 13 - services in rural areas. The Project Performance Audit Report (PPAR No. 5544) for Population I noted that benefits from the midwives were likely to be sustained over the long term and also noted that the DOB'e major policy initiative of introducing a decentralized nationwide PHC system under the Second Population Project was made possible because of the availability of the trained midwives in many parts of the country. Both projects suffered, however, from disbursement lags due in part to inadequate counterpart funds and in part to cumbersom Government procedures for transferring money between Government agencies. The Population St Special Account, which was established several years after effectiveness to alleviate some of these problems, became itself an example of many of these difficulties. Review of its procedures showed that the Special Account merely serves as a bookkeeping account for the DOH within the Central Bank and is subject to the same restrictions as DOH's regular budgeted funds. The proposed project includes disbursement and funds flow procedures designed to reduce the implementation delays which affected both previous projects. 2.38 Schistosomiasis control activities have been undertaken as components of four previous Bank projects, including National Irrigation I and II (Loans 1414-PH and 1526-PH, respectively), Rural Development II (Ln. 1421-PH) and Samar Island Rural Development (Ln. 1772-PH). Malaria control activities were undertaken as part of the Medium Scale Irrigation Project (Ln. 1809-PH). Bank financing for these disease control activities amounted to about US$27.0 million. These activities were executed successfully and on time by DOH, and schistosomiasis has ceased to be of public health importance in the areas covered by these components. 2.39 Rationale for Bank Involvement and Lending Strategy. Through its involvement in the two previous population projects, the Bank has played an important role, not only as a provider of resources for the expansion and improvement of the Government's family planning and health development programs, but also as an active participant in policy dialogue with the Government and other major donors to the sector. The proposed project would continue and expand this dialogue and would serve as a vehicle for the absorption of significant grant assistance to the sector through cofinancing. The project would thus assist the Government in addressing priority needs in its poverty alleviation efforts and would support the recommendations of the previously-mentioned Bank study of poverty in the Philippines (para. 1.1), which identified priorities for action, including expansion and improved targeting of public health and nutrition expenditures and measures that would support maternal and child health services, fertility reduction and community-based health initiatives 2.40 It is expected that activities initiated under this project would enable DOH to begin to address the longer term issues facing the hospital sector aad the health finance sector and that this process could result in another Bank-assisted project in these areas. - 14 - III. THE PROJECT A. Proiect Obiectives 3.1 The project is intended to support the Government's priorities to expand and improve public and primary health care, especially for high-risk groups; strengthen the efficiency and effectiveness of the DOug promote collaboration among the Government, local co sunitieu and NCOs in meeting counaity health needs; and establish improved mechanisms for future policy development. Specific objectives of the project would be tot (a) achieve improvements in the control of major communicable and endemic diseases; (b) reduce infant and child deaths as well as maternal mortality and fertility; (c) upgrade institutional capacities of the DOH at all levels to improve program effectiveness and managerial efficiency; (d) promote health equity by targeting services to presently under-served areas and high-risk groups according to degrees of risk and/or disease prevalence; (e) strengthen partnerships among the DOH, local governments and NGOs to improve the health conditions of local residents hile at the same time developing local capabilities for participatory planning and self reliance in undertaking community health projects; and (f) establish improved planning and consultation mechanisms for longer-tetm improvements in health policies and programs. B. Project Description 3.2 The project, with base costs of US$93.9 million equivalent, would be implemented over six years. The start date would be February 1989 when initial expenditures under the Japan Grant Facility were made. It would consist of the following components: (i) Four DOH Impact Programs (US$46.0 million base cost), comprising: (a) Malaria Control Program (US$19.8 million base cost). This component would assist the Government in reducing malaria to a level that no longer constitutes a public health problem, and would include: (a) drugs and equipment for epidemiological surveillance and treatment; (b) pesticides, equipment and vehicles for vector control, including residual spraying and elimination of breeding sites; (c) technical assistance for operations research and evaluation; and (d) incremental operating costs. - 15 - (b) Tuberculosis Control Program (US$14.9 million base cost). This component would strengthen the National Tuberculosis Control Program through improvements in case-finding, at- home patient treatment and follow-up of cases and would include: (a) drugs for tuberculosis treatment; (b) equipment, vehicles and materials for the upgrading of selected microscopy centers in existing health facilities for case identification; (b) staff training; (c) technical assistance for research and evaluation; and (d) incremental operating costs. (c) Schistosomiasis Control Program (US$8.3 million base cost). This component would assist the Schistosomiasis Program to sharply reduce the prevalence rate of the disease in schistosomiasis-infected areas to about 12 of the exposed population over the five-year project implementation period and would include: (a) drugs, equipment, vehicles, materials and technicel assistance for case-finding and for snail control; (b) drugs for treatment of the disease; and (c) incremental operating costs. (d) Maternal and Child Health Program (US$3.0 million base cost). This component would strengthen programs designed to reduce illness and death for women and children through the provision of micro-nutrients for both groups and support for the ARI program (para. 2.5) and would expand health and family planning services by the employment of 2,000 additional rural health midwives included under the Strengthening the DOH's Institutional Capacity component (below). The MCH component would include: (a) vitamin A and iron nutrient supplementation to strengthen childhood resistanice to disease, iron to reduce maternal anemia and vitamin A to prevent and treat xerophthalmia blindness; (b) drugs and equipment for treatment of ARIs; (c) materials, training and technical assistance to improve seriice delivery; and (d) incremental operating costs. (ii) Strengthening the DOH's Institutional Capacity (US$38.4 million base cost). This component would support the DOH's efforts to upgrade its operating and management systems by, among other things, improving management information and communications systems, planning and bldgeting procedures and capabilities and services delivery capacity. Funds would be provided for communications and information equipment and materials, laboratory equipment, vehicles for field units, IEC materials, provincial planning seminars, staff training, technical assistance, project staff on contract, and incremental operating costs. (iii) Community Health Development (US$8.9 million base cost). This compoG,ent would provide direct grant support for the organizing and implewenting of provincial-level partnerships - 16 _ between government and NGOs to facilitate local coumunity action. The project would provide planning and project grants to consortia composed of local governments, field offices of the DON and NGOs to carry out coanity health development activities. Funds would be provided for grants, computer materials and progrm manuals, equipment and one vehicle, technical assistance and training, and incremental operating costs. (iv) Policy Development (US$0.6 million base cost). This component would provide technical assistance, contract staff and studies to support the establishuent of institutional arrangements to facilitate improved planning as well as policy and program development. C. Detailed Project Description Strengthening DOH Health Impact Programs 3.3 Malaria Control Program (MCP). Malaria remains a major health problem in the Philippines. The resurgence of the disease during the years of decentralized malaria services since 1983 attests to the steady deterioration of control efforts. Under the DOH decentralization, the program's separate management structure was merged with that of other primary health care programs, resulting in a significant dilution of technical supervision efforts. Uni-purpose malaria program workers were converted to multi-purpose workers who now had many new demands on their time, and materials and supply management deteriorated. The primary health care program goal of having multi-purpose workers provide services under all health programs was too ambitious. The new reliance on volunteer workers worked less well in categorical (single-purpose) health programs as such workers often lacked special skills, and dropout rates from the program were h_gh. Malaria transport vehicles were diverted to other programs; this diversion led to continuous shortages of important supplies for the program. (See Map IBRD 21389.) 3.4 With the return to a focussed approach to disease control and the reestablishment of the MCP, the overall program goal would be to revitalize malaria control and reduce the incidence of the disease to a level that no longer constitutes a public health problem in the country. The project would support efforts under MCP to prevent reestablishment of endemicity in previously malaria-free areas, and to recapture earlier gains. Stratification of areas according to endemicity would be undertaken annually to establish target areas for the following year. 3.5 The major adtivity of the MCP woluld be chemical vector (mosquitos) control in which DDT and other pesticides would be sprayed into about 90 percent of houses in endemic areas. Mosquitoes landing on interior sprayed walls absorb the pesticide and die; at this strength, however, the pesticide is not considered a significant risk to humans and animals. The project would finance the purchase of about 650 tons of pesticides and 1,100 spraycans for use in barangay homes. Spraying schedules would vary in accordance with the annual parasite incidence and would be handled by the provincial level malaria organization. Locally hired and trained - 17 - spraymen would be directed and supervised by squad leaders who would report to a malaria sector chief. The project would provide 90 pick-up vans and 15 pump boats to the provinces for personnel transport. In addition, the RHU health educacors, assisted by the spraying sector chief and crew, would help organize community brigades to eliminate breeding sites through drainage, filling, impounding, and straightening and clearing of stream banks. Use of biological controls, including larva-eating fish and other natural enemies of the mosquito larvae, would also be encouraged. The project would also finance extensive training for spraymen and supervisors. 3.6 Besides the reduction of the malaria mosquito, the project would support the treatment of active cases of malaria throught (a) passive case-finding (investigation of febrile cases); (b) active case-finding (serological surveys); and (c) epidemiological investigation of positive cases. Remedial measures for positive cases would include presumptive treatment throigh the administration of medication, for which the project would finance 380,000 courses of anti-malaria treatment. 3.7 Information about the prevention and treatment of malaria would be provided by the health educators who, in cooperation with provincial coordinators of the MCP, would disseminate information on the transmission cycle of the disease and on personal protection using interpersonal and community-oriented methodologies. Health education programs would promote community treatment of mosquito nets with pesticides to supplement house spraying and the use of other insect repellents. The project would provide support for the development of IEC materials for this purpose under the Strengthening the DOH lnstitutional Capacity component (para 3.37) and for incremental operating costs. 3.8 An important part of the MCP would be operations research. This research would focus on areas most relevant to the implementation of the * intensified MCP and would include the following topics already identified: j (a) testing of new anti-malarial drugs; (b) screening and testing of alternative insecticides; (c) vector control and survei1lance activity evaluation; (d) alternative malaria control measures and (e) community- based approaches to the control of malaria. 3.9 Tuberculosis Control Program (TCP). The main objective of this component would be to assist the DOH in strengthening the Tuberculosis Control Program through support for training, acquisition of drugs and equipment, research, technical assistance and staff salaries. The program would seek to increase tb,'e number of diagnosed and treated cases from the current 160,000 and 90,000, respectively, to 250,000 diagnosed and treated cases, increase the pledge and technical skill of medical and support personnel, and develop an accelerated training program for health providers. The percentage of treated cases would increase from 36Z of the diagnosed cases at present to 1002 of the diagnosed cases by the end of the project. 3.10 To carry out these activities, microscopy centers would be set up in strategic RHUs or hospitals and a medical technologist hired as microscopist for each. Existing centers would be upgraded with adequate equipment, personnel and supplies. In total, about 500 microscopy centers would be established nationwide, of which 208 would be new centers set up - 18 - in areas without reasonable access to existing centers. A total of 800 new binocular microscopes would be purchased for the new centers and as replacements for outdated equipment in existing centers. The microscopist function included in each of the three disease programs has been designed not to overlap. 3.11 The project would support a specialized training program for tuberculosis control. In particular. natioral tuberculosis seminars would be organized to provide training for regional directors, tuberculosis consultants, and regional nurse supervisurs. Seminars would also be held at the regional level for physicians, senior public health nurses and other staff. Training would also be provided for tuberculosis microscopists, modical technologists, senior residents of district and provincial hospitals, and physicians in charge of government and non-government organizations. In addition, the program would undertake the development of an IEC campaign which would focus on the barangay captain-community leaders and NGO representatives. 3.12 The project would provide drugs and equipment essential to the control program, including 185,000 courses of short-course chemotherapy. In addition, the project would finance selected field expenses including staff travel and supervision costs. A total of 56 consultant-months of technical assistance would be provided to strengthen the program and to reinforce, in particular, the training program and studies on progress and effectiveness. 3.13 Schistosomiasis Control Program (SCP). Schistosomiasis is a blood fluke infection which is acquired from water containing larval forms which have developed in snails. Past locally funded programs to reduce the prevalence of schistosomiasis have usually had limited success as they have suffered from shortages of staff, equipment and drugs. Such shortages made it impossible to eradicate the i.termediate host vector (the snail) or to carry out health education/training programs to foster community self- reliance in controlling transmission of the disease. 3.14 With the success of the drug Praziquantel in schistosomiasis treatment, the national control program has shifted its emphasis from disease transmibsion to disease control. The goal of the SCP over the next five years is to reduce the prevalence rate in endemic barangays to about 1Z. The project would finance case-finding and treatment, vector control, and research. 3.15 Under the project, all endemic municipalities would have a schistosomiasis control team consisting of a driver, a stool collector, a public health nurse, and one or more microscopists. The team would carry out stool collection and analysis to determine individual infection, and would provide treatment for all individuals one year old and older. Teams would be provided with a facility for stool examinations, separate from the existing RHUs. The project would provide essential equipment including 200 microscopes. Quality of stool examination would be randomly checked by sending one slide per 10 to 20 slides from those found positive and one slide per 50 to 100 for those found negative for validation and identification of intestinal parasites at regional or district hospitals or other competent laboratories. - 19 - 3.16 To encourage annual testing of persons in endemic areas, stools would be examined for intestinal parasites, and appropriate anthelminthic and hematinic drugs would be administered. Cases would be treated with Praziquantel on scheduled days. The project would provide Praziquantel treatment for about 180,000 patients. Serious cases, as well as severely malnourished infected individuals, would be treated at district hospitals by resident physicians and public health nurses. Treatment vould include other supportive drugs for side reactions. Some 24 vehicles and 170 motorcycles, would also be provided u.:der the project. 3.17 The program would include mapping of snail colonies, especially those close to population centers, clearing of vegetation, and provision of adequate drainage prior to focal application of pesticides to kill the snails. The project would finance the purchase of 9 tons of the pesticide niclosamide for focal mollusciciding, which would be executed by DOH personnel. The clearing of vegetation and drainage works would be carried out with assistance from communities and pertinent government agencies such as the Department of Local Government and Community Development and the National Irrigation Authority. 3.18 Schistosomiasis IEC efforts would be coordinated with the broader DOH health education campaigns. The Research and Training Division of the Schistosomiasis Control Service has identified a series of research topics for support under the project, including drug resistance to Praziquantel and the screening and identification of appropriate molluscicides, plants and synthetics useful for focal mollusciciding aid eventual snail control beyond 1993. The project would also finance, as an operational research project, an attempt to eradicate schistosomiasis in six barangays of Bohol Province. This would involve case- finding, treatment, and focal mollusciciding and would be evaluated after four years to determine the success of specific chemotherapies and focal mollusciciding in interrupting transmission in a clearly defined and easily accessible geographic area. 3.19 Maternal and Child Health (MCH). The DOH has now completed a major redefinition of its HCH program, including risk factors and the corresponding service interventions, in order to package the services for women and children. A classification system would be established to identify high-risk children and barangays in selected provinces through the use of data on health and nutrition status. Areas and households designated as high-risk would be targeted for follow-up services including monthly growth and health monitoring activities by midwives, unlike the standard of quarterly monitoring for non-high-risk areas. Based on the outcomes of the monitoring, micro-nutrient supplementation of vitamin A and iron for moderately and severely malnourished, anemic and xerophthalmic (at risk of blindness) children would be provided. Iron supplies would also be provided to anemic pregnant women. Support would be provided for the employment of nutritionists to help map data to identify high-risk barangays and for the training of DOH staff and community volunteers in improved child care. Mothercraft classes would be given in high-risk barangays to teach appropriate care for high-risk children. 3.20 Under the Strengthening the DOH's Institutional Capacities component (para. 3.34), the project would support the employment of 2,000 additional rural health midwives to work in un- and underserved rural and - 20 _ urban areas. Since midwives provide most of the maternal and child health care available in poor rural and urban areas, and would have responsibility for identifying the need for micro-nutrients, ARI treatment, ante- and post-natal care for mothers and family planning services among the residents of their area, an increase in the number of midwives would increase accessibility to these services. Midwives would also play critical roles in the delivery of comunity-based family planning services, now that the DOH has overall responsibility for the provision of family planning services from the Population Commission. Improved maternal care services would thus help in reducing fertility. 3.21 The project would also support the phased adoption of a simplified procedure for detection and management of ARI cases. Implementation of the new procedures would take place over the life of the project, with provinces and districts witn high infant mortality rates, high ARI child mortality and high malnutrition rates given priority for initial implementation. Following a national preparation conference in the first year, the program would begin to operate in one district per selected province in each of the 13 regions. By Year Two, the program would expand to cover all municipalities of the first implementation province. During Years Three and Four, the ARI program would cover all municipalities in two provinces per region each year. By Year Five, the program would cover the remaining areas except in large regions, where only half would be covered. 3.22 Midwives in the designated barangays and staff at r.earby RHUs would be trained in a simplified protocol developed by WHO to detect and classify ARI cases. Cases once identified would be classified as mild, moderate or severe and treatment begun accordingly. For mild cases, only supportive treatment with no antibiotic would be required. For moderate and severe cases, antibiotics would be administered by the midwives, with hospital referral where possible. Regional, provincial and district-level trainers would be trained in Manila with WHO funds or in ARI training units in the regions in preparation for the region-or province-wide training of frontline service workers. Antibiotics, timepieces with alarms for use in counting respiratory rates, and oxygen concentrators would be provided for identification and treatment of cases. The project would also provide technical assistance for the development of detailed ARI guidelines focussing on case management at the BHS (para. 2.11), RHU and small hospital level, and these manuals would be distributed to involved health facilities. Funds for ARI-related staff travel would also be provided. 3.23 Given the synergistic relationship between infection and malnutrition, project assistance would strengthen two major elements of the child health program which now lack adequate support -- establishment of an ARI program to combat the leading cause of death among children in the Philippines and expansion of the existing small micro-nutrient program for high-risk children. 3.24 Other MCH activities including immunization, oral rehydration, family planning and other core MCH activities are expected to be assisted by USAID direct budget support to the DOH's MCH program. - 21 - Institutional Strengthening of the DOH 3.25 To assist DOH to modernize its operational and management systems and enhance its responsiveness to its priority programs and clients, the project would strengthen the Department's capabilities at the various administrative levels and in a number of specific functions. This would include improving its regional and provincial health planning capacity and field services as well as its overall cos=nication system, central laboratory, capability to carry out information, education and comunnications programs, training capacity, anc' project management, coordination and evaluation capabilities. Thus strengthened, DOH will be better equipped to carry out its priority impact programs as well as its other activities. 3.26 Strengthening Information and Communication Systems. To improve the transfer of information within DOH and facilitate effective management of operations, the project would support the establishment of a national information communication and management network for DOH, comprising some 120 central, regional and provincial sites utilizing packet radio. Packet radio combines 2-way radios and computers, allowing the error-free exchange of printed data while permitting the computer and radio to be used separately for other day-to-day activities. Where electricity and telephones are inadequate, the DOH's packet radio-computer network would be fueled by solar power. This low-cost network permits rapid, countrywide aggregation and analysis of management information data. Existing management and educational functions of the DOH requiring frequent and timely communication of information at all levels of the DOH would be supported by this on-line network. This support would include the communication of field epidemiological surveillance data, HIS data, MIS data and financial management information, including budget, procurement and expenditure data. Chart 4 provides a diagram of the proposed information and communications system and Chart 5 provides a diagram of the proposed packet radio system. 3.27 A feasibility study on the use of packet radios to transmit digital information from remote sites in the Philippines to the central office was completed during project preparation. A second-stage feasibility study to establish seven Beta sites (test sites forming part of a completed and operational network) is now in progress. The project would support the implementation of a nationwide network involving the establishment of approximately 120 such sites. The project would also support the acquisition of about 101 high frequency and 585 very high frequency radios for use in communications from provincial health offices to municipal health offices and RHUs. Equipment, materials, technical assistance and fellowships in information systems maintenance would be provided along with a vehicle for the central MIS unit. 3.28 The newly developed HIS is expected to simplify existing DOH reporting systems for health statistical data and facilitate the production of useful analyses for planning, budgeting, monitoring and evaluation. The new system, developed with USAID and WHO support, is being installed and assessec in four regions, and its expansion and computerization nationwide would be assisted under the project. This assistance would include consultants for the production of manuals and HIS forms, staff training an,d - 22 - a vehicle for the central HIS unit. The project would also support the establishment of a central geographic information system for use in mapping public health problems (malaria, for example) and micro-variations ir. coanity risk or health status requirlng spatial reporting and trend analysis. 3.29 The project would support development of a DON MIS to expand and upgrade the current small separate systems being used in various parts of the DOH. Routine informtion now being generated would be assessed for computerization and appropriate software developed to facilitate and speed up routine operations that affect management decisions. Technical assistance to evaluate the computer-readiness of key DOH operations at the central and field levels would be provided in the initial years of implementation. Specific units targeted for assessment include the financial subsystems, logistics, personnel management and management (with special priority on impact programs) and community health services. 3.30 The project would strengthen the MIS through the acquisition of about 300 microcomputers and the training of staff in computer operations. These computers would be installed in the various DOH units and linked with the MIS through the packet radio communications system. Technical assistance would be provided (a) to undertake a national assessment of the materials supply system, including the warehousing and distribution systems at sub-national levels and needeu computerized inventory systems for critical medical supplies and contraceptives and (b) to develop operating manuals for these systems. 3.31 DOH accounting and budgeting systems would receive support through technical assistance to develop financial operations manuals incorporating government-wide systems, staff training in financial operations and in computer skills. A system of health mapping and area classification would be established, building on the existing activities of the malaria and schistosomiasis programs. The project would provide materials, staff training and technical assistance to get the mapping system underway. A desktop publishing system would also be provided to facilitate the production of DOH manuals and IEC materials. Chart 6 provides a diagram of the proposed desktop publishing system and Chart 7 provides a diagram of the proposed data file management design. 3.32 Strengthening Regional and Provincial Health Planning Capacity. Under the DOH's decentralization, each province would be required to develop a five-year strategic plan to target health services to priority communities. During negotiations, the Government provided assurances that a written directive from the Secretary of Health requiring this action from each province would be issued by March 1, 1990 and that each province would submit its plan to DOH by October 30, 1990. The project would support the development of organizational and coordination skills for health planning and programming, including development and implementation of a six-stage learning module for provincial and regional health planners. To implement the modules, a series of planning seminars would be held, followed by on-the-job practice in applying the skills learned to actual provincial and regional health needR. In addition to annual strategic plans, by the end of Year Two of project implementation, all 12 regions would have completed their five-year health development plans and budget - 23 _ proposals which would in turn form the basis for the next national health plan. The project would provide two microcomputers, technical assistance, workshops for DOE, staff and operating costs to carry out these activities. 3.33 DOH Field Services. Continuing budget shortages have left DOH's peripheral health facilities with little usable medical equipment, supplies or transport. To address this growing problem, DOH has decided to upgrade RRUs, beginning with 300 located in high-risk comunities. Project support for field services would therefore be provided at the RHU level. Utility vehicles would be provided to each province (one vehicle per every three districts) and to each of the 300 priority REUs. In addition, 15 delivery vans would be provided to bring supplies from the regional center to the provinces and districts. The project would finance technical assistance for development of a program management manual for distribution to each RHU and would provide each of the 300 priority RHUs with a small additional yearly allocation for operational expenses. 3.34 The project would also assist DOH in increasing the number of midwives currently employed to about 12,722, from the 10,722 now serving 42,000 barangays across the country. In many areas at present, the anticipated number of midwives is inadequate at the same time that the midwife workload has expanded rapidly. The project would support the hiring of an additional 2,000 midwives, who would serve in high-risk rural and urban communities. The closing of the puericulture centers in urban areas and consequent release of several hundred midwives, added to an existing surplus of trained midwives would permit the hiring of this number of midwives during the project period. 3.35 Strengthening the DOH's Central Laboratory. The DOH's central laboratory lacks the equipment and trained staff necessary to offer adequate diagnostic and management support to DOH field operations. The project would upgrade laboratory facilities through the provision of improved equipment for laboratory operations in various public health disciplines. It would also provide technical assistance in laboratory administration and 39 overseas fellowships for central laboratory technicians to permit staff to acquire the skills needed to manage a modern public health laboratory. 3.36 Strengthening Information, Education and Communication (IEC). The capacity of DOE to develop and distribute effective IEC messages to its staff and clients is still being developed. Past DOH IEC efforts to communicate health behaviour messages were supported primarily by external funds, inevitably on a piecemeal basis, while locally funded programs have rarely had an IEC budget. As a result, many short-lived, narrowly focused programs were developed, with varying degrees of effectiveness. Although there are a sufficient number of IEC staff in the Public Information and Health Education Service, few have received training in IEC. As a result, many of the achievements of past IEC campaigns have been lost. 3.37 The project would support the development of an integrated IEC capability which would have as its goal the creation of integrated messages aimed at bringing about health behavior changes in target groups. This approach would replace past IEC efforts which focused on the materials - 24 - development, rather than the distribution, stage of a campaign and on the production of many specific, rather than a few integrated, messages. As part of project preparation, the DOH has prepared an overall IEC plan, and the project would provide the equipmnt and staffing inputs to implement the overall plan. The project would provide equipment, including a desktop publishing system, an audiovisual production and editing set, and IEC kits for each of the midwives. It would also provide IEC materials, in the form of posters, brochures, flip charts, billboards, a newsletter for DOH field staff and audiovisual supplies. The printing of smoe of these materials would be done on the printing press provided under the Bank-assisted Population II project. Technical assistance would be provided to help develop the prototype materials, and five new staff members including an editor, a layout artist, a desktop publishing technician and two feature writers, would be employed for the project period and would report to the chief of the Public Information and Health Education Service. The proposed IEC activities are shown schematically in Charts 8 and 9. 3.38 Strengthening the DOH's Training Capacity. The DOH has carried out a substantial amount of staff training, much of which has experienced difficulties similar to those of IEC campaigns. Until recently, training courses were usually developed and presented by staff of a upecific health program, and, as with IEC, with little regard for the needs of other programs. This approach has led to problems of overlap among courses; for example, in one year there were over 100 separate courses for DOH physicians causing substantial numbers of key staff to spend large amounts of time away from their workplaces. 3.39 The project would support a reorientation of DOH training from a focus on particular programs to a focus on the needs of specific levels of operation (such as that of the RHU) and those of specific categories of staff (such as midwives). Financing would be provided for development of basic, advanced and specialized courses for key DOH staff categories based on the overall needs of their jobs. A master training plan which incorporates both technical program and management procedure needs has been developed by DOH's Training Task Force. 3.40 Initial financing would he provided for technical assistance to carry out job content assessments of the key staff categories, and these assessments would then become the basis for curriculum and training course development. In some cases, courses would be developed for entire work units, such as financial administration, in order that the unit might better perform unit tasks. The project would provide basic training equipment for each of the 15 regions, including overhead projectors, VCRs with cameras and monitors, public address systems, and copier and mimeograph machines. It would also support 100 months of local technical assistance to help prepare the curriculum for the new training scheme. The training courses themselves would be supported under the project throughout the five years of implementation, and operating costs would be provided. Chart 10 provides a diagram of the proposed DOH training. 3.41 Project Management and Coordination. The project would provide support for project management and coordination activities. Office equipment and three microcomputers would be provided, as would two passenger vans and one sedan. Management skills in project coordination - 25 - would be upgraded through the provision of technical assistance, and contract staff would be hired for the life of the project, including a project coordinator, a project monitor analyst, four project staff assistants, a project accountant and a project secretary. 3.42 Zvaluation. The project would support improvements in the DOH's program evaluation capabilities. Technical assistance would be provided for evaluation design and implementation of needed baseline surveys, miu.- term assessment and end-of-project surveys. The baseline sample survey would be carried out at the start of the project, the mid-term survey midway through implementation and the end-of-project survey in the final year of the project. In measuring impact, the evaluation of the Strengthening the DOH's Impact Programs component would focus primarily on morbidity and mortality indicators. The evaluation of the Strengthening the DOH's Institutional Capacity component would focus on efficiency indicators such as time and cost savings and process indicators such as improved communication and coordination, as perceived by managers in both the Hanila office and field offices. The Community Health Development component evaluation would focus on equity indicators, such as the extent to which health conditions in depressed and deprived communities were raised relative to the average, and the qualitative factors which help explain such effects. Community Health Development 3.43 The promotion of community health deve'opment among selected disadvantaged communities would be achieved through targeted efforts to mobilize technical, social, economic and cultural resources in order to raise community health awareness, stimulate at-risk households and community members to take concrete steps to improve their own health conditions and sensitize the health system to be more responsive and creative in its delivery of basic health services. Specifically, the project would: (a) develop organizational and coordination capabilities for health planning and programming for disadvantaged communities among NGOs, local government units and DOH field units operating at the provincial and city level in 15 provinces/cities; (b) set up decentralized mechanisms for programming and management of funds at the provincial level; (c) build community organizational and technical capabilities for planning and managing community health-related self-help projects; and (d) provide a grant funds facility for community health projects. Chart 11 indicates the organization of the component. 3.44 The project would support technical assistance to the DOH's Community Health Service (CHS) in order to build up its technical and managerial capability to plan, monitor and coordinate the community health development process using the decentra-ized partnership approach. Observation tours and visits to existing projects with successful community health development experience would form part of the learning process for CHS staff. These activities would be supplemented by project-sponsored training to learn more about monitoring and coordinating community health development. 3.45 A Committee for Community Health Policy would be established by the DOH at the central level with CHS serving as its secretariat. During negotiations, the Government provided assurances that the Committee would - 26 - be establlshod and fully staffed by January 1, 1990 according to criteria developed during project preparation. The Committee would be responsible for settLng general policies and guidelines for the community health program and would also serve as the project review board to evaluate all project proposals submitted for funding under this component of the proposed project. Coeimittee members would include the DOH's Chief of Staff as Chairman, the CHS Chief, the Chief of Management and Finance, a Comission on Audit (COA) representative and representatives of regional health offices and of provincial consortia involved in the component's activitLes. 3.46 The regional health offices in the five involved regions would serve as !he technical and administrative link between the CHS and the provincial consortia. These offices would receive technical and training assistance to develop their capability for planning, monitoring and coordinating commiunity health development activities. 3.47 In the selected provinces, consortia composed of participating partner agencies would be established, with the CHS and local consultants administering the preparatory and organizational activities. During negotiations, the Government provided assurances that participating NGOs and other community-level organizations would be selected in accordance with criteria and procedures satisfactory to the Bank. Orientation sessions, staff development and planning activities would be arranged by the CHS with assistance from local consultants. The outcome of these activities would be the organization of the provincial consortium in each of the 15 provinces/cities. Roles, functions and responsibilities of each consortium member would be defined as part of this process. Training courses, observation tours and fellowships would be provided to consortium participants. 3.48 Technical assistance would be extended to provincial consortium members by the CHS and others to facilitate preparation of the project proposals. These proposals would be eligible for grant funding assistance subject to the criteria and guidelines established by the Community Health Policy Committee. Priority barangays for receipt of project support would be identlfied by the provincial consortium, subject to the criteria set up by the Committee and consistent with each provincial health plan. The provincial consortium would meet regularly for purposes of planning and decision-making. Support would be provided under the project for monitoring visits to oversee development activities in targeted communities. 3.49 A fund of US$9.1 million equivalent (including contingencies) for community health development would be established, auG would be managed by the CHS, subject to the criteria and guidelines of the Committee. The project would provide funds for provincial planning grants and for project implementation grants to be allocated through this facility. The grant funds provided to these consortia would be used primarily for projects that build up community- level capabilities for self-management and for community-identified health and health-related projects with grant funds divided about 25:75 between the two activities. About 252 of the grant funds would be allocated for administering the capacity-building activities at the community level. The balance of about 751 of the total would be used to finance community health projects identified by the community - 27 - through participatory processes. Pertinent requirements of the Department of Budget and Management and the Commission on Audit would be applied in approval of projects by the DOH. MonitoEing of fund use and implementation of proposed community health development activities would be done by the CHS and corresponding regional health offices. During negotiations, the Government provided assurances that a DOH directive would be issued by January 1, 1990, establishing the fund and setting forth its operating guidelines and procedures on terms and conditions satisfactory to the Bank. Policy Development 3.50 In order to strengthen the capacity of the DOH to identify and analyze important health policy issues and facilitate consultation among concerned groups, the project would support the establishment of an improved mechanism for health policy development and would provide funds for studies. 3.51 A National Council for Health Policy Development would be established. Members of the Committee would include senior representatives of the DOH, the National Economic Development Authority (NEDA), the Department of Budget and Management (DBM), the COA, Congress, other concerned agencies and the private sector. A technical secretariat would be established to provide staff support to the Committee. The Committee would identify priority issues requiring investigation, appoint ad hoc commissions to carry out needed studies, and adviEe the DOH on future policy directions. The project would provide technical assistance and contract staff salaries for the secretariat and for the carrying out of appropriate policy. It is expected that an early priority of the Committee would be a review of the institutional, financial and structural needs of both public and private hospitals in the Philippines, and the development of an action plan to address problems in the hospital sector. During negotiations, the Government provided assurances that the National Council for Health Policy Development with terms of reference agreed with the Bank would be appointed by March 1, 1990. IV. PROJECT COST AND FINANCING A. Costs 4.1 The total cost of the project is estimated to be US$108.4 million equivalent, net of duties and taxes. Foreign exchange costs account for US$40.6 million, or 37? of project costs. Base costs are estimated at US$93.9 million (872) and contingencies at US$14.5 million (13Z). There are no physical contingencies in the project. Annual price contingencies are as follows: for foreign exchange expenditures, 5.31 in '990-91 and 4.12 thereafter; for local costs 92 in 1990-91 and 82 therea.ter. Project costs by component appear in Table 4.1 below. (See Annex 9-11) for further cost details.) B. Financing 4.2 Of the total project costs of US$108.4 million, US$25.9 million equivalent would be financed by the Government and US$70.1 million equivalent, representing 65? of total project cost net of duties and taxes, - 28 - by the proposed Bank loan. Grant cofinancing on a parallel basis would be provided by the Government of Italy to support the tuberculosis program (US$ 8.1 million equivalent). The Government of Japan would finance technical assistance and training (US$4.3 million equivalent) from the Japan Grant Facility. Table 4.1 Proiect Costs Estimated Costs La Local Foreign Total (USS Million) Strengthening DOH Impact Programs Malaria Control Program 9.2 10.6 19.8 Tuberculosis Control Program 7.6 7.3 14.9 Schistosomiasis Control Program 4.8 3.5 8.3 Maternal and Child Hea.th 0.7 2.3 3.0 Subtotal 22.3 23.7 46.0 Strengthening DOH Institutional Capacity DOH Information Systems 1.7 2.1 3.8 Regional/Provincial Health Planning 1.6 - 1.6 Field Services 9.5 7.3 16.8 Central Laboratory 0.6 1.7 2.3 Project Management 0.7 0.1 0.8 Information Education & Communication 1.8 0.3 2.1 Training of DOH Staff 6.7 0.1 6.8 Evaluation 1.3 - 1.3 Project Preparation/Start-up 1.7 1.2 2.9 Subtotal 25.6 12.8 38.4 Community Health Development Community Health Development Fund 7.4 - 7.4 Community Health Systems Support 1.2 0.3 1.5 Subtotal 8.6 0.3 8.9 Policy Development Subtotal 0.6 - 0.6 Total Base Costs 57.1 36.8 93.9 Price Contingencies 10.7 3.8 14.5 Total Project Costs /a 67.8 40.6 108.4 /a Does not include duties, taxes or fees, estimated at US$2.6 million. _ 29 - C. Procurement 4.3 Procurement planning is at an advanced stage, with preparation of most specifications and some bidding doc ients completed. No civil work. are included. Drugs, pesticides, equipment and vehicles totalling US$28.9 million would be procured by International Competitive Bidding (ICI) subject to ptior review, and would be financed by IIBD. The preference for local manufacturers described in Appendix 2 of the Bank's Procurement Guidelines would apply to ICB. ICB vould be used for any procurement with an expected contract of more than US$200,000. Limited international bidding would be authorized for the purchase of DDT under the Bank loan due to the limited number of suppliers, and would cost about US$1.5 million. Limited international bidding transactions over US$200,000 would also be subject to prior review. Although most of the drugs and pesticides would be procured generically it may be necessary to provide some drugs or pesticides which are proprietary; such requirements would be reviewed by thc Bank on a case-by-case basis. Local Competitive Bidding (LCB) totalling about US$6.2 million would be used under the Bank loan for drugs, equipment, materials, locally contracted training, planning services and contract staff expected to have a value of less than US$200,000. DOH procurement procedures and policies for LCB have been reviewed and are acceptable to the Bank. All consultants financed by the project would have qualifications and experience satisfactory to the Bank, and would be employed in accordance with 'Guidelines for the Use of Consultants by World Bank Borrowers., 4.4 Community health development grants totalling about US$9.1 million would be made by the Government. Local and/or international shopping may be used for transactions not exceeding US$25,000 each up to an aggregate total of US$1,500,000. This authority would apply tc the DOH central procurement unit and also to recipients of Community Health Development grants. The aggregate shopping expenditure record would be maintained by the DOH's central procurement unit. Local or international shopping would usually require three or more quotations, and acceptance of the lowest quotation. Review by the Bank would be ex post on a sampling basis. 4.5 Procurement under the Italian Grant would be tied. Procurement under the Japan Grant Facility would be done according to Bank Guidelines. - 30 _ Table 2 Procurement Arrangements (USS Million) Procurement Method Tied Italian Project Element ICB LCB Grant Other Total Drugs and 13.8 0.7 6.9 1.5 La 22.9 Pesticides (13.8) (0.7) (1.5) (16.0) Equipment, Vehicles 15.1 5.5 1.0 - 21.6 and Materials (15.1) (5.5) (20.6) Grants - - 9.1 9.1 (9.1) (9.1) Training, Technical - - 0.2 16.1 16.3 Assistance and Planning Seminars (14.4) (14.4) Contract - - 15.9 15.9 Staff (10.0) (10.0) Project Preparation/ Start-up - - - 2.9 2.9 Staff Travel - _ _ 5.4 5.4 Salary - - - 14.3 14.3 TOTALS 28.9 6.2 8.1 65.2 108.4 (28.9) (6.2) (35.0) (70.1) Note: Figures in parentheses ar3 the respective amounts financed by the Bank. /a DDT by limited international bidding. - 31 - D. Disbursement 4.6 The Bank loan of US$70.1 million would be disbursed over a period of seven years on the following basis: (a) 1002 of expenditures for imported drugs, pesticides, equipment, vehicles and materials; 1002 of local expenditures (ex-factory cost) for drugs, pesticides, equipment, vehicles and materials manufactured locally; ar.d ao0 of local expenditures for any other items procured locally (off-the-shelf). Materials include laboratory reagents and supplies; boots; manuals; charts and teaching guides; computer software and supplies; supplementary maintenance support for priority RHUs; and IEC supplies; (b) 1002 of expenditures for consultant's and other services (including salaries of contractual staff) and training; (c) 1002 of grants for services under the Community Health Development component. 4.7 Disbursements would be made against Statements of Expenditure for the following: training; planning and project grants; and contracts costing US$200,000 equivalent or less each for equipment, vehicles, drugs, pesticides and materials. A Special Account in an amount of US$4.0 million equivalent is proposed under the project. The disbursement schedule is provided in Annex 12 and is derived from the Philippines disbursement profile for all sectors. 4.8 In accordance with the agreement (dated June 3, 1987 and an agreement to entered into) between the Bank and the Government of Japan, the Bank would administer both the preparation and implementation grants from the Japan Grant Facility. The Italian tied grant would be made on a parallel basis and would be administered by the Italian Government. E. Accounts, Auditing and Reporting 4.9 The DOH accounting system is adequate to provide information on project finances and expenditures. The Government would cause DOH to maintain separate accounts of project expenditures in accordance with sound accounting practices. Proposals from NGOs under the Community Health Development Component would include related audit and record-keeping requirements. During negotiations, the Government provided assurances that audited accounts and financial statements, including a separate audit of statemerts of expenditure, would be sent to the Bank within six months of the end of each Government financial year. The Government also provided assurances that it would submit semi-annual progress reports to the Bank, provide status reports for visiting missions and prepare, within six months of the closing date, a project completion report. - 32 - V. PROJECT IPLEMENTATION A. Status of Prolect Preparation 5.1 The project was prepared by DOH with assistance from local consultants financed under the Population I1 Project (Cr. 923-PH) and by the Japan Grant Facility. Implementation manuals have been prepared for each component of the project and would be reviewed during negotiations. A detailed project procurement plan satisfactory to the Bank has been completed, as have detailed implementation plans for IZC, training and evaluation. The first stage of the packet radio conunications activity (para. 3.26) was satisfactorily pilot-tested in late 1988 by DOH with assistance from a United States NGO; this testing was supported under the Japan Grant Facility. An implementation schedule for project activities is provided in Annex 13. A project coordinator with experience and qualifications satisfactory to the Bank has been selected. Draft arrangements would be presented to the Bank after discussion with the concerned agencies (DOH, DOF, DBH and COA) for: (aj conditions and procedures for approval and distribution of grant funds within the project; and (b) appropriate documentation of DOH expenditures to permit such expenditures to be eligible for reimbursement under the Bank loan. During negotiations the Government provided assurances that these arrangements would be finalized and implemented among the concerned agencies. The status of these arrangements would be reviewed with the Government on the initial project review mission. B. Organization and Management 5.2 Overall responsibility for project management would be vested in the Undersecretary of Hedlth and Chief of Staff, who would also serve as Project Director. The project staff assistants would each be responsible for one of the four project components. The undersecretary would be assisted in this task by a full-time project management staff (para.3.41). The project coordinator would be responsible for managing the day-to-day operations of the project and would report directly to the Project Director. The project staff assistants would each be responsible for one of the four project components. During negotiations agreement was reached that a project coordinating unit would be established in DOH and adequately staffed, that the project coordinator would be formally appointed, and that officers responsible for project implementation in each implementing DOH division would be designated as a condition of effectiveness. 5.3 The Undersecretary for Public Health Services would be responsible for implementation of the impact programs component. The Undersecretary would be assisted in this responsibility by the Service Chiefs of the units responsible for the impact programs and by the full-time project assistant assigned to this component as a member of the project management staff. The Malaria Service would manage the MCP, with the provincial coordinator for the MCP responsible for handling the spray operations. Malaria surveillance would be under the control of the district MCP coordinator, who would rely on the RHU - 33 - network for active case detection and treatment. The Tuberculosis Control activities would be implemented by the TCP, with case identification and treatment the responsibility of the RHU nearest the patient. The Schistosomiasis Service would be responsible for managing the SCP, with its Field Operations Support Division at headquarters handling field logistical support. Implementation of the MCH program would be the responsibility of the MCH Service, with direct client services being provided by rural health midwives and RHlUs. 5.4 The responsibility for implementation of the Strengthening the DOH's Institutional Capacity component would be that of the Undersecretary for Management Services, who would mainly be assisted by an Assistant Secretary and Service Chiefs of the pertinent units. However, implementation of project activities for the Central Laboratory would be the responsibility of the Undersecretary for Standards and Regulation. The implementation of the Community Health Development component would be the responsibility of the Undersecretary for Health and Chief of Staff, supported by staff of the Community Health Service. The Policy Development component would also be the responsibility of the Undersecretary of Health and Chief of Staff, supported by the project coordinator. Annex 13 gives the implementation schedule and Annex 14 provides details on implementation responsibilities. C. Monitoring and Evaluation 5.5 The Project Coordinator would be responsible for monitoring project implementation. An annual program review would be conducted as a means of assessing project implementation progress. Management of the program review would be contracted out to consultants, who would then be responsible for preparation of the annual review workshop. The results of the annual program reviews would form the basis for the annual work and financial planning of project activities. During negotiations, agreement was reached that annual reviews of the health programs and activities supported by the project would be carried out by the DOH, not later than October of each year of implementation. 5.6 The DOH would undertake three categories of evaluation activities under the project. These include: (a) performance evaluation; (b) process evaluation; and (c) impact evaluation. The performance evaluation activity would focus on the annual measurement of the DOH's program outputs with respect to physical accomplishments, financial performance and client satisfaction. The performance evaluation would include a longitudinal client-based analysis of the DOH's performance as well as a quantitative analysis of program indicators. Data for evaluation would be generated from the program HIS and MIS monitoring systems, surveys and from ongoing beneficiary analysis. This assessment would be undertaken to assess the overall - 34 - accomplishments of the project, identify problems and issues and recommend measures to accelerate activities or redirect efforts to facilitate goal achievement. Technical assistance would provided to manage and direct the performance evaluation. 5.7 The process evaluation would examine the factors that went into project implementation and seek to explain variations in levels of performance despite comparable project inputs. A participant- observer approach would be used for the evaluation, employing technical assistance to carry it out. Process documentation would be used for all components and would concentrate on the Community Health Development component; it would entail the hiring of process observers to record and assess the qualitative aspects of project implementation The impact evaluation would focus on results obtained in terms of morbidity/mortality reductions, improved efficiency of DOH systems and achievements in equity of access to DOH services. 5.8 An additional element of the annual program review would be an annual area-based evaluation, using the province as the basic unit. The area-based evaluation would permit a closer look at project inputs in a specific geographic area as would evaluation of the impact of the additional resources going under the field services subcomponent to priority RHUs. A stratified sample of provinces and RHUs would be selected for purposes of evaluation. Stratification would be based on the combination of component activities implemented in the particular province or RHU. Annex 15 gives further details on evaluation implementation and Annex 16 describes the Bank's proposed FY90 project monitoring schedule. VI. PROJECT BENEFITS AND RISKS A. Benefits 6.1 A principal benefit of the project would be the reduction of the prevalence of malaria, tuberculosis and schistosomiasis in areas of the country identified as meeting high-risk criteria. The project would also assist in the reduction of mortality among women and children in high risk communities and would support the lowering of fertility through improved maternal health services. The DOH's capacity to identify and monitor high-risk households within communities would be improved under the project, increasing both the equity and efficiency of its use of resources. The project would also help to enhance the DOH's planning, management, communication support and evaluation capacities, which would lead to a more effective and efficient delivery of services. Community resources would be mobilized under the project through the partnership of local governments and NGOs with the DOH, permitting communities to better meet critical health needs in their own localities. Finally, the project would lay the groundwork for future policy development. L - 35 _ B. Risks 6.2 The project faces the risk that comunities with high level. of malaria, tuberculosis and schistosomiasis as well as maternal and infant mortality, would be in areas of potential instability, and efforts to reach these comunities might be affected by future political developments. However, sufficient flexibility exists in the selection of communities to be supported by the project to overcome the risk that such developments might affect project scope, although some deserving comunities might not receive support under these circumstances. There is also a risk of slow implementation due to delays in counterpart funding and to the general complexity of fund flow procedures. These risks would be minimized through an annual review of project performance and financial requirements by DOH and the Bank, through the required agreement between DOH, DOF, and DBM regarding the flow of project funding, and through the establishment of a Project Coordination Unit and the designation of individuals responsible for monitoring and problem solving in each of the implementing units of the DOH. C. Impact on Women 6.3 The proposed project would support the recruitment of a substantial additional number of midwives, who provide the most important source of women's health care in both rural and urban settings. The major activities of midwives are those with the greatest potential for reducing maternal mortality and morbidity, including pre- and post-natal care for mothers and babies and safe deliveries. The activities of the midwives would help to refocus attention on the largely neglected maternal health services within the MCH program. The project would also assist DOH in the restructuring of maternal care and family planning programs away from their current focus on delivery of a given set of services to one of reducing risks to mothers and children based on community and household risk factors. The efficient and effective delivery of these services is essential to the reduction of maternal morbidity and mortality and to the provision of high-quality health services to women. Other elements of the proposed project would help improve the health of families, thus reducing the burden to women of caring for the sick. D. Environmental aspects 6.4 The proposed project would include the use of pesticides, especially DDT, for malaria control. Vector control (i.e. a reduction in the number of mosquitos) through the use of pesticides is still the most cost- effective method of disease reduction. In addition, vector control would be combined with chemotherapy, both to avert and to treat the disease. With regard to environmental hazard, the manner in which pesticides are used for the control of disease vectors differs sharply from their use against agricultural pests. For vectors of human disease, pesticides are frequently applied in or around human dwellings, and hence must be demonstrably safe not only for the spray personnel but also the inhabitants of the treated areas. Also, the quantities used are generally much smaller than those used in agriculture. As a result, while DDT adversely affects the - 36 - reproduction of same bird and fish species when used as an agricultural pesticide, 4i,re is no significant environm.ental contamination when used as an indoor residual spray for malaria control nor any known adverse effects on the people whose homes are sprayed. 1/ Therefore, DDT remains the pesticide of choice for malaria control in areas where resistance has not been demonstrated. VII. AGREWENTS REACHED AND RECOMMEKDATION. 7.1 During negotiations, the Government provided assurances that: (a) a written directive from the Secretary of Health would be issued by March 1, 1990, to the provinces, requiring the development of a five-year provincial health plan, and each province would submit its plan to DOH by October 30, 1990 (para. 3.32); (b) the Committee for Community Health Policy would be established and fully staffed by January 1, 1990, according to criteria developed during project preparation (para. 3.45); (c) participating NGOs and other community-level organizations to receive grants from the community health development fund would be selected in accordance with criteria and procedures satisfactory to the Bank (para. 3.47); (d) a DOH directive would be issued by January 1, 1990, establishing the community health development fund and setting forth its operating guidelines and procedures on terms and conditions satisfactory to the Bank (para. 3.49); (e) a National Council for Health Policy Development with terms of reference agreed with the Bank would be established no later than March 1, 1990 (para. 3.51); (f) audited accounts and financial statements of the project, including a separate audit of statements of expenditure, would be sent to the Bank within six months of the end of the Government's financial year. The Government would submit semi-annual progress reports to the Bank, provide status reports for visiting missions and prepare within six months of the closing date, a project completion report (para. 4.8); 1/ For further information on this topic, see Guidelines for the Use, Selection and Specifications of Pesticides in Public Health Programs, filed with OPN 11.1, September 29, 1987. - 37- (g) the arrangements for approval and distribution of grant funds within the project and the appropriate documentation of DOH expenditures to be eligible for reimbursement under the loan 3juld be finalized and implemented among the concerned agencies (para 5.1); and (h) an annual review of the health programs and activities supported by the project would be carried out by the DOH not later than October of each year of implementation (para. 5.5). 7.2 A special condition of effectiven4se of the proposed loan would be the establishment in DOH and adequate staffing of a project coordinating unit, the appointment of the project coordinator, and the designation of officials responsible for project implementation in each implementing DOH division (para. 5.2). 7.3 With the above conditions, the proposed project would constitute a suitable basis for a Bank loan of US$70.1 million equivalent to the Republic of the Philippines, with a term of 20 years, including a grace period of 5 years, at the standard variable rate. - 38 - ANNEX 1 HEALTH DEVC_MW OJtCT PHIL LPPIE COMPMATIVE SOCIW-ECOMIC DIDICATRS LOW INDICATORS PHILIPPINES MALAYSIA KOREA INDONESIA THAILAND MIDDLE INCOME TOTAL POPULATION (MILLIONS) (1966) 57 16 41 166 63 691 URBAN POPULATION (MILLIONS) s9 38 64 25 16 36 CBR (PER 1,000 POPULATION) 3C 29 20 28 2S 36 CDR (PER 1,000 POPULATION) 7 6 6 11 7 10 ANNUAL POPULATION GROWTH X 2.3 1.9 1.2 1.8 1.6 2.3 (1966 - o000) TOTAL FERTILITY RATE 4.6 3.6 2.2 3.6 3.0 4.7 EXPECTATION OF LIFE AT BIRTH 63 69 69 67 64 69 (1986) POPULATION/PHYSICIAN (1981) S8S0 3910 1390 12300 6870 7880 POPULATION/NURSE (1981) 2640 1390 350 2300 2140 1760 DAILY PER CAPITA (1965) 2260 2601 2806 2476 2399 2611 (CALORIES SUPPLY) PER CAPITA INCOME (ONP) (1986) 560 1830 2370 490 810 760 AVERAGE GROWTH CDP (X) -1.0 4.8 8.2 3.4 4.8 1.8 (1960-1966) HEALTH EXPENDITURE (1) (1986) 6 - 1.6 1.9 6.7 4.0 (1980-1966) MID-1966 UNLESS OTHERWISE STATED SOURCE: WORLD DEVELOPMENT REPOR-, 1988 - 39 - ANNEX 2 PHILIPPINES HEALTM DEVILOPHENT PROJECT Total Population Size, Crude Birth and Death Rates and Total Fertility Rates for Selected Years Year Population CBR CDR TFR 1930 23.5 1935 23.3 1940 31.9 1945 19,234,982 21.8 1950 17.9 1955 53.0 14.5 1960 27,087,685 46.0 13.7 6.9 1965 44.0 12.6 6.3 1970 36,684,486 39.3 11.8 5.7 1975 42,070,660 34.8 8.7 5.2 1980 48,098,460 35.0 8.8 5.0 1985 54,668,332 33.0 8.0 4.5 Sources: Censuses; NEDA, Projections of Philippine Population 1980-2030 UPPI, University of the Philippines Population Institute, Various Publications and Surveys. - 40 - ANNEX 3 PHILIPPINES HEALTH DEVELOPMENT PROJECT Trends in Infant, Child and Maternal Mortality and Life Expectancy, 1930-85 Expectation Child Year IMR of Life at HMM death Birth rate 1930 165.0 1935 153.4 1938-> 40.0 1940 135.8 1945 /a 1948-> 42.4-45 1950 101.6 1955 84.3 1960 73.1 62.8-53.3 1965 68.5 1968-> 58.7 2.0 11.0 1970 60.0 57.6-59.6 1.9 1975 53.3 59.3 1.4 1980 45.1 61.1 1.1 1984 39.4 0.8 1985 48.0/b 63.1 0.8 4.0 /a No data. /b Derived from the World Development Report, 1987. Source: Zablan, Zelda C. (1987) 'Maternal and Infant/Child Health, Nutrition and Mortality: Levels, Trends and Determinants: University of the Philippines Population Institute, Quezon City. * 41 - ANNEX 4 PHILIPPINES HEALTH DEVELOPKENT PROJECT Number of Midwives by Region, 1973, 1986 and 1987 Region 1973 1986 1987 I 637 1,030 1,013 II 300 695 548 III 991 1,071 778 IV 1,903 1,107 1,368 NCR - 644 607 V 364 756 820 VI 754 1,053 926 VII 541 897 926 VIII 308 752 737 IX 237 580 596 X 419 766 652 XI 308 633 662 XII 285 706 644 Philippines 7,047 10,690 10,278 Source: Department of Health; Planning Services. Notes: The 1973 figures are understated since the Health Manpower Survey for that year failed to obtain reports from a few provinces. PHILIPPINES HEALTH DEVELOPMENT PROJECT Trends in Leding Cause of Morbiditt Year Percent Cha-- 1976 1979 1ow 1:i mvl Caue. ICD No. 1973 1979 1960 1961 1962 1983 1984 1979 1960 19N1 11 1to 1934 1.0 Bronchitis 490-49N 455.6 471.3 427.3 507.0 652.2 577.6 1,039.6 8.8 -9.3 18.7 6.9 4.8 70.9 2.0 Influenza 470-474 468.7 400.0 419.9 446.6 446.6 447.9 783.3 -16.9 8.4 6.1 0.0 0.S 74.9 8.0 Diarrhea 006-009 462.6 466.2 413.0 462.7 186.6 443.6 962.6 0.6 -11.4 16.6 -.6 1.6 106.9 4.0 Pneaonias 40-4U6 248.6 272.2 242.7 246.6 106.3 287.5 337.6 9.4 -10.3 2.4 -56.4 119.8 42.1 5.0 Tuberculosis, all form 010-019 260.5 283.6 232.4 235.8 206.2 179.2 2".0 -10.8 -0.C 1.5 -12.6 -18.1 49.6 6.0 Malaria 065 77.7 68.2 82.1 89.1 68.9 66.0 207.4 -12.2 20.4 6.5 --22.7 27.7 185.7 7.0 Mallignnt Neoplamm 140-209 48.6 43.4 39.6 50.0 - 49.7 30.6 -0.8 37.6 -16.4 - - - 8.0 Dyentry, all form 004-006 60.7 60.7 56.7 54.4 66.7 - - 0.0 -6.6 -4.0 22.6 - - 9.0 measles 065 81.2 62.8 56.4 54.6 67.8 71.7 126.6 2.6 -11.6 -1.4 28.8 6.5 76.4 10.0 Whooping Cough 0ii 31.6 - 41.1 38.7 31.3 27.4 - - - -0.1 -19.1 -12.5 11.0 Infectious Hepatitis 070 - 19.0 - - 16.6 17.6 26.3 - - - - 6.7 00.9 12.0 Accidents 600-999; - - - - - - 156.6 - - - - - - E800-949 Source: Philippine Health Statistics, 1978-84. Health Intelligence Service, DOH. - 43 - ANNEX 6 PhILIPPINES HEALTH DEVELOPMENT PROJECT Trends in Malnutrition, by Region and Tarasted Areas, 1970-85 Area 1976 /a 1979 /a Philippines 30.6 32.6 National Capital Region 30.4 31.2 Region I - Ilocos 31.0 30.8 Region II - Cagayan 29.3 28.7 Region III - Central Luzon 32.3 42.5 Region IV - Southern Tagalog 29.3 28.8 Region V - Bicol 30.6 40.0 Region VI - Western Visayas 39.0 34.8 Region VII - Central Visayas 27.0 28.0 Region VIII - Eastern Visayas 36.6 39.7 Region IX - Western Mindanao 28.9 30.2 Region X - Northern Mindanao 28.2 25.8 °egion XI - Southern Mindanao 24.9 26.1 Region XII - Central Mindanao 27.7 23.2 /a Includes 2nd and 3rd degree cases only. Source: Diamson, B. and F.S. Villamejor "Philippine Malnutrition Update' in Iglesias et al. (eds)., Severe Malnutrition of Filipino Pre-School Children, UPCPA (Manila). - 44 - hEL H KW IPT UOJC Prolectiesl for sadetary Al lecati for tho Sector. 1l96-U V.ersona) Actusl annual Annual average Eatimat Projoctilons average 1970-6 i9s 1967 193 199 1990 191 1991 1987-92 Econoeic Services 35.9 17.3 19.9 21.6 23.9 26.8 29.4 30. 25.1 Agriculture TI TI 9 7 7 4 T 2 9 171 Industry, Trade A Tourim 3.1 0.7 1.4 1.9 2.4 2.8 8.0 3.8 2.6 Utilitie A Infrostructur- 28.5 13.4 14.8 14.0 15.0 16.1 17.2 17.9 15. Social Sorvices 20.2 16.3 21.6 24.6 23.4 31.4 36.7 39.2 30. Education 12.3 10.2 11.5 18.2 14.1 14.9 17.1 16.7 16.0 HeIth 3.9 8.0 3.4 4.2 6.9 6.6 8.2 9.6 6.8 Social Security A Welfare 2.1 4.7 6.2 6.2 6.2 6.8 6.4 6.4. 6.2 Housing & Comm Dov 1.9 0.4 0.4 0.9 2.2 8.6 4.0 4.5 2.7 Defense 14.0 6.9 7.4 7.3 8.0 8.4 3.6 8.9 6.1 3eneral Public Servicos 20.0 10.0 11.3 14.7 15.7 13.7 12.3 9.6 12.9 Debt Service Fund and Net Lending La 11.9 47.6 40.0 30.8 26.0 20.2 16.1 12.0 23.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 / ror 1987 onwards, this item includes a portion of the external liabilities of Government financial institutions to be assumd by tUs National Government, but excludes debt sorvico on liabilities of the Philippine Nuclear Power Plant. Source of Basic Data: NB and NEDA. - 45 - eslth Teruste as Outlned in MTlidr Devi_s^ms Plan. 1992 "lad lar Eotl_es Ter" Annual 2"0 XW7 19" TI9|9-M 190 lffl averaee 1. Health Life *xpectancy (years) 63.4 68.? 64.0 64.8 64.6 64.9 65.2 6.8 Crude birth rat. (per 1,000 pop) 81.7 81.8 80.3 80.8 29.8 29.2 26.6 80.0 Crude death rate (per 1,000 pop) 7.8 7.6 7.5 7.4 7.2 7.1 7.0 7.8 Infant (below I yr) mortality rate (per 1,000 live births) 55.6 54.2 52.9 51.6 50.8 49.0 47.8 51.0 Child (1-4 yr) mortality rate (per 1,000 pop) 4.9 4.7 4.7 4.8 4.1 8.9 8.7 4.2 Maternal mortality rate 0.9 0.9 0.6 0.6 0.6 0.7 0.7 0.6 2. Nutrition Percentage of pro-schoolorc with wt loss than 75X of standard wt-for-age 21.7 20.8 18.3 17.4 16.0 14.5 13.0 16.7 Percentage of schoolchildren aged 7-10 yr3 with wt less than 90X of standard wt-for-age 18.0 12.7 12.3 11.6 11.3 10.8 10.8 11.5 Percentage of schoolchildren aged 7-10 yrs with wt lose than 765 of standard *t-for-age 14.1 18.2 12.2 11.2 10.3 9.4 8.4 10.8 PIMIPPINES IlUtllt DEVLOPOlElT PROJECT S41650 ACCDUSES COST SUi653 (p1s0s I006 WS$5 IUS 0 "C leSol ---------------------------------------- --------------I----------- ---------- % fro.ig 4 local Eor lotal tocal foreign lola) lachang. Ceas I lIv(S;Ht(Ul wCs3 a mUCs ASN PESIICIUS 6 056 -VMS 2565815 5 256.5l.758 - 12,218. 170 12.215. 110 600 Z. PESI)CIIDS - 167, 5u4, 000 6T, S. .00 - 7 950. IS0 t,9se. 960o 60 9 Sd-1otal ODRUS asO PESIICtDES - 424. 655.157 424. 669.257 - 20. 695. 361 20. 19S. 361 toe 2o tt f4UOR*ElIt 52. 179.81 IL 2a9.t22 130.44S.S42 2.484.753 3. 727. 630 5.211.,U3 60 t C. vINICICS - 634. 736. 0O 694.736.000 - 9.273. 143 S.2u3. 143 600 0 0. $M1lEISIS l 01NER 3ATE6IAtS 30. 246. 63) 20. 150, 794 50. 401. US 1. 440, 054 960. 03 2. 400. 0o 40 J 2. IEC VAlalts 28.323. 539 3.147.071 31.470.710 6.145.74s 149."56 .49. 609 10 2 SU-1o0al ItRIAtS 54. 5U4.770 23,307.825 1.572.SSIS 2. 7U 7.7 IO. H09.59 3.U9599 ,i 4 1. COSM NAI*IN OtVit GRAMlS 6. PtAlIICG GR3tN6S S.400.000 - S.400.0o0 2U7. 643 - 257. 143 - o 2. PIOJCI GRlS 0. o00.000 - 690. 000. goo 7. 142.87 - 7, 142.57 - _ - -- - - - - - -- - -- - - --- - -- -- - - -- - -- -- - - - - - -- - -t-- - Sb-6ota% C0114 H(tIll VE6 G5IS 5 Ue 9 .00.00 - 155 400. O0 7.400.00O - 7.40e0.00 - S L- TRAlINING 6. FOrkIUG ItILONSHIP - 11,469.400 I1.469.400 - 545.162 5451.2 15ot I 2. LOCAt TRAINING 144. s4u. 00o - 144. S48. 000 h .U3. 23 - B. U3. 23 - I Sub-total TRAINING 144.940.000 61.459.400 69.067. 400 5.853.231 546.1 62 7.423.400 T I S. ItCNIC*t1 SssisIAUcf 1. 1o01c1t - 15.654.000 t654.000 - 749,0600 74.000 t ooe 1 2 tOCAt 7S6. ee.9 0o - 76. s5. Ot 3. 4s. 52 - 3. 49.952 - a SAb-lotal IECNM(CAt 5SSIS1Au6CE 716.sS.000 19.14. 000 92. 20. 000 3. 1545.992 74s. 00 4. 390.n92 67 s 66 COEIRtACI SlIf1 334,003.400 - 334.003. 400 19. 204.924 - Is.9104.24 - n1 L PtAIMIIG SENIlUSAS 30. Iso.0o0 - 30.750.000 1.464,2 - 1.454. 28 - 2 a. P30EC1 P5rf993llt J PREI6,PIEN1IN)h1)OII 36.540.000 24.360.000 a.300.s000 1.740.000 . o660.000 2.900.000 40 9 lotal IIWESINIUC COSTS 555.0S.5987 771.95s.521 6I.60.504.969 42.311.952 3G.7M.562 79. Of.U4 40 U Is. REtUREnl COStS A- STA41 tRAEi 817.720.385 - 87. 720. 359 4. 1711 161 - 4, 6??. .65 - 4 S. s581*15s 222.m 66. S - 222ss66. SW s 0.o95.405 1L s 40 tt total 4ECUlHEPI cosrs -310.256.US - 310.255.U5S 14.79S,566 - 14. 75. S - Is lota) BASEIIK COSIS 6.195.537. 872 771. 953, 525 1 .90.791.400 97. 067.515 335.793.632 3.U44.218 39 In Price Cntnimnqcies 225.477,734 71.478. 123 304.955.917 10o737.035 3.71, t 1 14. 521,710 25 Is lToal PROlECT CO05S 1,424.319.66 4 C st431.51 2.275.74U.36I 62. 524. 556 40.544. 364 l0t 358 920 31 6I S :=:::==::=: :::::=5::::: ::::=:=::: :2:::=::::= :2::::0::=$ :S22=l5-J=: =-3 S28*2 *23:- t hay 2., 1959 6005 PHILIPPINES HEALTH DEVELOPMENt PROJEC1 Project Caqponents by Yer IPESOS '0001 4ss Costs reU 2 3 4 P ffStlS SIISW ' A SIRENGICNENINC go ImIpCt PR40R6tS I 11IURJA COllROI PROCRttI tII 107.307.250 102.374.840 82.961.3ss 70,677.519 S2.708.600 416.031.S57 19.11.0l1 2 lU8ERCUtOSIS CONTROL PttOCUU I 2 1 63.438.000 75.420.000 71.370.000 59.060.000 42.900.000 312.0MSW 34. 133 3. SCHISTOSOKIASIS CONTROL P00R0K I 3 1 36.007.300 40. 109.250 35.496.300 37.372.550 29.549.500 173.534.,90 B. 2U.ff7 4 AlUEIMAI AND CHILD HIEALTI 1 4 1 4.590.453 8. 87. 143 12. 777. 981 16. 623.375 21.s58.359 64. 737. 311 3. M. M Sub-Total SIRENGIHENINtC O0 IMPACT PROGRAMS 211.343.003 226.791.233 202.607,639 178.733.444 146.916.549 966.391.0 46I01D,0N S. SREEtNGIHENING ONS ItSIITUIIONAL CAPACIIY I DON INFORNIATION SYSTEMS I 5 I 32.844.68 12.I807.200 13. 98. 500 12. 679. 500 7.585.000 M0. 164. M 3.6SUL326 2. REGIONALI - PROVINCIAL HEALIH PLANNING 3I 6 \ 16.367.000 15.470.000 500.060 500.000 500.000 33.331.0N 1.S. 418 3 fiftD SfRVICES 1 7 1 166.430.000 27.900.000 40.800.000 50.sso5. 000 6.800.000 352.480.0W Is. lot.M 4 CtNTRAt 18 I 8 3 14. 211. 180 20.786, Iso 12.301.512 9s7.600 - 48. 25M.442 2207.06 5 PROJECI NANACENENT I 9 I 7. S33. 400 2.13.400 2. 183.400 2. 183. 400 2.183.400 It. 2M.0 114.619 6. INFO EOUCAIION COHN I 10 1 11.325.270 7.978.940 7,805.625 7.697.330 7.852.055 42. 65m 2.031ni 7 IRAINING Of DON SAlIl I 11 I 47.755.7so 35.375.750 28.204.500 19. 317.000 13.002.000 143.,H5.00 6. M.114 S. EVALUAFION 1 12 1 8.482.000 3. 182.000 4.082.000 2.732,000 S.782.000 27.280.0W 1. 2184M 9. PROJ PREP / PREIlPLEN I 13 1 30.450.000 30.450.000 - - - 60.0N0.0 2. SW.I Sub-IotsI SIRENGINENING DOOHS INSTIIUIIONaL CAPACIIT 335.399.285 156. 133.440 109.845.537 96.616.830 10. 004.455 04.3M.547 34.133.312 . C. COlISINITY HEAtlH OEVELOPHENI *t 1. COIMUNITiY HEW4tl DEWEtOPMEtI FUND I 14 1 31,080.000 31.080,000 93.240.000 - - 15S.440.0" 1.40.0S" 2. COINWUITY HEAtlH SYSIENS SUPPORI IIS I 4.562.355 4.037.355 9.832.925 6.512.425 6.454.925 31.30M5 1.4".231 Sub-lotal COIlttITY NEA4tIH DEVEtOPMENT 35.642.355 35. 117.355 103.072.925 6.512.425 S.454.925 1". M. in B.0M. 231 D. POliCY OEVEtOPIEHI 1. HtAITH POtlCy Of(ELtoPnix I 16 I 2.920.000 2.920.000 2.420.000 2.420.000 1.920.0oe 12. 900.a M .0W Sub-Total POtlICY DEVELOPIIENT 2.920.000 2.920.000 2.420.000 2. 420.oo 1. 120.000 12."D.0 00 .0" lotal BASELINE COSTS 55.304.643 420.962.025 417.946.101 284.n22.699 262.295.929 l. 9o0.lI.400 98.541.210 Prici Contingencies 30.968. 661 43.977.578 80.738.228 65.170.522 84.100.128 304.35S.917 14.521.1l0 Total PROJECT COSTS 616.273.304 464.939. 606 498.684.329 349.453.221 346.395.657 2.215.14?.37.3?7 306.3s6. foroign Exciange 370.474.285 146.652. U6 131.175.229 112. 903. 161 0. 228.091 51.431.,51 46.144.38 may 22, 1989 10: 06 10 I PIIIPPIUECS HEALtN KEVELt NIJ PIOJICT Summry iccounis by T"e Totals InEluding Conti gmci.s Totals lncldi CMiagtles; (PSOSn It ii loss pii llIga 1 2 3 4 f lotol I 2 3 4 5 Tg4bl .t.lssn"ss tsss=hz =.tasthhssa. u s.s.... .. .. ......r*t. .. = ...... -.-- -. ....... .......E.. - - ---.- I I.NmSuTw t COSTS *. MD165 HS P(STICIKS 1. 8116s St.6US 61.0OU 65.300 61.1531 S13.3 23.0 n3 2. 461 2.30i 3.110 2.930 2.SU 13.9f7 2. PESTICIKES 49. S35 43.932 3S. 963 35. 137 24 017 Ii Se4 2. 359 2. 092 1.713 1.673 t, 144 il6 Sub-Total MCS iMD PESTICIDES 101.,20 f1,.000 101.263 U6. SU 77.527 481.6?7 4.620 S.000 4,622 4.603 3S.2 222 U? B. LIU1PIEiT It. 37 3 ".6G1 24. 053 13. 900 6.467 147. 414 3.400 t.410 1. 145 U2 4023 1.N6 C. VEHICIES IN.864 1.03 3. 3U - - 203.255 '.471 SO IU - - 9. S7 D. MiEUIILS 1. OltEi iATERIILS 9.6SE 11.365 12.41S 13.079 16.109 62. 664 462 541 Sol 623 *6E 2.94 2. IEC MATERIALS 6.820 7. 3U S.06 A. 644 39. 40. 231 322 351 324 412 448 1,91S Sub-fotal NA4EItlS IE.516 15.746 20. 471 21.723 25. 506 102. 63 76 633 975 1,034 1.215 4. 83 E. COllt HtEAtlH BEKEt RAINTS 1. P1LMI8Il 68i11S 1. 179 1.261 4, 64 - - 6.646 56 61 1I" - - 311 2. PnOCI GiANFS 32.761 315.70 116.210 - - 184.lU, 1.60 1.700 5.34 - - V794 Sui-Tetal CONM HEAtlH lDEYEt GCIRtS 33.140 36,. 3 120. 394 - - 191. 329 1.616 1.762 5.733 - - .111 1 f. IUAINIHG 1. FORlIGNt FEIttOiSHIP 3,339 2,174 63 iI 1. i82 1. se 12. 87 ISS 123 175 iN 7* 614 co 2. tOCAL IMINING 33.543 42,17 40. 45 33. 381 21. S12 181.904 1. U3 2.044 1. 31 I1. S 1. 215 8.3 o I Sofb-lotal ISIHING 42. 8U8 41.492 44,226 31. 183 27. 012 154.801 2.042 2. 166 2. 10S 1.671S 1,28 C .216 G. IECHICAI ASSISIANCE 1. FOREICt 8.391 3.658 3.8" f . 1IDS - 16. 32 400 174 182 53 - iUS 2. LOCAL 34. 99 14,317 12. 752 3.430 20.400 91.897 1. 67 682 607 443 373 4.321 Sob-lotal TECiUICAi ASSISTIMCE 43. 39 17.974 I1. S1U 10.534 20,400 1U E7S 2. ON n56 790 502 S71 S. Itf H. ClRUACT STAlF 28. 30 96.U45 82. 182 69 322 S7, 004 334.003 1.350 4.607 3.932 J.301 2.714 1t. "S 1 PLANHIHO SEIIIIARS 16. SI1 17.533 367 418 412 35.302 U7 831 Is 20 22 1.tU 4. PiJECT P1(PAIATION / PREINPLEitNTATION 30.450 30.4s0 - - - 60.300 1.450 1.450 - - - 2.300 Total IitESTENit COSTS S63.SS1 399. 58 413. 264 247 746 216,371 t, C60,523 27. TU 1t, 026 13. 679 11.7S8 10. 303 N. " II. ECIONT COSIS A. STAFF TRAVEL 12.543 25.459 25.679 25.43? 251 179 114.297 517 1.212 1,223 1.211 1. In S.443 B. SAEi4IES 20. 160 3. 692 59,741 76.268 104,646 300.927 96l 1.00 2.i45 3.632 4. 92 14.,10 Total iECUIRElT COSTS 32.723 6H,3S1 6,420 101.705 130,026 41S,224 1. 55 3. 1i2 4.00 4.43 IL I"2 19.773 :zz====T : -zzz-= _-==== z%z:zzzz.===.zz -=_Es5 =.5f .. ....... .... . ... X..t :-ts8 . IotaU PROJECT COSTS 616. 273 464. 40 4936.64 349. 43 346. 33? 2. 275 747 23. 346 22. 140 23 747 16.641 OIL 49 too,30 Nay 22, 1983 10: 06 - 49 - ANNEX 12 PHILIPPINES HEALTH DEVELOPMENT PROJECT Estimated Schedule of Disbursements IBRD Fiscal Year Disbur,se_nt I Cumalative Z Disburament and Semester Semester Cumulative amount Profile for (US$ million) Disbursed Philippines (Z) Projects (2) FY90 Jul-Dec.89 4.0 L 4.0 5 3 Jan-jun.90 1.0 5.0 6 4 FY91 Jul-Dec.90 3.5 8.5 11 9 Jan-Jun.91 3.5 12.0 16 16 FY92 Jul-Dec.91 4.7 16.7 24 24 Jan-Jun.92 4.7 21.4 30 32 FY93 Jul-Dec.92 8.6 30.0 43 40 Jan-Jun.93 7.6 37.6 53 48 FY94 Jul-Dec.93 6.2 43.8 62 56 Jan-Jun.94 6.2 50.0 71 63 FY95 Jul-Dec.94 6.0 56.0 80 71 Jan-Jun.95 6.0 62.0 88 78 FY96 Jul-Dec.95 4.5 66.5 95 86 Jan-Jun.96 3.6 70.1 100 94 FY97 Jul-Dec.96 100 L UD$4.0 million Special Account Note: Closing Date: December 31, 1996. - 50 - ANEX 18 Fe 1 of 7 _Imelmetstl. Schdle Aetivity Y °er 0 Your lVYear 2lY*ar $iYoer 4JYoar 61 Malaria 1. Procur_met of Druo & Pesticides Multi-yeor contract x Procuremnt of Stero.scop.s and Spray Cans x Procure_ent of Vehicles, Pick-ups, Pump boats A Hulls x 2. T O R of Resreh Studie (O R) x T 0 R of Consultants (O R) x T O R of Trainor (O R) x 3. Recruitment of OR Consul-aSnt*/Trxinor- xxxxxxxxxxxxxxx 4. Bid and Award 0 R Studies, Multi-year contract x S. Malaria Toaching Aid (copies) xxxxxxxxxxxxxxxxxxxxxxxxxxxxx 6. Recruitment A Hiring of Staff x 7. C F - Treatment, Spraying, etc. xxxxxxxxxxxxxxxxxxxxxxxxxxxxx Schixto 1. Procurement of Drugs A Pesticides Multi-year contract x Procurement of Lab Supplies A boots Multi-yeor contract x 2. Procurement of Binocular Microscopes x Procuremen; of Micros PC-AT x Procurement of Overhead Projectors x Procurement of Paper Copiors x Procurement of Bush Cutters x Procurement of Vehicles x 3. T 0 R for Snail Control Studios, Morbidity Study x T 0 R for Proj et Monitoring A Evaluation Systm x 4. Recruitmnt of Consultants-Project Benefit Monitoring A Evaluation System x Snail Control Studies, Morbidity Study xxxxxxxxxxxxxxxxxxxxxx S. Schisto Conference design x 6. Staff Screening A Recruitment x 7. Case Finding Treatment, Snail control etc. xxxxxxxxxxxxxxxxxxxxxxxxxxxxx Tuberculosis 2. Procurement of Drugs (SCC) Multi-year contraect x - 51 - AEX 15 Pag 2 of 7 A"tI vIty Year Olyear IlYear 2ttYoor Slear 41Yeor 51 I. Preur of stusteear Miloeeps _ Precurmst of stieslaer Miero.e.p.s Spr parts Pr eureset of Utility Vehicles 5. Selection of Priority Cities for TB Prgt rm Expension x 4. Recrultment of Loeal and Foreign Exports x (Local-Multi year eontract by) x S. Seloction of Training Follows xxxxxxxx S. Identification of Fellowship Training Couroe/Program x 7. Selection/R.cruitment of Med Techu and Sputum Canvassers x 8. Trainitn of Med Tech and Sputum Canvassers x Distri'bution of Microscopes x 9. Drug Dlstrlbution System Studies xxxxxxxx (Component 2) 10.TB Strategic Program Review xxxxxxxx (Evaluation) CCS 1. Procurement of Drugs - Multi-year x contract Procurement of Micronutrionts - Multi-yoer contract x Procurement of Oxygen concentrators Multi-yoar contract x 2. Identification of Priority District. for A R I x Phasing of A R I Implementation x S. Development of A R I Manuals x Development of Vitamin A and Iron Teaching Guides x 4. Reproduction and Printing of Manuals x S. Production and Reproduction of Growth Charts-Multl-year contract x 6. Recruitment/Hiring of Nutritionists x 7. Risk Classification of Barangays and Households x - 52 - ANE 13 Pg9e * of 7 Aetiviy Ye r OY oer IVYer 2 Year SlY r 41Yer ar S. Midwive special Course (A U I) - Traintlg a 9. A R I - 1 distelet, I provinc per region x A F I - all dietric6w in pilot provinces x A R I - additional 2 provinces per region xxxxxxxx A R I - all regton except large reglon. 1/2) x Info-Cm 1. T 0 R of Local and Foreign Consultants xxxxxxx 2. Recrultmnt/Hiring of Consultants Communications, Foreign x b Computer Meintenance x c. Radio Transmission Maintenance x d. MIS Master Planner x . Progrm Budget Systm x Materials Mng nt A Inventory System x g. Personnel Information System x h. System Analyst/Progr _er x I. Computer Operator/Techniclon x J. Communications, Local x k. Progrm Management (Development of Manual) x 1. Procurement/Logistics System (Development of Manual) x 3. T 0 R Health Mapping Reserch Grant x 4. Bid and Award-Health Mapping Roesarch Grant x S. Procuremsnt of Microcomputer Hardware A Software x Procuremet of Coemunication Equipmnt x Procurement of Vehicles x Procurement of Supplios x Procurement of Manuals x 6. Identification of Follows and Fellowship Programs x 7. Ase_ ement of D6'ug Supply and Distribution System x S. Study of TB Drug Distribution System x 9. Health Mapping/Aroe Classification Study x - 53 - Acti vity lVear OlYear lJYar 2t1yar s1Year 4!r u 1O.Dev.l.ma"t of Mawale, "raw. a. Rapreduti.. of 1Maas. Program b. Developmet of Manal.s, Procur.meat/Legistice 3 C. Introduction tf Manuals, Procuremwt/Loglatie x *. Development of Manuale, HIS x f. Reproduction of Manuals, HIS x g. Devolopment of Program Budgeting x h. Reproduction of Manuel, Progrm Budgeting x T. Developmnt of Manuals, Porsonnel Informtion System x j Reproduction of Manuals, Personnel Inforsation System x k. Developmnt of Manuals, Info-comunications x 1. Reproduction of Manuals, Info-communications x m. Developmnt of Manuals, Program- Users Manual x n. Reproduction of Manuals, Program- Users Manual 3 ResionallProvincial Health Planning 1. Procurement of Laptop Computers x 2. T 0 R of Consultants-Planning/Training Method Development xxxxxxx S. Development of Training Methods xxxxxxx 4. Policy Directive to Initiate Provincial Planning Process x S. Selection of Provincial Trainors x 6. Training of Trainor* xxxxxxxx 7. Organize/Active Provincial Health Planning Committee of Provincial Developm_nt Councils xxxxxxxx S. Selection of Priority Regions for RDC Tours x 9. Selection or Setting-up of projects for RDC Observation/Study Tours x 10. Organization of RDC Study Tours xxxxxxxxxxxxxxxxxxxxxxxxxxxx 11.Setting of Provincial Planning process in Motion xxxxxxxx - 54 - Page S ot 7 Activity IYor OIY r l|Y r 2|Y r 1!YO r 4!YO r Sl Field Hmlth Sbraies 1. Pro* rear en Sleitriutlon of Imfe-e vbelh e x 2. Idmtifi eatles of priority PHU fos et eOlve eupgPortt a. Crte1ria for Sel ction x b. Maem_im for Supleme_tel MOE x 8. T 0 R Consultant (Development Program Manag*ment Manual) xxxxxxxx 4. Recrultment A Hir;ng of Consultant x S. Recruitmnt A Hiring of Midwives x Central Lab 1. Procurement A Installation of Equipment xxxxxxxxxxxxxxx 2. Selection of Follows, Fellowship Program x 8. Selection A Recruitment of Foreign Consultants x Proiect Manement 1. Recruitment of Project Management Staff xxxxxxxx Recruitment of Management Consultant xxxxxxxx 2. Procurement of Vehicloe and Equipment x 3. Organization of NICC - T 0 R x 4. Orrnization of Pro-implementat- S. Planning . Setting-up of Project Managemnt System x S. Manag etnt of Day to Day PHDP Operatlon xxxxxxxxxxxxxxxxxxxxxxxxxxxxx -55- I~ ~ ~ ~~~N 1w1 ~~~~~~~~~iVer o Veer z jY*r gIvOr *IY Vo, 4IY . 5 IEC 1. T ORC Iltast, EE Plamalog cmeiteet xxMxxxxxs T OR C. _lt.ts Key Me"o" comatat xxxxxxxx I T 0 R Consultante, EEC Review Comeuts nt axxxaxxx T 0 R Consultants, Schlto lEC Developm_t xxxxxxx 2. R.crult.snt/Hiring of Consultants/ Staff S. Conduct annual IEC Planning Workshop. xxxxxxxxxxxxxxxxxxxxx 4. Prototype lEC Nlwel otter-Dovlopment of Systm x Training 1. Laboratory A Training Needs Anssc m_nt/ Consultent (6 months) x Laboratory A Training Needs Asesm_nt/ Workshops (6 workshop.) x 2. Curriculum Developmnt/Consultant (18 months) x Curriculum D.v*!opment/Workshope (8 workshops x 8. Cours Development Consultant xxxxxxxxx 4. Trainors' Training x S. Training of Various Personnel xxxxxxxxxxxxxxxxxxxxxxxxxxxxx 6. Training Evaluation Grant x Evaluation 1. T 0 R of Annual Program Review (Orant) xa T 0 R of Base lino and lpect Surveys (Orent) as T 0 R of Proc_es Evaluation (Consultant) a. T 0 R of Evaluation Officer (Consultant) I months/year) Xe T 0 f of Evaluation Comlttee x 2. Organization of Evaluation Comittee x * with MULTI-YEAR Contract -56- AEX 18 Page 7 or 7 ActlvWIty YVeer OIY.er llYear 2iYar S.lyear 4IYear S1 S. Ruc mlml med Hirlag a. Casltig Flum (Anneal Program Review) me b. Ca t Fire (t.O.lle_/Sep.et I:m xx s. Ceaultet Pr-ess Evalueteon) M d. Coo"ltat (Evelutio Off ler) x 4. Identification of Prlority Municipalitto x S. Identificotlon of Sample Provinceo for Evaluation x 6. Implementatlon of Evaluation Activitios xxxxxxxxxxxxxxxxxxxxxxxxxxxx a. Annual Program Revise xxxxxxxxxxxxxxxxxxxxxxxxxxxx b. Baseline Survey x c. Impct Survey x d. Process Evaluation Xxxxxxxxxxxxxxxxxxxxxxxxxxxx Community Health Supwort 1. Organization of 04S Coordination Staff x 2. Procurement of Equipment A Vehicles x 3. Recrultmnt A Hiring of Consultants a. Development of Manuals x b. Developm_nt of Training Design/ Curriculum x 4. Selection of Pilot Provinces/ Comunities x 5. Firm-up Financial Grant Managemnt Procedures x 6. Organization of Community Health Policy Committee x 7. Recruitment/Training of Contractual Proj ct Staff xxxxxxxxxxxxxxx S. Implementation of Component S Activitios: xxxxxxxxxxxxxxxxxxxxxxxxxxxx a. Organizational Development b. MO-COP Partners Training c. Set-up CHDF Grant Fund Mechanism d. Awarding of grants and implementation of community health projecto o with MULTI-YEAR Controct - 57 - AN 14d n"xi mLTim rav u N)ECT ImalemenUtetie R......ibi I it, Activity WUm SIETRAY DON SUICES Malaria Public IeNlth 1. Pre",rmamt of Drug a Pesticides Malaria Control blitt-yer eostract Services (MCI) Pr.cuueamt of Storee oepee and Spray Cam Prcsurs ef Veilel, Pick-ups, Pump beat A Hul s 2. TO R d Isrch Studies (O R) MCIS T OR do Coneltamt (O R) T C t of Trailnrs (O R) 3. Recrultmn_t of OR Consultanta/Trainors dCS 4. Bid and Award 0 R Stud;de, Multi-year contract Bios and Award Committee (BAC) 5. Malaria Teaching Aid (coples) MCS, HMD&TS 6. Recrultment & Hlrlng of Staff MCS, P1O 7. C F - Treatment, Spraying, etc. PHO Schlito Public Health Schistosomiasis Services (SCS) 1. Procurement of Drugs A Pesticide. Multl-yer contract Procure m t of Lab Supplio A boots Multi-yer contract 2. Procurem_nt of Binocular Microscopes PLS, BAC Procurement of Micros PC-AT Procurement of Overhead Projectors Procure mnt of Paper Copi-rs Procurement of Bush Cuttero Procuremet of Vehicles S. T O R for Snail Control Studios, Morbidity Study SCS T 0 R for Project Monitoring A Evaluation System 4. Recruitmnt of Coneultanto-Project Benefit SCS Monitoring A Evaluation System Snail Control Studies, Morbidity Study S. Schlito Conference design SCS S. Staff Screening A Recruitment SCS 7. Case Finding Treatment, Snail control etc. PHO Tuberculosis Public Health Tuberculosis Contol 1. Procuremnt of Drugs (SCC) Service (TBS) Multi-yer contract PLS, BAC -58 - ANE 14 room 2 of 0 HEALTH DEVELOPMENT PROJECT mlemantati.n ReeaonsibIIlty Aetivitj UNER SECRETARY DOF SERVICE I. Pre ms=k of Sirnoelar Mlere.ee Precurcm at of Slnclar Mereeope PLS, BAC S1pare Parte Proeuremat of Utilily Vehicles S. Selection of Priority Cities for TO TCS TCS Progrm Expenelon 4. Recruit mn t of Local and Foreign Experts (Local Multi yer contract. TCS S. Selection of Training Follows TCS S. Identification of Fellowship Training Cou_rs/Programs TCS 7. Seloction/Recrultmoet of Med Tech. and Sputum Canvassers PHO S. Training of Med Tech and Sputum Canvassers Distribution of Microscopes RTU 9. Drug Distribution System Studies (Comonent 2) UM, PLC 10.T3 Strategic Program Revlew (Evaluation) UCS CCS Public Health 1. Procurement of Drugs - Multi-year PUi;, SAC contract Procurement of Micronutriontc - Multi-year contract Procurement of Oxygen concentrators Multi-year contract 2. Identification of Priority Districts for A RI MCHS Phasing of A R I Implementation S. Developmnt of A R I Manuals Dovelopmet of Vitamin A and Iron MCHS Teaching Guides 4. Reproduction and Printing of Manuals PIHEC 5. Productlon and Reproduction of Growth Charte-Multi-year contract MCHS 6. Recrultment/Hiring of Nutritionists PHO 7. Risk Claooificatlon of SBrangays and Householde PHO, RHO - 59 - J1I 14 HEALTH SEVELIPf 7 !mDlemsntatin Reseuiilitw Aetivity UHDR ISCUETARY DH SWEICE S. Midwives Sp Cal Course (A R I) - Training R1U 9. A R I - 1 district, 1 province per region A R I - all district. in pilot province. A R I - additional 2 provinces per region A R I - all regiono except large regions 1/2) MOHS Info-Coi 1. T 0 R of Local and Foreign Consultants Manemelo nt 2 Recrultment/Hiring of Conoultants MAS a. Communications, Foreign b. Computer Maintenance c. Radio Transmission Maintenance d. MIS Master Planner a. Program Budget System f. Materials Management A Inventory System g. Personnel Information System h. System Analyst/Prograumer i. Computer Operator/Technician J. Communications, Local k. Progrom Management (Development of Manual) 1. Procurement/Logistica System (Development of Manual) 3. T 0 R Health Mapping Research Grant MAS 4. Bid and Award-Hoelth Mapping Rosrch Grant MAS, PLS 6. Procurement of MIcrocomputer Hardware A Software Procurement of Communication Equipment PLS Procurement of Vehicles Procurement of Supplies Procurem nt of Manuals S. Identification of Follows and Followship Program MAS 7. Asoeesmnt of Drug Supply and Disetribution System MAS, PLS S. Study of TB Drug Distribution System PLS 9. Health Mapping/Aroa Classification Study MAS, UPH - 60 - ANEX 14 i*ge 4 of I HEALTH DEVELOPENT PROJECT Iemlsmantioa Rtoeoo"lbmib ltY Activity UHitR SECTARY DOFu SEtRICE 1O.D.velo.p_mt of Manuals, Prorm m ao *mU, MA . Reproduction ot Manuals, Progrm Maagemiat b. Dovelop_snt of Manuals, Procure_ent/Logi stics c. Introduction of MLnunls, Procurem_nt/Logl tiTc e. Develo_pmnt of MLhU1l1, HIS f. Roproduction of Manuals. HIS g. Developmnt of Progrm Budgoting h. Roproduction of Manuals, Progra Budgoting 1. Deovlopmet of Manuals, Personnol Inforation System Roproduction of Manuals, Porsonnel Information Syst4m k. Devolopmsnt of Manuals, Info-come 1. Rcproduction of Manuals, Info-comm m. Developmnt of Manuals, Program- Usors Manual n. Reproduction of Manuals, Program- Users Manual Realonel/Provincial Heloth Plannina Chief of Staff 1. Procuremont of Laptop Computers PLS 2. T 0 R of Consultants-Planning/Training Mothod Dovolopment UCS S. Doevlopmont of Training Methods HIDTS 4. Policy Directive to Initiate Prov'l Planning Procoes UCS S. Selection of Prov'l Trainors RTU S. Training of Treinors RTU 7. Organize/Activo Prov'l l+alth Planning Committee of ProvlI Dovelopment Councils RHO S. Selection of Priority Regions for RDC Tours UCS 9. Selection or Setting-up of projectu for ROC Observation/Study Tours UCS 10. Organization of RDC Study Tours UCS 11.Setting of Prov'l Planning process In Motion UCS - 61 - AM I IEALnT DEWlL WPE PrOJECT ActivitW UIMm UECETAV Do 11ic Flild Health Servle Public NseltA 1 Procuremet and Distributlon of Infeo-corw vehicle PLS, SAC 2. Identifleation of priority SHUj for InteIsivo support: a. Critoria for Seloction UCS b. Mechanlim for Supplemental MOE 3. T 0 R Consultant (Development Program Management Manual) UPH 4. Recrultmnt A Hiring of Consultant UPH 5. Recruitment A Hiring of ildwwves PHO Central Lob Standards and Regulation 1. Procurement & Installation of Equipment PLS, SAC 2. Selection of Follows, Fellowship Program USR 3. Selection A Rocruitment of Foreign Consultant. USR Projlct Managoeont Chiof of Staff 1. Recruitment of Project Manag met Staff Recrultment of Managoent Consultant UCS 2. Procurement of Vehicles and Equipment PLS, SAC S. Organization of NICC - T O R UCS 4. Organization of Pro-implementat- ion Planning UCS S. Setting-up of Project Management System ucs S. Managent of Day to Day PHDP UCS Operation - 62 - IM&YTS DEV PlUM P"OJECT Imel.mst one RsmsemslbLlitX Activity U1D11 SECUETARV DtH SE1VICE IEC Chlef of Staff 1. T 0 R Conwultante, IEC Planning C _ Itent T 0 R Com ult nts, Key eo9ege Consultant PINES T 0 R Consultants, SEC Review Consultant T 0 R Consultants, Schlto EEC Developmen, 2. Recruitment/Hiring of Consultants/ Staff PINES S. Conduct annual IEC Planning Workshope PINES 4. Prototype IEC Newsletter-Dove lopment of System PINES Training Chief of Staff 1. Laboratory A Training Needs Asoseent/ Consultant (6 m*n m*nothe) USR Laboratory A Training Needs Assessment/ Workshops (C workshops) 2. Curriculum DOvelopment/Consultant (16 *en sonth.) HMDTD Curriculum Developm.nt/Workshop. (a workshop. 8. Course Development Consultant HMDTD 4. Trainers' Training HUDTD S. Training of Various Personnel HMDTD S. Training Evaluation Grant NMDTD Evaluation Chlof of Staff 1. T 0 R of Annual Progrm Roview (Grant) UCS T 0 R of Beeoline and Impact Surveys (Grant) UCS T 0 R of Process Evaluation (Consultant) UCS T 0 R of Evaluation Officer (Consultant) 3/year) ucs T 0 R of Evaluation Coneittes UCS 2. Organization of Evaluation Comitteo UCS * with ULTI-YEAR Contract - 63 AiW 14 f~~~~~~~~~~~~~~~~~~~~~~Pg 7 of HEALTH DVELPMNT PUOJIECT 1lese"Was llleellbI I Ilt Activity UWD SECRETARY CON SERVICE S. Recrui_tmA NW Hiring a. Consulting Fire (Annual Progrm Rev) UCS b. C...ltl. Pire (flr lime/lIpet Survey) c. Consultant (Procees Evaluation) d. Consultant (Evaluation Off leer) 4. Identification of Priority UCS Municipa lties 6. Identifietlon of Semple Provinces for Evaluation UCS 6. Implmentation of Evaluation Activities a. Annual Program Riosw USC b. Basoeline Survey c. Impct Survey d. Process Evaluation Comunity He ath Support Chief of Staff 1. Organization of 04S Coordination Staff 2. Procurement of Equipment A Vehicles CHS S. Recrultment A Hiring of Consultants PLS, BAC a. Dovelopment of Manuals b. Developmnt of Training Design/ CHS Curriculum 4. Selection of Pilot Provinces/ Communities CHS 6. Firm-up Financial Grant Management Procedures CHS 6. Organization of Comunity Health Policy Comittee CHS 7. Recrultment/Training of Contractual Project Staff CHS 8. Impleontation of Component 3 Activities: a. Organizational Developmet CHS b. NCO-GO Partners Training c. Set-up CHDF Grant Fund Mechanism d. Awarding of grants and liplemntation of community health projects Health Policy Devolopmnt Chief of Staff * with MULTI-YEAR Contrect - 64 - ANNEX 14 Page 8 of 8 PHILIPPINES HEALTH DEmVLOPMENT PROJECT List of DON Services Responsible for Implementation* Under Secretary, Chief of Staff (UCS) Under Secretary, Management (UM) Under Secretary, Public Health (UPH) Under Secretary, Standards and Regulations (USR) Malaria Control Service (MCS) Bids and Award Committee (BAC) Pr3vincial Health Office (PHO) Schistosomiasis Control Service (SCS) Tuberculosis Control Service (TCS) Regional Health Office (RHO) Regional Training Unit (RTU) Procurement and Logistics Service (PLS) Maternal and Child Health Service (HCHS) Public Information and Health Education Service (PIHES) Management Advisory Service (HAS) Health, Manpower Development and Training Service (HMDY) Community Health Service (CHS) *In order of Implementation Schedule, Annex 13 - 65 - ANNEX 15 Page 1 of 2 PHILIPPINES HEALTH DEVELOPHUENT PIOJECT Evaluation Tasks 1. The evaluation of the Philippine Health Development Project would provide information on how and why measurable changes in health conditions took place over the life of the project. The nature and magnitude of the health changes would be determined by the on-going monitoring, or performance evaluation and the measurement of results, or impact evaluation. These evaluations would draw heavily on the Health Information System (HIS) recently instituted within the Department of Health (DOH) and the Management Information System (MIS) now being integrated into DOH. The emphasis in these evaluations would be on quantitative reporting of program accomplishments at periodic intervals not exceeding one year. 2. While the disease eradication components of this project would benefit largely from feedback from the performance and impact evaluations, the managerial and community-oriented components would better lend themselves to process evaluations 'aimed at elucidating and understanding the internal dynamics of program operations.w1 Improvements in the functioning of the DOH would best be understood from in-depth interviews with key managers as to their perceptions of changes in the work for which they would be responsible occasioned by the new technology and communications systems introduced by the project. Other aspects of the project each as targeting high-risk households would be evaluated by both 'luantitative measurement and qualitative interviewing. The dominant mode of analysis to be employed in the evaluation of the community health component would be process-oriented. Here, the challenge would be to understand the nature of the interaction and communication between local DOH and other government personnel, NGOs and the community, and and why this motivates the community to increase its own initiative and self- reliance in health care. 3. The specific areas of this project which would receive at least partial attention from process evaluations would be the following: (a) The beneficiary, or client-centered, approach and, within this, (i) The utility of targeting high-risk households; (b) Management decision making within the various levels of the DOH by, 1 Michael Quinn Patton, Qualitative Evaluation Methods, Sage, 1980, p.60. - 66 - ANNEX 15 Page 2 of 2 (i) Tracing cost and time associated with various key processes (getting disbursements or requisitioned items to field offices for instance) at periodic intervals over five-year life of the project: %b) Intervieving selected officials in Manila and field offices regarding their perceptions of changes in management efficiency re: issues vital to success of programs such as delivery of drugs to field health units; (c) The impact of involving non-governmental organizations in the public health program on sustained, improved health status, with particular regard to: (i) The nature and effect of the partnership between NGOs and government (health and non-health), especially as perceived and acted upon at the level of the community; (ii) The process of empowerment, or increasing self- reliance at the individual, household and community levels--how is this done, to what end and with what result:--how are resources mobilized within the outside of communities for health and other developmental purposes? (iii) The manner in which the NGO-governmental partnerships at the local level affect decision making with~.n the DOH. (iv) High-risk household identification and targeting as a prominent NGO activity and the influence of this process on improving health status--to be compared to DOH areas where NGOs are not involved. 4. Evaluation would be the responsibility of the DOH. Performance and impact evaluations which largely monitor quantitative program achievements would be done by DOH. The process evaluation, however, which assesses perceived change among DOH managers and the nature and effect of local DOH/local government NGO-community interactions, would be carried out by host-country consultants, and research agencies in coordination with DOH. Given the experimental and sensitive nature of the Community Health Development component in particular, the use of a third party in the evaluation should enhance the credibility in the eyes of the community of beneficiaries and of the larger public as well. The Bank would join the DOH in the annual program reviews of health programs and activities to which these evaluations would contribute. - 67 - ANNEX 16 PHILIPPINES HEALTH DIVELOPMEN? PROJECT Proposed FY90 Proiect Kanitorina Schedule July 1989 - Launch Workshop The project began officially in February 1989 with the implementation of the first activity financed by the Japan Grant Facility. Terms of reference for a number of pre-implementation activities have already been initiated, including the development of implementation volumes for each project component. The first Bank project monitoring activity would be to participate in a Launch Workshop tentatively scheduled for July 1989. During this workshop, sessions would be held on the following subjects: 1. Procurement Packaging and Scheduling 2. Community liealth Development - Implementation Tasks, Schedule and Respon:;ibilities 3. Communicable Disease Control Implementation - Malaria - Schistoso:iiasis - TuberculoEis 4. Health Policy - Structure and Implementation 5. DOH Institutional Strengthening - Informationlcommunication System - Program - Budgeting - Provincial Planning - Central Laboratory (mainly procurement) - Field Service Support - IEC - Training 6. Project Management and Coordination 7. Evaluation and Monitoring September/October 1989 A second Bank supervision mission would follow up on issues identified during the Launch Workshop. February/March 1992 A third supervision mission would coincide with preparation of the proposed Philippine Health Development II project. - 68 - ANNEX 17 Selected Documents in the Project File A. General Studies and Reorts 1. Philivines Medium-Term Develovment Plan, 1987-1992. Manilas National Economic Development Authority, 1986 2. National Conference on Safe Motherhood. Manila: DOH September 1987. B. Reports Relevant to Project Design 1. DOH Project Proposal for the Philippine Health Development Project. Manila, DOH, 1988. 2. DOH Prolect Procurement Plan. Manila, DOE, 1988 3. Packet Radio Demonstration Summary Report. Manila, Volunteers in Technical Assistance, 1988. 4. DOH Philippines Health Development Project Workshop Report. October 20-21, 1988 5. DOH Draft Bid Document for the supply, Delivery and Installation of various goods, 1989. 6. DOH Draft Department Order on Development of Five Year Provincial Health Plans, May 1989. 7. Agreement between DOH and the Philippine Institute for Development Studies regarding PIDS-DOH Joint Research Project on Health Policy and Development, August 1988. 8. DOH TerLs of Reference for the Committee for Community Health Policy, 1989. 9. Draft Conditions and Procedures for DOH Approval and Distribution of Grant Funds within the Community Health Development component of the Health Development Project, April 1988. 10. Draft agreement between DOH and DBM on Guidelines for Standardizing Finance - Related arrangements with Government Organizations and NGOs. HEALTH DEVELOPMENT PROJECT Malaria Morbidity and Mortality Trends Rate per 1000,000 Population (1966-1986) 230- 220- 200- ISO -~~~~~~~~~~~~~~~~~~~~~~~~ ISO -~~~~~~~~~~~~~~~~~~~~~~~~ 160$f 8Itt II 140 - 120 I 100~~~~~~wo0 so -- 5~~~~~~~ 60 0T 1966 1968 1970 1972 1974 1976 1978 1910 + 191 im S: D1H M66 197 0 PHIUPPINES HEALTH DEVELOPMENT PROJECT OrganIaton Stucture Departmet of Hth |SECRETAR OF HEALTH CHIE OF ECICTARYS STAIFF,TM ATTACHED AGENCES L.aiUu*.. AI: a R *~~~~~~~~~~~~ _ Cuim. upuur' Lbm- * Pipla M. MWescn cam * M" ~ "tinSAl * Da-mrom Dnrp B * pulft h a _ @ 8 s , ~~~~ ~~~~~~~~* Hal,hmImasSei * hts m i ^ P I u i a | i - - - - |~~~~~~~pm- Foramip Amlmmijuim CusmWot Se8 Ol1o For Pic HalM SWvi O1 Fr Homp. & FIcO F d Serv. Olb a d_ & P co 1 _ Tidurclosis angolHoSpIita M i l s_ m o l ~~~~~~Exe ouF H D_ CogStel l Nll~N. Flul l | 15 Aom d 131 H_I Famnb P| C OdH ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~~~~Om PARgmd Skuctr E. O. 119 (1987) PHILIPPINES HEALTH DEVELOPMENT PROJECT DOH Regional and Provincil Structure -FHsD Prvid Hosm r | I 1 DHO ll 2 | |DHOX | | DH004 | . I~~~~~~~~~~~~~~~~~~~~~~~ l h CZchnD E44"I PHUPPM. HLA&IN DVKLOPMENY PROJECT Wo Non Co u dlomn -0- -G-~ ~ ~ ~ ~ ~ ~~~~~~~~~~~~~~L- PcATLwat PO,AKESrAtlON - t(/ PACIO //ErAWX S\A MI Om/ A/ > A- I _\ / // T~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~. PHILIPPINES HEALTH DEVELOPMENT PROJECT Pocket Radbo SchematiK Dagram * l es.. SOLAR CELL m Mvc.s 5mm ams RADK) lCEMR ;=S}mPOlo ERn Sem COMPUIER IERMNALX mgsols .-i0 asinine. sueC memmue~~~~~~~~~~~ ama. R.~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ....... I~~~~~~~~~~~~~~~~~~ PHUUPPINE5 HEALTH DELoPMEN PROJECT Dab Fl - Mf *RSl SWIATIRCL DOkTA DESKfOPWNH ARD DW LASER ERt . -F 7L - + _ =^ _ I . I~~~~~~~~~~~~~~~~~~ROMDISK GRAPHIC ROllER~~~~~~~~~~~~~~~~BLOGARI 1-~~~~~~~~~~~~~~~~~~~~~~~dw --_S f ~~~~~~~~~~~r' W _, EVA INN GRMAIC PLOTTER PROPSAL PbWS~~~~~~~~PHVI CE*_ PHIUPPINES HEALTH DEVEOPMENT PROJECT irVoiffrotion. Education a CommunxicxAti (1EC) Schemati DESKrOP IAUDO AI PROUCIO PRODU n N PAC(TRADIONEQK' Y\/ m _ * - * SQ DOH PROGRA SERS COMIC BOKSERIES 0 RADO SRSM V SERIES '-4 ~~~~~~~~-dm6 WPUFNES MMNEALmEOF~OMEW! PbOJECT %IDifO PRCOUCIWON ea~~~~~~~~ - _~~~~~~~~~~~~~~~~~~~~~~OO I _~ mcoocompim.om CAMM(PORTA- ) _~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~A OM C(Aen '\~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ OC COLORMW"OLR MtWnoR COLCRz01N VVE00UJ-2 %4M &) ALA 7c~~ID) P,V KCR bt t 72 !~~~~ eU- , . , , w60 PL R 11 I ~~~~~~~~~~~~~~~~i I i~~~~ V.I PHIUPPINES HEALTH DEVELOPMENT PROJECT Orgenb*Um Stucture COMMUNITY HEALTH DEVELOPMENT (COMPONENT 11) OFFICE OF THE CHIEF OF STAFF SERVICES ~~ROINIA ~a 14I0K III I~~~~~~~N E i}~~~~~~PO4I HCHS N^lOVUL IL PROVWNCL OFFICER PFKUE'T comuN_E PHILIPPINES IBRD 21388 SCHISTOSOCMIASIS Known Endemic Areas as of December 1987 Endemic Municipalities Below 5% Prevalence 13 Cities , Prevalence of 5% - 9% Bouarovince Prevalence of 10% and above (See IBRD 21389 for names) KILC)METLIRS 0 100 200 300 Region Boundaries I I I I I I I I- -- --T III MILES 0 50 100 150 200 CALAAJV 2>§C 2 2 Nau~a iifj/( IV 295°S \0 3 7 n 3iian 12'~~~~~~~~~~~~~~~~~~~~~~~~~1 12~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~,1 44 Vll'5 Thi-, ph; hae.o prlired °on 7hr Wnr0id H.ank/ tzs /Sni sh h-olnda, /4 7 5 Tu Oum Huenmsla * Imuav m XIPOLOG lWl / < ANGA C~~~~~~~ORQUETA ~ 56 XB IXA_ CITY ~ ~ . 7 '. T-~ ~ ~ 74;i9L Ti.,-IZ.- 124- 105 CLASSIrI(:ATION (OF PROVINCES PHILIPPINES BY G.t; RAPHICAL REGIONS INCIDENCE OF MALARIA AS I IItIOci VI WFSTERN VAYAS OF JANUARY 1987 00 1 Imos Noe [18 AMtar IS or 2 AMo. [31 Capi- [ llos s 40 Antique 4 M-oUntje 41 iso High incidnc 5 L Union 42 NW.rn Ot idoenu l 6 Sengiot 4.1 Nqgro dd No.1* Los incidence 7 .a ..iras VII CENTRAtVISAYASi II CAGAYAN VALLEY 44 Ceuo ' [77 Noan Mairious t BoUns 45 Neg-ns Oriental 'I Cagyar 46 8nlo 11) aImng-Apay.o 4 7 Siqup N.,ation-l CApit ls 11 hboLa Vill EASTERN VESATAS / 1 2 Iogan -8 Nothern S.m-r 9 Province Bo..ndarieo 1 N-o Vi-oya 40) , S.- 1 4 Qirino 50 Eaot-r Sanra, 2 - o III CENTRAL LIZON 51 Iyte 10 15 Ne EdRa 52 Sout-en tV /I 16 Tala I XA WESTERN MIN4DANAO International Boundaries 1 7 Zabralares 5 [1 Za.o.aang dd Noe 55-n 1 8 ampana 5 4 Zn.boangadd Sat 1 9 8 IXfB WESTERN MINDANAS 2 4-5, 20 IlMan 55 Baifis, I VA NATIONAt flAL REGION 5 s..,. 1S3 14 I V SOUTHERN CAPITAI 5 7 T-otEawi - / \t 21 Aora X NWMHETE MINDANATAO 22 Q-oo 58 Sanyo don N-IS L l L 2 0 23 R-aa1 59 Ca-i6 i 21 jI 2 4 Ctianit 6() Aosn ddt Non / 16S ooae a so too too zoo 25 agoea 61 Moas OiednslX 2h6 (Ma.p 62 Mui-an O r l 1 7 1 8 1 9 27 Maridoqmw 63 &"n N- / / ' I 1 s 2 E Mini- Orental 64 Ao d.l1sa 2S. 29 Mindw Ocdd-l XI EASiItEN MINIOANAO IVA o [30 R-mshin 65 San&n5I [1 Polawmn 66 DnvtoaOI / ttai|2 V V 8i501 6 7 Da.- / 22 32 Cam esn Nwet 68 Daa don S/, 333 Ca.sairn Sir 69 Sa1h CEI\E.at 34 Canoioad XII CENTIUI MINNONAO 35 Alby 70 La d Na 7\Is 31 Sonog 71 t- on Sar 3 7 MasE-e 72 NoE CoiahaR, 73 AtaMgttInV 74 S&un Vdat 29i [ akr4l,/ ' / /4~~~ ~~~~~~~~~44 Vil 3 431/ ) ) 12 s. no- >\ff~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~r :''"'IAs9 .3~~~~~~~~~~~~6 I~~~~~~~~~~~~~~~~~~IB7 I~~~~~~~~~~~~~~~~~~~~~X _- CJ ; _ r.r_- r - _~~~~~~~~~~~~- I I- I tN t, I N _g as r__5G NHiN I N . 5