Document of The World Bank Report No: ICR2876 IMPLEMENTATION COMPLETION AND RESULTS REPORT (IBRD-72900) ON A LOAN IN THE AMOUNT OF USD 16 MILLION TO THE REPUBLIC OF THE PHILIPPINES FOR A SECOND WOMEN’S HEALTH AND SAFE MOTHERHOOD PROJECT December 20, 2013 Human Development Department East Asia and Pacific Region CURRENCY EQUIVALENTS (Exchange Rate Effective 00000000) Currency Unit = Peso (PhP) 1.00 Peso = US$ 0.02 US$ 1.00 = Peso [50] FISCAL YEAR January 1 to December 31 ABBREVIATIONS AND ACRONYMS BEmOC Basic Emergency Obstetric Care BEmONC Basic Emergency Obstetric Care and Newborn Care CAS Country Assistance Strategy CEmOC Comprehensive Emergency Obstetric Care CEmONC Comprehensive Emergency Obstetric and Newborn Care CPR Contraceptive Prevalence Rate CPS Country Partnership Strategy CSR Contraceptive self-reliance DOH Department of Health HSRA Health Sector Reform Agenda ICR Implementation Completion and Results IBRD International Bank for Reconstruction and Development IEG Independent Evaluation Group IMR Infant Mortality Rate IL Investment Loan IP Indigenous People IPDP Indigenous People’s Development Plan IUD Intra Uterine Devices LGU Local Government Units LOGOFIND Local Government Finance and Development M&E Monitoring and Evaluation MCP Maternal Care Package MDG Millenium Development Goal MERD Monitoring, Evaluation, Research and Development MOA Memorandum of Agreement MMR Maternal Mortality Rate NHIP National Health Insurance Program PBG Performance Based Grant PDO Project Development Objective PhilHealth Philippine Health Insurance Corporation PIP Project Implementation Plan PPF Project Preparation Facility QER Quality Enhancement Review RHU Rural Health Unit RRA Rapid Results Approach SP Sponsored Program SWHSM Second Women’s Health and Safe Motherhood WB World Bank WHSM Women’s Health and Safe Motherhood WHSM-SP Women’s Health and Safe Motherhood – Service Package WHT Women’s Health Team TBA Trained Birth Assistant USAID U.S. Agency for International Development Vice President: Axel von Trotsenberg Country Director: Motoo Konishi Sector Manager: Toomas Palu Project Team Leader: Roberto Antonio F. Rosadia ICR Team Leader: Kumari Vinodhani Navaratne THE REPUBLIC OF THE PHILIPPINES SECOND WOMEN’S HEALTH AND SAFE MOTHERHOOD PROJECT Contents Data Sheet A. Basic Information B. Key Dates C. Ratings Summary D. Sector and Theme Codes E. Bank Staff F. Results Framework Analysis G. Ratings of Project Performance in ISRs H. Restructuring I. Disbursement Graph 1. Project Context, Development Objectives and Design ............................................... 1 2. Key Factors Affecting Implementation and Outcomes .............................................. 5 3. Assessment of Outcomes .......................................................................................... 16 4. Assessment of Risk to Development Outcome......................................................... 20 5. Assessment of Bank and Borrower Performance ..................................................... 21 6. Lessons Learned ....................................................................................................... 23 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners .......... 24 Annex 1. Project Costs and Financing .......................................................................... 25 Annex 2. Outputs by Component ................................................................................. 27 Annex 3. Economic and Financial Analysis ................................................................. 38 Annex 4. Bank Lending and Implementation Support/Supervision Processes ............ 40 Annex 5. Beneficiary Survey Results ........................................................................... 42 Annex 6. Stakeholder Workshop Report and Results................................................... 43 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR ..................... 44 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders ....................... 45 Annex 9. List of Supporting Documents ...................................................................... 46 MAP A. Basic Information Second Women's Country: Philippines Project Name: Health & Safe Motherhood Project ID: P079628 L/C/TF Number(s): IBRD-72900 ICR Date: 12/20/2013 ICR Type: Core ICR REPUBLIC OF THE Lending Instrument: SIL Borrower: PHILIPPINES Original Total USD 16.00M Disbursed Amount: USD 10.45M Commitment: Revised Amount: USD 16.00M Environmental Category: B Implementing Agencies: Department of Health Cofinanciers and Other External Partners: B. Key Dates Revised / Actual Process Date Process Original Date Date(s) Concept Review: 01/29/2003 Effectiveness: 12/28/2005 12/28/2005 Appraisal: 06/21/2004 Restructuring(s): 08/16/2010 Approval: 04/21/2005 Mid-term Review: 10/01/2008 10/31/2008 Closing: 06/30/2012 06/30/2013 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Moderately Unsatisfactory Risk to Development Outcome: Low or Negligible Bank Performance: Moderately Unsatisfactory Borrower Performance: Moderately Unsatisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Quality at Entry: Moderately Satisfactory Government: Moderately Satisfactory Moderately Implementing Moderately Quality of Supervision: Unsatisfactory Agency/Agencies: Unsatisfactory Overall Bank Moderately Overall Borrower Moderately Performance: Unsatisfactory Performance: Unsatisfactory C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments Indicators Rating Performance (if any) Potential Problem Project Quality at Entry No None at any time (Yes/No): (QEA): Problem Project at any Quality of Yes None time (Yes/No): Supervision (QSA): DO rating before Moderately Closing/Inactive status: Unsatisfactory D. Sector and Theme Codes Original Actual Sector Code (as % of total Bank financing) Central government administration 15 15 Compulsory health finance 3 3 Health 75 75 Other social services 2 2 Sub-national government administration 5 5 Theme Code (as % of total Bank financing) Administrative and civil service reform 14 14 HIV/AIDS 14 14 Health system performance 29 29 Population and reproductive health 29 29 Social safety nets 14 14 E. Bank Staff Positions At ICR At Approval Vice President: Axel van Trotsenburg Jemal-ud-din Kassum Country Director: Motoo Konishi Joachim von Amsberg Sector Manager: Toomas Palu Fadia M. Saadah Project Team Leader: Roberto Antonio F. Rosadia Teresa Ho ICR Team Leader: Kumari Vinodhani Navaratne ICR Primary Author: Kumari Vinodhani Navaratne F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) The project will contribute to the national goal of improving women's health by: 1) Demonstrating in selected sites a sustainable, cost-effective model of delivering health services that increases access of disadvantaged women to acceptable and high quality reproductive health services and enables them to safely attain their desired spacing and number of children. 2) Establishing the core knowledge base and support systems that can facilitate countrywide replication of the project experience as part of mainstream approaches to reproductive health care within the framework of the Health Sector Reform Agenda Revised Project Development Objectives (as approved by original approving authority) (a) PDO Indicator(s) Original Target Formally Actual Value Values (from Revised Achieved at Indicator Baseline Value approval Target Completion or documents) Values Target Years % of births delivered by skilled attendant (health professional), either in a facility Indicator 1 : or at home Value 59.80% (2003 NDHS quantitative or 80% 88% data), 54% (DOH Data) Qualitative) Date achieved 12/31/2003 06/30/2005 11/30/2013 Comments Average from the 5 intervention provinces using DOH data. DOH Baseline data (incl. % are as of 2006. achievement) Indicator 2 : % of births delivered in a health facility Value 37.50% (2003 NDHS quantitative or 75% 89.0 % data), 30% (DOH data) Qualitative) Date achieved 12/31/2003 06/30/2005 11/30/2013 Comments Average from the 5 intervention provinces, using DOH data. DOH Baseline data (incl. % are as of 2006. achievement) % of deliveries by the poor in BEMOCs and CEMOCs financed through Indicator 3 : PHILHEALTH Sponsored Program Value quantitative or 8% (DOH data) 75% 33% Qualitative) Date achieved 12/31/2006 06/30/2005 11/30/2013 Comments (incl. % achievement) % of deliveries by the poor in BEMOCs and CEMOCs financed through DOH- Indicator 4 : LGU Performance Based Grant Value NA at approval 25% 81% quantitative or Qualitative) Date achieved 06/30/2005 06/30/2005 12/31/2012 Comments (incl. % achievement) Indicator 5 : Increase in the contraceptive prevalence rate Value 46.5% (from the HH quantitative or DOH data), 38% 56.5%, 48% 39% Qualitative) (provided by DOH) Date achieved 12/31/2006 06/30/2005 11/30/2013 Comments (incl. % achievement) % of RHUs that have not experienced stock outs of pills, injectables and IUDs Indicator 6 : for past 6 months Value quantitative or 16% (DOH data) 100% 100% Qualitative) Date achieved 12/31/2006 06/30/2005 06/30/2013 Comments (incl. % the average was calculated using the 5 provinces data achievement) 80% births delivered in a health facility in each project LGU (defined as a Indicator 7 : province) Value quantitative or 42% (DOH data) 80% 87% (DOH data) Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % The average from all 5 Provinces. achievement) 40% of deliveries in BEmONCs in each project LGU (defined as Province) Indicator 8 : financed by PhilHealth Sponsored Program Value quantitative or 10% 40% 38% Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % achievement) Increase in CPR in each project LGU (defined as province) by 10 percentage Indicator 9 : points Value quantitative or 35% 45% 39.4% Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % achievement) 100% of BEmONCs in each project LGU (defined as province) are PhilHealth Indicator 10 : accredited for its maternal health care package Value quantitative or 9% 100% 86% Qualitative) Date achieved 12/31/2006 09/30/2010 11/30/2013 Comments (incl. % achievement) 100% of project LGUs (defined as a province) have passed an ordinance on Indicator 11 : contraceptive self- reliance Value quantitative or 36% 100% 80% Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % achievement) % of project LGUs (defined as a province) sustaining their enrolment for the Indicator 12 : Philhealth sponsored Program to at least 75% of the city and municipal targets Value quantitative or 81% 75% 90% Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % achievement) Indicator 13 : 100% of BEmONC teams in project LGUs (defined as a province) trained Value quantitative or 36% 100% 106% Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % achievement) (b) Intermediate Outcome Indicator(s) Original Target Actual Value Formally Values (from Achieved at Indicator Baseline Value Revised approval Completion or Target Values documents) Target Years 100% of the BEMOCs that have PHILHEALTH accreditation for maternity Indicator 1 : package Value (quantitative 13% 100% 70% or Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % achievement) Indicator 2 : 50% reduction in the number of normal spontaneous deliveries in CEmOC Value (quantitative 23% 50% 29% or Qualitative) Date achieved 12/31/2009 09/30/2013 11/30/2013 Comments (incl. % achievement) Indicator 3 : 80% of women who delivered in the past 6 months had birth plans Value (quantitative 65% 80% 81% or Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % achievement) 100% of FP users and ante-natal clients screened for STI according to prescribed Indicator 4 : protocol Grant Value (quantitative 59% 100% 87% or Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % Value is the average of FP and ANC clients screened. achievement) 70% of women who know the 3 ways (abstain, be faithful, consistent and correct Indicator 5 : condom use) of preventing the sexual transmission of HIV Value (quantitative 39% 70% 55% or Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % FP clients using hormonal, barrier methods are screened during history taking achievement) Increase to 16% from baseline the total proportion of women or their partners Indicator 6 : using permanent FP methods Value (quantitative 2.4% 16% 4% or Qualitative) Date achieved 12/31/2009 09/30/2010 12/31/2012 Comments (incl. % achievement) Indicator 7 : 70% of non-poor FP clients paying for contraceptives (may be paying through private sector providers or suppliers or through user chargers in the public facilities) Value (quantitative 40% 70% 70% or Qualitative) Date achieved 12/31/2006 09/30/2010 11/30/2013 Comments (incl. % achievement) Increase LGU enrollment for the PhilHealth Sponsored Program coverage and Indicator 8 : sustain to at least 75% of the target poor households at the municipal and city level Value (quantitative 82% 75% 88% or Qualitative) Date achieved 12/31/2006 09/30/2010 11/30/2013 Comments (incl. % achievement) 100% of BEmOCs share maternal care revenues with WHT according to Indicator 9 : guidelines Value (quantitative 39% 100% 47% or Qualitative) Date achieved 12/31/2007 09/30/2010 11/30/2013 Comments (incl. % achievement) Indicator 10 : Inclusion of WHSM standards in the Sentrong Sigla accreditation criteria Value (quantitative Not included Included or Qualitative) Date achieved 12/31/2009 11/30/2013 Comments The Sentrong Sigla has been replaced by Philhealth accreditation and the WHSM (incl. % standards are included in PhilHealth accreditation criteria. achievement) First edition of WHSM services guidelines for LGUs and local WHSM teams Indicator 11 : disseminated and used by LGU managers and WHSM teams Value (quantitative Not prepared Completed or Qualitative) Date achieved 06/30/2005 12/31/2007 Comments Service guidelines launched and disseminated in 2006 and SWHSM (incl. % Implementation Guidelines launched and disseminated in 2007. achievement) 80% of WHT, BEmOC and CEmOC teams have completed training on the Indicator 12 : integrated WHSM-SP Value Not carried out Completed (quantitative or Qualitative) Date achieved 06/30/2005 11/30/2013 Comments (incl. % achievement) 100% of LGUs in project sites use routinely collected WHSM-SP monitoring Indicator 13 : and evaluation data (including maternal death reviews) in their annual plans Value (quantitative None 100% or Qualitative) Date achieved 06/30/2005 11/30/2013 Comments (incl. % achievement) Selected innovative elements of project documented and impact measured with Indicator 14 : results used for scaling up Value Some operations (quantitative Not carried out research carried out or Qualitative) Date achieved 06/30/2005 11/30/2013 Comments (incl. % achievement) G. Ratings of Project Performance in ISRs Actual Date ISR No. DO IP Disbursements Archived (USD millions) 1 06/09/2005 Satisfactory Satisfactory 0.00 2 02/14/2006 Satisfactory Satisfactory 0.38 3 05/21/2006 Satisfactory Moderately Satisfactory 0.38 4 03/21/2007 Satisfactory Moderately Satisfactory 0.43 5 11/04/2007 Satisfactory Moderately Satisfactory 0.63 Moderately 6 02/13/2008 Moderately Satisfactory 0.63 Unsatisfactory Moderately 7 07/03/2008 Moderately Satisfactory 0.74 Unsatisfactory Moderately 8 12/14/2008 Moderately Satisfactory 0.88 Unsatisfactory Moderately 9 02/13/2009 Moderately Satisfactory 1.01 Unsatisfactory Moderately 10 08/11/2009 Moderately Satisfactory 1.45 Unsatisfactory 11 01/04/2010 Moderately Satisfactory Moderately Satisfactory 2.07 12 11/17/2010 Moderately Satisfactory Moderately Satisfactory 3.59 13 08/13/2011 Satisfactory Moderately Satisfactory 4.80 14 09/23/2012 Moderately Satisfactory Moderately Satisfactory 7.96 Moderately Moderately 15 03/17/2013 8.57 Unsatisfactory Unsatisfactory Moderately Moderately 16 06/25/2013 8.94 Unsatisfactory Unsatisfactory H. Restructuring (if any) ISR Ratings at Amount Board Restructuring Disbursed at Restructuring Reason for Restructuring & Approved Restructuring Date(s) Key Changes Made PDO Change DO IP in USD millions The restructured design will eliminate sub-project financing for LGU-level civil works and equipment with the project financing focusing on the organization and the training of health personnel, and the operationalization of support systems for the delivery of WHSM services through performance-based grants. The 1.5 million USD originally allocated for sub- project financing and 200,000 USD from the unallocated portion of the loan was re-allocated to the 08/16/2010 N MS MS 2.55 performance-based grants. Although there will be other re-allocations across the other project categories, this re- allocation is the most substantial of all the reallocations. The re-alignment of the project to support the national policy will have the re-structured project funding the national scale up of behavioral change communication interventions, upgrading of government training capacity, and investments in blood supply ISR Ratings at Amount Board Restructuring Disbursed at Restructuring Reason for Restructuring & Approved Restructuring Date(s) Key Changes Made PDO Change DO IP in USD millions systems. I. Disbursement Profile 1. Project Context, Development Objectives and Design 1.1 Context At appraisal of the Second Women’s Health and Safe Motherhood (SWHSM) project in 2005, the Philippines reported a maternal mortality rate of 180 per 100,000 live births (1995), a total fertility rate of 3.5 children per woman, contraceptive prevalence of 49% (2003) and a population growth rate of 2.36% per year (1995 -2000). Women’s health services are provided through a network of health facilities managed both by the private and public sectors. In the early 1990s, the Government devolved the health sector to Local Government Units (LGUs) to improve the targeting of services to the most needy populations. At this time, the public sector services were increasingly ‘less free’ to the population and around the same time a national health insurance program (NHIP) was started with the establishment of the Philippine Health Insurance Corporation (PhilHealth) to ensure universal access to services. The Sponsored Program (SP) of NHIP offered fully subsidized membership premiums for the poor from the early 1990s, but this program took off only in 2001, and even at appraisal the uptake of the services by the poor had been low due to the various reasons including the difficulties faced by the poor to pay the co-payments required by the providers. Furthermore, many health facilities were unable to gain accreditation from the PhilHealth. Women’s health services to ensure safe motherhood was addressed through a series of policies and strategies in the Philippines which evolved from providing services through Trained Birth Assistants (TBAs) at the home of mothers to hospital based deliveries. The SWHSM project envisaged that in selected sites, all pregnant women would deliver in hospitals, a strategic change from what was carried out under the First Women’s Health and Safe Motherhood (FWHSM) project. Challenges of managing the service delivery package and in providing the supporting systems were expected and measures were to be taken to address them under the project. Rationale for Bank Assistance The first bank supported Women’s Health and Safe Motherhood Project supported a risk based strategy where pregnant women delivered mainly at home under the guidance of TBAs. As this approach did not observe the expected results it was agreed that the SWHSM project should support a package of facility-based services to improve maternal mortality outcomes in selected areas of the Philippines. The Bank was requested to bring in technical assistance to develop a cost effective package of services and to ensure financing of this pilot intervention. Link to Country Assistance strategy The project objectives were consistent with the Country Assistance Strategy (CAS) and its two critical paths: achieve poverty-reducing growth and ensure that the poor 1 participate and benefit from development. Furthermore, the project was supporting the CAS objective of empowering the poor by improving investments in human development and in ensuring access by the poor with a particular focus on increasing the utilization of and satisfaction with the quality of health care services provided especially among the low income households. 1.2 Original Project Development Objectives (PDO) and Key Indicators (as approved) The development objective of the project was to contribute to the national goal of improving women's health by: a. Demonstrating in selected sites a sustainable, cost-effective model of delivering health services that increases access of disadvantaged women to acceptable and high quality reproductive health services and enables them to safely attain their desired spacing and number of children. b. Establishing the core knowledge base and support systems that can facilitate countrywide replication of the project experience as part of mainstream approaches to reproductive health care within the framework of the Health Sector Reform Agenda The following were the original performance indicators at the time of Board approval: • % of births delivered by skilled attendant (health professional) either in facility or at home • % of births delivered in a health facility • % of deliveries by the poor in Basic Emergency Obstetric Care (BEmOC) and Comprehensive Emergency Obstetric care (CEmOC) facilities financed through PhilHealth Sponsored Program • % of deliveries by the poor in BEmOCs and CEmOCs financed through DOH – LGU Performance Based Grant • Increase in the Contraceptive Prevalence Rate (CPR) • % of Rural Health Units (RHUs) that have not experienced stock outs of pills, injectables and Intra Uterine Devices (IUDs) for past 6 months These performance indicator targets were in the first phase to be achieved by the LGU beneficiaries of Sorsogon, Surigao del Sur Provinces and Iloilo City. These targets were based on baseline statistics drawn from national level estimates. These targets were to be adjusted with the agreement of the World Bank upon the completion of the baseline survey. Furthermore, newer targets were to be set for the Phase two provinces, at lower levels for other LGU beneficiaries which were expected to start implementation later into project’s implementation in 2007. 2 1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and reasons/justification The Project was restructured (Level II) in September 2010. The original PDO was retained with a few changes to the PDO indicators as follows. • 80% births delivered in a health facility in each project LGU (Project LGU is defined as each province) • 40% of deliveries in Basic Emergency Obstetric and Newborn Care (BEmONCs) in each project LGU is financed by PhilHealth Sponsored Program • Increase in CPR in each project LGU by 10 percentage points • 100% of BEmONCs in each project LGU are PhilHealth accredited for its maternal health care package • 100% of project LGUs have passed an ordinance on contraceptive self- reliance • % of project LGUs sustaining their enrolment for the PhilHealth sponsored Program to at least 75% of the city and municipal targets • 100% of BEmONC teams in project LGUs trained The original PDO indicators were revised to better align with the Government’s strategy to reduce maternal and newborn mortality. But at restructuring, the targets for the 3 new provinces were not defined and the original measurements for the indicators were also not updated based on the baseline survey findings (which was available by February 2008) as mentioned in the original Loan Agreement. The project continued to monitor both sets of indicators – 6 of the original indicators and the 7 revised indicators (the data sheet lists the original 6 indicators first while the revised indicators are numbered from 7-13). 1.4 Main Beneficiaries The Primary target group under the project includes the disadvantaged women living in project demonstration provinces. The disadvantaged group of women includes the women in families belonging to the PhilHealth Sponsored Program and the LGU identified indigents. The project also intended to work with the service providers through the Department of Health (DOH) by building their capacity to provide the required maternal care services to the target populations in the demonstration sites and to the wider population of women in the reproductive age group living across the Philippines. 1.5 Original Components (as approved) Component A: Local delivery of the Integrated Women’s Health and Safe Motherhood Service Package (WHSM-SP) (appraisal estimate USD13.4 million; actual USD 5.19 million). This component was planned as two sub components 1 and 2. 3 Sub component 1 planned to: (a) develop and enhance the capacity of the LGU beneficiaries to establish and operate a network of providers of the WHSM SP, including teams for women’s health, basic obstetric care, comprehensive obstetric care, adolescent and youth health, and itinerant teams through the provision of (i) sub project financing for goods and works for LGU owned facilities; and (ii) goods and works for DOH-owned facilities; and (iii) consultant services, training and workshops. (b) to assist LGUs in the development and implementation of cost effective and sustainable approaches to reach three high risk groups: female sex workers, returning overseas workers and young adults. Sub component 2 planned to establish and operate reliable and sustainable systems for the delivery of WHSM-Service Package included; (a) drug and procurement security , through the provision of goods and services for (i) the establishment of efficient province and city wide logistics planning, management and procurement systems, (ii) the segmentation of local markets for appropriate targeting of subsidized financing and free distribution of contraceptives and (iii) complementary establishment or expansion of social marketing initiatives for contraceptives; (b) safe blood supply through the provision and services for the setting up of a network of blood service facilities at different levels of the health care system. (c) behavior change interventions through: (i) pilot testing of performance based grants to selected LGUs, health service providers and users; (ii) the provision of goods and services for advocacy, communications and information dissemination (d) sustainable financing of local WHSM services and related commodities through (i) increased LGU financing and increased revenues from PhilHealth benefit payments and (ii) application of a market segmentation mechanism that would allow LGU beneficiaries to raise user charges from non-poor clients and encourage use of WHSM services by eligible poor clients through grants and awards. Component B: National capacity to sustain WHSM services (appraisal estimate USD 2.5 million; actual USD 5.10 million). This component had 4 sub components; (1) develop, adopt and implement operational and regulatory guidelines for the provision and use of WHSM services. (2) develop a network of training providers that are accredited to provide courses on: (a) appropriate delivery of the integrated WHSM–SP; and (b) team work and collaboration for the various types of WHSM teams. (3) (a) develop a system to monitor and evaluate the implementation of the WHSM – SP and publicly disseminate the monitoring and evaluation of results; (b) carry out project baseline and impact evaluation studies; and (c) support policy and operations research on WHSM (4) establish and maintain project management capacity at the national and at the local level. 1.6 Revised Components 4 The project which was restructured on September 30, 2010, included a few changes within the original components; • The Subproject Financing for goods and works for LGU owned facilities which had an allocation of USD 1.5 million was removed. • The section on providing sustainable financing of local WHSM services and commodities through (ii) the application of a market segmentation mechanism was removed. • The originally allocated expenditures to the sub project financing (USD 1.5 million) and a USD 0.2 million from the unallocated funds at the beginning of the project were reallocated to the PBGs. • Training facilities were expanded to include out of project sites but the allocation was reduced to USD 1,500,000 from USD 1,700,000. • Allocation for PBGs provided to the LGUs, beneficiaries and service providers was increased from USD 3.3 million to USD 5 million. Also, the financing mechanism was changed from providing advances to reimbursements of the PBGs. An extension of the closing date from December 31, 2011 to June 30, 2013 was approved. 1.7 Other significant changes None 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry Project Preparation The project was formulated based on the request of the Government of the Philippines to support WHSM initiatives to achieve rapid improvements in maternal health related outcomes. Even though the first WHSM project, which was partly supported by the World Bank, had an unsatisfactory implementation progress there still was a need to find an appropriate solution to address maternal health outcomes. The second WHSM project was designed to demonstrate a new approach of facility based deliveries for all mothers in the selected demonstration sites. But this demonstration meant that nearly all the hospitals including the Rural Health Units (RHUs) in the demonstration provinces had to be accredited by PhilHealth to perform BEmOC services when at the time of project preparation (2005) nearly none of the RHUs managed by the Local Governments across the Philippines had been accredited by PhilHealth for a Maternal Care Package (MCP). Project preparation was carried out in consultation with other partners involved in supporting health services in the Philippines. But the World Bank was one of the first donors to support the Health Sector Reform Agenda (HSRA) and the first to back the DOH strategy to link reforms in a key national program like the WHSM to the HSRA framework. 5 Project Design The project relied on the use of government systems, incorporating the devolution of health services to the LGUs in the Philippines. The project intended to introduce a new MCP at selected provinces (initially 3 and later to scale up to 6 provinces from a total of 80 provinces in the Philippines). The project had two components where the first component was the implementation of the MCP and the other component was to provide the LGUs with the necessary capacity building to implement the MCP and to scale up the intervention across the country. The project was to be implemented by the respective LGUs in each of the demonstration provinces and the DOH. In addition, the LGUs in the first set of provinces were also required to work with another ongoing World Bank financed project called Local Government Finance and Development (LOGOFIND). Risk analysis and lessons applied during project preparation A quality enhancement review (QER) was not carried out at preparation. But following the FWHSM project, the World Bank’s Independent Evaluation Group (IEG) recommendations had highlighted; (i) the need to involve the LGUs as active partners in project preparation, implementation and monitoring; (ii) to establish a professional project management office; (iii) to resolve fundamental cross cutting management issues related to financial management, procurement and human resource management. In addition, the team identified many critical risks and possible controversial aspects which included; (i) complex governance structure of the health sector involving the DOH, LGUs and PhilHealth with weak coordination, (ii) strategies selected for the WHSM-SP delivery and financing included both untested and new initiatives which may become technically inappropriate or ineffective, (iii) insufficient project management and technical capacity at DOH and LGU levels to lead project activities, (iv) complicated project management arrangements for batch one sites as the DOH and the LGUs as they also were to coordinate with the LOGOFIND team, (v) likely delays in fund flow by national government and LGUs for project implementation, (vi) possible collapse in contraceptive supplies if LGU financing did not materialize in an environment where the National Government did not purchase contraceptives for LGUs, (vii) difficulties in placing and retaining skilled staff for WHSM teams. The project at preparation had an overall risk rating of substantial. The design team attempted to address these issues by including the following mitigation measures in the risk analysis of the project; (i) a MCP was only to be introduced in a few provinces with clear cut tasks to achieve project deliverables; (ii) highlighting the soft interventions through capacity building; (iii) by having a detailed plan for monitoring, supervision and financing arrangements;, (iv) by phasing the interventions to batch one and two provinces to allow adequate time for learning from the batch one sites; (v) to secure the project budget in the DOH and LGU budget plans; (vi) to create a drugs for commodities swap to address contraceptive availability; (vii) technical assistance to improve human resource planning and management capacity. The design team also mitigated the risks by introducing conditions of effectiveness. The effectiveness conditions included; (i) issuance of a PhilHealth Board policy statement 6 supporting the national WHSM package and authorizing piloting of various measures in the project sites supporting WHSM; (ii) all LGUs in the batch one provinces were required to make an initial deposit of 3 months of counterpart funds into their newly opened project accounts (iii) the Project Implementation Plan, (PIP), Procurement Implementation and Financial management Manual were to be adopted, (iv) signed subproject loan agreements under the LOGOFIND project for the batch one project sites, (v) ratified environment and waste management operating guidelines, environmental assessment report, indigenous peoples (IP) strategy, indigenous people’s development plan (IPDP) and resettlement policy framework in the batch one demonstration provinces. The project design required the DOH to sign a Memorandum of Agreement (MOA) with all LGUs (there are approximately 18 LGUs on average in each province) in the demonstration provinces. The LGUs also had to open bank accounts to receive funds from the DOH for the Performance Based Grants (PBGs) and to transfer funds from the LGUs as counterpart funds for expenses that were to be managed by the provinces. Furthermore, in addition to the MCP intervention which was new to the LGUs in the demonstration provinces, the project tried to also introduce a new mechanism of financing with the introduction of PBGs for some of the interventions proposed in the MCP. In addition, encouraging contraceptive self-reliance (CSR) by LGUs was the feasible but risky intervention especially because there was a ban on the use of National Government funds to procure family planning commodities. Therefore, designing the project to include CSR by the LGUs encouraged by the DOH with an incentive of providing a matching grant for the cost incurred to secure CSR for life saving drugs was expected to address this issue. These measures created a complex project design from the beginning of the project. The proposed project intervention had high ownership at the DOH and LGU levels. The project was planned to be implemented under the leadership and management of the DOH in close collaboration with the LGUs, which had the decision-making powers. Lending Instrument The project was financed using a Specific Investment Loan (SIL). A SIL was used as the project attempted to introduce a new intervention that had to break through cultural, political and behavioral challenges, which was implemented in a highly devolved environment. The team argued that this required continuous focused attention and coordinated action at different levels of government and this was best possible using a SIL. 2.2 Implementation Initiatives taken to encourage facility based deliveries Many initiatives were taken to pilot the behavior change from a home delivery to a facility-based delivery. Initially the DOH increased the advocacy for this change through the Regional and the Provincial Health Offices in the pilot provinces on the advantage of providing facility-based services for mothers delivering babies in their health facilities. Thereafter, the LGUs were encouraged to get their RHUs accredited by PhilHealth for 7 providing the MCP services. This resulted in high rates of the MCP accreditation of LGU health facilities (from a total of 84 LGUs in all 5 pilot provinces) to nearly more than 60 LGUs at the time of project closure. The LGUs were also encouraged to establish Women’s Health teams (WHTs) whose membership included the TBAs and other health volunteers in the community. Nearly all the LGUs, at time of project closure, had created WHTs whose main role was to provide the important linkage with the facility and the home so that women would want to come to the facility for their delivery. With the introduction of PBGs for establishing the WHTs in each village, encouragement of PhilHealth accreditation for MCP and the allowances provided to the mother herself by the LGUs for using a facility for delivery, both demand side and supply side interventions were introduced under the project. At the end of the project, it was noted that on average a 45% increase in health facility delivery during the project period. Factors that contributed to successful implementation: DOH and LGU ownership: The DOH was much committed to demonstrating the benefit of encouraging facility- based deliveries in the Philippines especially as there were diverse views to the likelihood of success of this approach of encouraging facility-based deliveries. The DOH took this up as a challenge and used the SWHSM project to pilot this initiative. The DOH successfully created the demand for encouraging facility-based deliveries with the LGUs. PhilHealth accreditation: Even though PhilHealth was established in 1995, PhilHealth usage was low for MCP services in the Philippines at the time of project initiation in 2006 as most facilities were not accredited for these services. With the planned pilot in the demonstration provinces, PhilHealth was required to create an accreditation process for the MCP the same time. This was most important as the project also attempted to make services accessible to the indigent populations of the demonstration provinces. The LGUs also benefited to register more poor populations as the PBGs and the PhilHealth payments were made available to them. BEmONC / BEmOC services in health facilities: At time of project initiation, most of the RHUs and other district level health facilities were not equipped to provide BEmOC (later on expanded to Basic Emergency Obstetric and Newborn Care services (BEmONC). PhilHealth accreditation required certification of staff trained in BEmONC services. As a response to this, the DOH was able to initiate the development of teams of experts to carry out the required training. At the end of the project nearly 100% of the health facility teams were trained on BEmONC services. Furthermore, the project was able to establish a total of 29 training centers (project requirement was just 5) all over the country that provided BEmONC training to include all other non-project provinces across the Philippines. Infrastructure development of facilities: The project had included a partnership with another ongoing project supported by the World Bank - the LOGOFIND project - to support the civil works required in the facilities in the batch one demonstration provinces. Even though at the initial stages these 8 funds were utilized, it was noted that towards the second half of the project implementation, the SWHSM Project seem to have been a catalyst for attracting many other grant funding sources. Therefore, even though the original allocations under the SWHSM project for civil works were not utilized, the LGUs had adequate resources throughout the project period to improve their health facilities. PBGs: PBGs were introduced as a pilot for the first time under the SWHSM project. PBGs were linked to the achievement of (i) the establishment of Women’s Health Teams (WHT) in each village (Barangay), (ii) facilitation of LGU enrollment in the PhilHealth sponsored program for MCP services (iii) encouragement of LGU financing of family planning and essential drug (commodity) inputs. It is noted that this new approach of incentivizing for these results were able to help stimulate the behavior change required thus increasing facility-based deliveries in the pilot provinces. IEC approaches taken to change behavior towards facility deliveries: The DOH and the LGUs had to change the behavior of the communities who traditionally preferred home-based deliveries. The interventions introduced through the WHTs, the advocacy programs with the LGUs, communities, and the communication messaging were noted to have helped the reported increase in facility-based deliveries in the demonstration provinces. WHTs: The establishment of WHT’s in approximately every village in the demonstration province, whose membership included the TBAs and other women volunteers from the community, were instrumental in moving from home-based delivery to a facility-based delivery in the demonstration provinces. Furthermore, they are still functioning as the link between the community and the facility and also help improve the quality of care given to the pregnant mothers by improving pregnancy tracking, encouraging 4 Antenatal visits during pregnancy and by helping data reporting by sending mobile updates of all pregnant women in the community to the area midwife in the LGUs. Factors that gave rise to delays in project implementation Conditions of effectiveness and delays with project implementation: With initial implementation of the project, major delays occurred in getting most of the conditions of effectiveness (described in section 2.1). Even though the condition of effectiveness related to LGUs in the phase one provinces were required to make an initial deposit of 3 months of counterpart funds into their newly opened project accounts were not met, on 28 December 2005 the project was made effective with an exemption issued by the World Bank. This particular condition of effectiveness, which was essential for successful project implementation, got completed late into project life which continued to delay implementation. The project activities effectively started only in late 2007, which delayed the start up activities of the project by more than one year. 9 Policy changes related to pilot and scale up of WHSM services: The project intended to introduce the Women’s Health and Safe Motherhood–Service Package (WHSM-SP) in two phases. The phase one was expected to include 3 provinces that were selected on maternal mortality rate (MMR), infant mortality rate (IMR), contraceptive prevalence rate (CPR) levels, population size, and interest of LGUs to introduce a WHSM package. But, very early on during project implementation, when one of the identified provinces opted out, the DOH and the World Bank (WB) have agreed to use only 2 provinces (Sorsogon and Surigao del Sur) as the phase one provinces in the demonstration pilot. Just at the same time as the new WHSM-SP was getting introduced in the phase one demonstration sites, the Government in 2006, incorporated the Batch one provinces to the Fourmula One for Health (F1) strategy which had many similarities to the WHSM-SP but not the full package identified in the project. In addition, in 2009, with some successful interventions seen in the demonstration sites under phase one provinces, but without any evaluations, the Government issued an Administrative Order to scale up and expand the facility-based interventions for MCP (which also newly included New Born care) across the country. This scale up excluded interventions for family planning, overseas Filipino workers, and STI prevention. The phase two provinces (Albay, Catanduanes, and Masbate) which started the pilot in 2010, may not have got the attention required both from the DOH and the LGUs to run the full pilot intervention package as by then the scale up to all provinces had also taken place. This reason led to the reduced services introduced at all demonstration provinces from what was planned as the WHSM-SP at the beginning of the project. WHSM-SP: The project was most ambitious to try out a comprehensive package of services as a pilot intervention in 6 provinces of the Philippines. None of the demonstration provinces introduced the complete WHSM-SP during the project period. Among them interventions for the freelance sex workers, returning overseas workers and young adults were never initiated. In addition, drug and contraceptive security initiatives were initiated in much lower scale. Behaviour change communication programs for encouraging contraceptive usage were not initiated. Similarly, impact evaluations, operations research and the end line survey were not carried out. In addition, the BEmOC package that was later expanded to be a BEmONC package only included 3 (provision of oxytocin, steroids and neo-natal resuscitation) of the globally accepted 6 signal functions (manual removal of products of conception, parental administration of anti-convulsants and performing assisted vaginal delivery, administration of uterotonic drugs, anti-convulsants and antibiotics, and neo-natal resuscitation). Implementation capacity of the DOH: Even though the DOH has had experience in carrying out WB-financed operations, implementation capacity was somewhat weak as the project required many transactions with many LGUs in parallel. The required human resources, i.e. Procurement and Financial Management specialists, and Monitoring and Evaluation Specialists; were not 10 hired as planned due to procurement delays and also due to changes made by the DOH. The tasks of managing the training requirement for the country along with the behaviour change communications that were required to be done through consultancies were later decided to be managed by the DOH that created a higher demand on the DOH existing capacity. This resulted in the DOH’s inability to systematically implement lessons learned during the implementation phase and to institute the necessary changes for improvement. Furthermore, the monitoring and evaluation capacity, procurement and financial management capacity continued to be issues throughout the project implementation period. Implementation capacity of the LGUs: Even though the LGUs were involved from project design stage difficulties arose with the implementation of the LGU activities and reporting back of expenditures related to activities, especially the PBGs, carried out by them. The project team faced many obstacles with regard to procurement and financing processes at the LGU level. The proposed mitigation measures were also not adhered to during the project’s implementation period. PBGs: While the PBGs were instrumental in creating the much required WHTs and in facilitating the behaviour change towards using facilities for delivery and in encouraging LGU enrollment in the PhilHealth Sponsored Program it was not successful in encouraging LGU financing of commodity inputs. The use of PBGs in the health sector at the level of the LGU was a new initiative that faced constraints when creating budget lines and reporting expenses to the DOH and therefore faced many liquidation issues throughout project implementation. Furthermore, there was no validation mechanism established to verify the results against which the payments were made under this component. Therefore, even though this approach of using PBGs achieved good results the process faced many obstacles and was too complicated which delayed transactions with the LGUs. Hiring of consultants: The DOH faced many obstacles in hiring and managing consultants – both individuals and firms - throughout the project period. The hiring of the required additional consultants for Monitoring and Evaluation, Procurement and Financial Management were not carried out and eventually the DOH staff ended up managing these tasks. In addition, some of the firms that were to be contracted for behaviour change communication and human resource development were not awarded as the DOH felt that they had the required competencies to manage these tasks. The end line survey and the other efficiency studies were never awarded due to delayed procurement processing. Mid-term review: The mid-term review was conducted in October 2008 at 2.5 years into implementation when disbursement was only just over 5% of the project funds and the project was rated moderately unsatisfactory. But the mid-term review recommendations were mainly to 11 introduce a rapid results approach which reviewed milestones every 100 days and a few reallocations but did not cancel funds even though originally considered by the team. Restructuring and project extension: Even though from as early as 2007, restructuring and even cancellation of funds were discussed, the project underwent only one Level II Restructuring in September 2010, which was by then 5 years into project implementation. It seems that the restructuring was more a ‘corrective restructuring’ while this late restructuring should have been an ‘adaptive restructuring’ as the interventions piloted in the first phase were scaled up to all provinces from 2009 onwards, just prior to the formal restructuring of the project. The team requested a project extension to support the scale up of interventions proposed by the Government. As the WHSM–SP interventions identified in the original pilot were never fully piloted, the restructuring should have also attempted to improve the modalities of improving the service package. Reallocations: The restructuring process included requesting reallocations from non-performing components to better performing components. Therefore excess funds available from civil works (as the LGUs by then had received many other sources of funds for refurbishing and improving the health facilities) were moved to the PBGs category. The modalities of reporting and other issues related to processes for managing PBGs were addressed by moving from providing advances to LGUs to reimbursement to LGUs at restructuring. But the utilization of this allocation was lower than expected at time of project closure and the reporting back of expenses continued to be delayed. 2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization Monitoring and Evaluation Design: The M&E of the project was to be managed under the monitoring, evaluation, research and dissemination component headed by an M &E specialist contracted under the project. The following sources of data were to be used; (i) regular assessments of inputs and processes related to the Project Development Objective and sub components, (ii) semi- annual reporting of service delivery performance, (iii) survey data from a baseline and end line surveys with comparison groups, (iv) operations research studies that were supposed to evaluate the effectiveness of innovations introduced under the project, (v) mechanisms for dissemination of results to support evidence based management. All six PDO indicators identified for the project were relevant and appropriate. These included indicators to assess the effect of the WHSM-SP in the demonstration sites. But the measurements of these results, as the project was designed to demonstrate effectiveness of a package of services, were relying on baseline and end line surveys and other applied surveys. The revised PDO indicators had fine-tuned the original PDO indicators, also added one new indicator on BEmONC training and removed the section of the indicators related to CEmOCs. The revised PDO indicators also attempted to get 12 data by each LGU level. Only 3 of the original 6 PDO indicators had a baseline value from a survey even though targets had been provided for all PDO indicators. The intermediate indicators included in the project were many (14 indicators) that were also all related to the WHSM-SP. But nearly none of them had any baseline values at project approval. Most of them were not removed or edited during restructuring of the project. Furthermore, the monitoring and supervision plan was not updated/followed by the bank and project teams. Monitoring and Evaluation- Implementation Monitoring, Evaluation, Research and Development (MERD) Specialist: The project was expected to hire the services of a MERD specialist but this post was not filled throughout most of the project implementation period. Furthermore, the Baseline survey result that was supposed to provide baseline data was made available in February 2008, 2.5 years into project effectiveness. The team also did not come up with an alternative arrangement for result monitoring at restructuring and only edited the original PDO indicators. The end line survey for the project was never carried out. Furthermore, the original and restructured indicators were not regularly updated even with alternative sources of data. Evaluation reports: With the project’s successful implementation of the batch one provinces, USAID and other development partners including the WB team, have carried out a few evaluation studies 1 on the WHSM-SP interventions and its effect on improving the health system and on the successes reported with the introduction of the PBGs for the establishment of WHTs at the village levels. This study highlighted that a systems approach to addressing maternal health shows synergistic positive effects. Rapid Results Approach: The project team introduced the Rapid Results Approach (RRA) in about 2009/10 when project implementation was struggling to take off. The technique of planning for achieving a result with clear milestones that need to be monitored throughout a 100 day period seem to have helped improve project implementation from 2010 onwards. Disbursement which was around 5% in 2008 and 18% in 2010 at restructuring improved with this monitoring approach. The provinces continue to use this process even as the project has closed. Monitoring and Evaluation – Utilization 1 The paper on ‘ A systems approach to improving maternal health in the Philippines’ was published in the Bulletin of the World Health Organization in 2012 was carried out by Dale Huntington, Eduardo Banzon, and Zeneida Dy Recidoro. 13 Minimal mechanisms were in place for utilization of data for planning and monitoring even though this project was planned as a demonstration pilot. The main data source that was used to review progress during project implementation was service level data. To support and validate this data, the baseline and end line surveys were recommended to be carried out in time. The DOH was also supposed to carry out applied surveys to provide further insight to the effects of the project intervention. While the baseline survey was carried out (though much later than planned) the end line survey was never carried out. Thus, at the end of the project, the pilot intervention was not evaluated well enough. The teams also did not utilize the baseline data to adjust the planned results targets of the project as agreed in the loan agreement. But the observed increase in facility based deliveries in batch one provinces influenced the government when they decided to scale up the intervention to all provinces in the Philippines long before the pilot intervention was to be completed under the WHSM-SP. The Bank team could have considered this change in policy and accommodated a change in the PDO when the project was restructured in 2010. 2.4 Safeguard and Fiduciary Compliance Safeguard Compliance: The project was rated as an Environment Category B project and was expected to address issues related to potential adverse effects of health care waste and associated construction works. The project team was required to develop (i) environment and health care waste management operating guidelines; (ii) the indigenous peoples strategy; (iii) the resettlement policy framework. At time of project design stage, an environment assessment was carried out and an environment management plan was developed by the environmental health unit of the DOH. The DOH already had existing regulations on the management of health care waste. These guidelines were further refined and updated by the DOH through the assistance of the World Health Organization (WHO). Only minor civil works were carried out in batch one provinces under the LOGOFIND project and most of the other planned civil works were not carried from finances from the Second WHSM project. In the few contracts carried out under the project, the environment management plan had been included as a contractual obligation in the civil works contracts supported by LGUs. There was general compliance with the provisions of the EMP and with the Health Care Waste Guidelines of the DOH. The project also complied with the safeguards on Indigenous Peoples. The DOH developed an Indigenous Peoples Planning Framework (IPPF). The safeguard on Resettlement Policy Framework was not triggered during the life of the project. Fiduciary compliance: The project has complied with the financial covenants which include the submission of the quarterly Interim Financial Reports (IFR) and the annual audited project financial statements despite significant delays in some submissions. Out of the seven audit reports received on the audit of the project financial statements, three have qualified audit opinions (CY2006, 2007 and 2009), one adverse opinion (CY2011) and three were unqualified or clean opinions (CY2008, 2010 and 2012). Among the 14 issues raised by the Commission on Audit (COA), the supreme audit institution mandated to conduct the external audit of the project, included (i) misclassification of accounts in 2006; (ii) understatement in cash balance and negative balance in Other Payables account in 2007; (iii) forex loss and receivables from LGUs in 2009; and (iv) unreconciled balance per books and the Bank’s Client Connection and fund transfers made to LGUs and Operating Units although there were still unliquidated balances in the subsidiary ledger accounts. The issues were followed up and subsequently addressed. The DOH developed the required (i) financial management manual; (ii) procurement implementation manual. During implementation, due to various reasons the DOH did not continue to have procurement and financial management specialists dedicated for activities under the second WHSM project. Throughout the project implementation, delays were reported in opening local accounts, transferring counterpart funds, reporting expenditures and requesting advances, and reporting back processes. This seriously affected the performance of managing PBGs – which after restructuring amounted to nearly one third of the value of the loan. Even at the time of project closure, large amounts of funds still needed to be reported on as some payments had been advanced by the LGUs, but due to delays of submitting the expenditure statements to the DOH, their payments have not been completed. The project’s financial management performance varied throughout the life of the project with a mix of moderately satisfactory and moderately unsatisfactory in some periods. In points where financial management implementation had been rated moderately unsatisfactory the issues raised included (i) significant delays in the submission of the interim financial reports and audit reports; (ii) significant delays in preparation and submission of Withdrawal Applications and Statement of Expenditures; and (iii) several issues raised in the audit reports. Though it took the DOH a long time to process procurement contracts, there were no problems encountered as to the outcomes of the procurement process. As in our previous health projects, we did not receive any complaints as to how DOH conducts it procurement. 2.5 Post-completion Operation/Next Phase The project team at the DOH has encouraged development of sustainability plans in each of the 5 pilot provinces. This includes identifying mechanisms to continue the incentive payment to the women’s health teams, which was introduced as a new initiative under the project. In addition, the hospitals and the LGUs have identified mechanisms to provide financing to maintain the accreditation of the hospitals for MCP with PhilHealth and the required capacity development process has been institutionalized. Most of the performance indicators can still be monitored as the main objective of introducing facility-based deliveries in the Philippines seem to be institutionalized. The expansion of the strategy piloted under the project to across the country during the project’s lifetime 15 also indicates the high ownership of the new strategy piloted under the project. A follow- on project is not planned. 3. Assessment of Outcomes 3.1 Relevance of Objectives, Design and Implementation The overall relevance of objectives and design was rated as Substantial. Relevance of objectives: The PDO and the key areas identified for reforms by the project was the main objective of the DOH, Government of the Philippines. The PDO remains relevant, as Philippines still strives to improve its maternal mortality rate under the Millennium Development Goals (MDGs), and was consistent with the CAS. The project intended to demonstrate the usefulness of a pilot intervention and at midway into project implementation the majority of the pilot interventions package was scaled up nationally. Therefore the PDO of the project’s relevance reduced. In addition, the demonstration pilot was never fully evaluated as the end line survey was not carried out at the time of project close and the interventions packages usefulness was not demonstrated scientifically. Relevance of design: The project components matched the project objective. The project supported a pilot to introduce a completely new strategy of moving mothers to deliver in a health facility from their existing practice of delivering at homes. A pilot design was appropriate as the proposed intervention was attempting to make relevant changes in the health system both from the supply and demand aspects. But the relevance of the project being a pilot design was low with the national scaling up of the interventions at midway into project implementation. Relevance of implementation: Even though the project had an appropriate design that planned to introduce a new strategy, the initiation of the pilot project was far too delayed. The project team only did a Level II restructuring 5 years into project implementation and did not make efforts to cancel unwanted resources as the Government by then had mobilized other resources for some identified tasks originally planned under the pilot. Furthermore, very early in the project’s actual implementation, the Government of the Philippines in 2009, introduced the same strategies that were being piloted as a national strategy and the project team at the time of restructuring only introduced a few changes to incorporate this issue but continued to call the batch 2 provinces a pilot intervention and the PDO remained unchanged. Relevance of the newly introduced intervention implemented under the SWHSM project as a pilot remained high even at time of project closure in the Philippines. During the project implementation period, facility-based deliveries reported an increase, a factor that is known to help reduce maternal deaths and illness. But at time of project closure, even though facility-based delivery proportions had increased, the Philippines is not yet on 16 track to achieving its MDG targets related to maternal and child mortality and therefore the interventions introduced under the project are still sufficiently relevant to achieve further improvements in maternal health outcomes but a pilot intervention as proposed in the project is no longer required. 3.2 Achievement of Project Development Objectives Achievement of PDO: The PDO of the Second WHSM project aimed to; (a) Demonstrate in selected sites a sustainable, cost-effective model of delivering health services that increases access of disadvantaged women to acceptable and high quality reproductive health services and enables them to safely attain their desired spacing and number of children, (b) Establish the core knowledge base and support systems that can facilitate countrywide replication of the project experience as part of mainstream approaches to reproductive health care within the framework of the Health Sector Reform Agenda. Both these objectives were only partially achieved during the project period. Achievement of PDO outcomes: Out of the 6 original PDO outcomes that were identified to measure the achievement of the PDO, 4 were achieved. Two outcomes were not achieved, as CEmOC and Family planning services were not improved during the project period. (Table 1). Out of the 7 PDO indicators that were monitored since restructuring, 3 were achieved, 3 others were partially achieved while the indicator on contraceptive usage remained unchanged (Table 1). Table 1: Status of achievement of PDO indicators at end of project (as of June 2013). Description Status at project closure Original PDO indicators % of births delivered by skilled attendant (health Achieved professional) either in facility or at home % of births delivered in a health facility Achieved % of deliveries by the poor in BemOCs and CemOCs Not achieved financed through PhilHealth Sponsored Program % of deliveries by the poor in BemOCs and CemOCs Achieved financed through DOH –LGU Performance Based Grant Increase in the Contraceptive Prevalence Rate Not achieved % of RHUs that have not experienced stock outs of pills, Achieved injectables and IUDs for past 6 months Revised PDO indicators 80% births delivered in a health facility in each project Achieved 17 LGU 40% of deliveries in BEmONCs in each project LGU is Not achieved target, financed by PhilHealth Sponsored Program upward trend noted. Increase in CPR in each project LGU by 10 percentage Not achieved. points 100% of BEmONCs in each project LGU are PhilHealth Not achieved target, accredited for its maternal health care package upward trend noted. 100% of project LGUs have passed an ordinance on Not achieved target, contraceptive self- reliance upward trend noted. % of project LGUs sustaining their enrolment for the Achieved Philhealth sponsored Program to at least 75% of the city and municipal targets 100% of BEmONC teams in project LGUs trained Achieved The achievement of PDO is rated as Moderately Unsatisfactory. The project was not able to meet 2 of the original PDO targets out of which the increase of services for the poor was not achieved and had only disbursed 18% of the total project disbursement at time of restructuring. The rating against the original PDO indicators is moderately unsatisfactory. Out of the restructured PDO indicators, only 3 (out of the 7 indicators) were fully achieved with nearly 82% of the total disbursement occurring from 2010 onwards. Furthermore, at end of the project nearly 37.5% of the total project value was undisbursed. The rating against the restructured PDO indicators is moderately unsatisfactory. 3.3 Efficiency Rating: Modest Comprehensive efficiency analyses were not carried out during the project period. But a costing analysis had been carried out during midway of project implementation period to identify the cost of expanding the pilot interventions across the country. This assessment had indicated that the pilot was cost effective and recommendations were made for scaling up the SWHSM project intervention to across the country in 2010 at the same time as the batch 2 pilot interventions were introduced to 3 other provinces and therefore much earlier than the pilot introduced through the project was evaluated. No other efficiency assessments were carried out during the project period. The Philippines public expenditure review report published by the World Bank (2011) notes that the Philippines under performs in three key health indicators – life expectancy, child mortality and maternal mortality, compared to similar regional group of countries. Public and private spending for health services is significantly below the regional average but it is noted that use of public health services is pro poor and therefore improving the public health services are most essential to improve the health outcomes of the poor. 18 Furthermore, the public expenditure report also highlights that 80% of public health spending is at the LGU level but inter regional disparities across LGUs in spending is large leading to large disparities in health outcomes in different regions. The SWHSM project selected mainly the Bicol region for demonstrating the pilot package of interventions which had a high poverty headcount of 51.1% and a 9.6% of the share of the poor in 2006. While the SWHSM project aimed to increase the investments in the pilot demonstration provinces, the efficiency of project execution as measured by the speed of disbursement was poor. Actual disbursement significantly lagged behind planned and at 5 years into project implementation only 18% of the funds were disbursed. Majority of the project disbursed in the last two years of project implementation. At restructuring, none of the funds were cancelled. Overall, slow disbursement created an opportunity cost by tying up resources that could have been used by other projects or new activities. The project was efficient in targeting poorer women who would have otherwise never come to a hospital to deliver their baby through the provision of project resources to WHTs through the PBGs. Furthermore the PBGs helped increase the enrollment of the poor for MCP under PhilHealth which helped increase the use of health services for MCP. Analysis is not yet available to quantify the improvements of health outcomes among the poor. The project also turned out to be efficient in being a catalyst for mobilizing other financial and technical resources to further develop Rural Health Units and District hospitals but data in 2013 is not yet available to demonstrate these efforts but the public expenditure review highlights that the poorer people use the LGU managed health facilities more than DOH managed health facilities in regions. Even though minimal effort had been taken to assess the efficiency of the interventions piloted under the project the project interventions package is practiced by many other countries with similar economic status and based on the need and the experience from the project, the interventions package has now been scaled up to across the country. 3.4 Justification of Overall Outcome Rating Rating: The overall outcome rating is moderately unsatisfactory. The relevance of the project is substantial at the beginning but low by project closure, and the project has achieved less than 50% of its planned outcomes. 3.5 Overarching Themes, Other Outcomes and Impacts (a) Poverty Impacts, Gender Aspects, and Social Development Services for the indigent population 19 At the time of project design, PhilHealth was not covering majority of the indigent population due to poor identification of the indigent by the respective LGUs. But with the completion of a national level survey of the poor in 2009 for the Conditional Cash Transfer Program, the Government of the Philippines identified the indigents and they were sponsored by the government to receive PhilHealth. Issues are still persistent with low usage of services by the indigent population due to the need of submitting documents when using the PhilHealth card and the rules and regulations for PhilHealth coverage which includes restrictions on coverage for MCP services for mothers in their fifth pregnancy and beyond or if an unmarried mother avails of these services. But now, a majority of the indigent population seem to have access to PhilHealth for MCP services and efforts are now needed to address the larger issues of increasing contraceptives usage and reducing teenage pregnancies in the Philippines. (b) Institutional Change/Strengthening PhilHealth Registration The project seems to have been a catalyst to encourage PhilHealth registration by clients. PhilHealth was in existence since 1995 but even at the time of project preparation and early implementation, only a very few of the facilities were accredited by PhilHealth for MCP and only a very small fraction of the population were registered with PhilHealth for seeking MCP services. At the time of project closure, the supporting systems seem to have improved which have led to a change in acceptance for PhilHealth for MCP services (client perception and also facility registration) in the pilot provinces and also in the other provinces across the country. Use of incentives for better performance While the project introduced PBGs for the first time to establish WHTs, the concept is incorporated quite comprehensively across the country along with the observed PhilHealth registration increase. The LGUs have also conceptually agreed to sustain the incentive for WHTs (now called Community Health Teams) through PhilHealth copayments. (c) Other Unintended Outcomes and Impacts (positive or negative) Investments for Infrastructure improvement for MCP in health facilities The project seems to have been a catalyst to secure the required funds for improving health facilities to provide MCP services. Since the use of some of the allocated funds under LOGOFIND for infrastructure at the beginning of the project, fund allocation for subsequent infrastructure was not required as other sources were made available by other funders, LGUs and the national government helping the sustainability of the interventions introduced under the project. 3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops Not carried out. 4. Assessment of Risk to Development Outcome Rating: Low 20 The Philippines health outcomes related to maternal care was poor with a MMR of 186 per 100,000 live births and 37.5% of deliveries occurring in health facilities at time of appraisal in 2005. At the time of project design, many other different strategies were tried to reduce the maternal deaths which included training of TBA for providing skilled delivery and efforts taken to improve the risk approach with some linkages to nearest hospitals. This interventions package was piloted under the first WHSM project also partly supported by the World Bank. The SWHSM Project introduced a health system improvement strategy which required interventions from all sides – both demand and supply side – to change a home based delivery model to a facility based delivery model while encouraging increased health insurance for the poor and improvements in health facilities to manage a higher burden. This systems approach of improving maternity services seems to have become institutionalized at time of project end. Given this situation, it is most unlikely that the services will revert back to homes and therefore it is expected that the expected MMR reduction can be achieved by using this approach. In addition, there were quite a few interventions and policies that were introduced through the life of the project that will be sustained. These include: (i) the scaling up of the interventions package to across the country even while the pilot was operational, (ii) the establishment of 29 training centers for BEmONC and CEmONC services which will help expand the number of facilities accredited by PhilHealth for MCP, (iii) the acceptance of the concept of using Women’s Health teams to link mothers and health facilities, to improve early registration of pregnant mothers and for improving data reporting. 5. Assessment of Bank and Borrower Performance 5.1 Bank Performance (a) Bank Performance in Ensuring Quality at Entry Rating: Moderately Satisfactory The original PDO and the related indicators were well aligned to the CAS and to the health sector needs of the Philippines at time of project design. Furthermore, the team was supporting through the project a pilot interventions package that had not been tried in the Philippines before but was a package that had been used to reduce maternal mortality and related outcomes in other countries in the region and in countries with similar economic status. In addition, as health is fully devolved to the local government level, risks were well identified at time of project design and necessary covenants and conditions were in place to mitigate against this risk. Given the impracticalities of managing a project at each LGU level, the design required the DOH to be in charge of the project even though delivery of health services is fully devolved. Lessons from previous projects were only somewhat incorporated at project design. (b) Quality of Supervision Rating: Moderately unsatisfactory 21 The implementation support missions were carried out regularly at the beginning of the project with full teams. The project had 4 Task Team Leaders over the life of the project and the TTL and the team with a high local knowledge that designed the project had moved on very early in the life of the project. The new teams seem to have waited far too long to restructure the project and/or cancel as only less than 5% of the project funds had been disbursed even at 2 years into project implementation. In 2010, the team restructured the project, when disbursement was at 18%, but the restructuring was not extensive and even though previous teams had mentioned cancellation of some of the funds due to the policy changes on the ground and poor disbursement the restructuring only included some changes to the PDO indicators and reallocation of funds to PBGs from the funds available for civil works. The PBGs had 18% of the project allocation which was increased to nearly 30% of the total project funds at restructuring but at time of project closure nearly 50% of the allocation was not utilized. The team was aware of the issues faced by processing delays and attempted to address this by moving out from providing advances to the LGUs to providing the funds on a reimbursement basis. Even at the time of project closure, there were a large proportion of PBG allocations unsettled with the LGUs. The team had made many efforts to improve this situation; the final one was to endorse the request of DOH to provide a one-time advance to the Designated Account after the closing date and an extension to the disbursement grace period, to settle these issues. Overall on these implementation issues, the team performance should have been more proactive and should have sorted out these processing delays that go back to 2010/2011 much earlier than project closure period. However, several issues which included (a) very low disbursement performance prevented an increase in the Designated Account ceiling; and (b) significant delays of the DOH in completing the refund of unused funds for a lapsed grant also delayed approval of a request for the one-time advance. Furthermore, throughout the project implementation period, the team has faced many obstacles to the timely receipt of updates on the results identified in the results framework. As the team has solely relied on the baseline and end line survey findings at time of project closure a majority of the results were not reported. As the team was aware of the long procurement delays the project underwent for procuring a firm to carry out the baseline and end line surveys, the team should have addressed the data reporting aspect much more comprehensively at restructuring. As the baseline data, which was supposed to be available in 2006, was available only in 2008 and therefore the procurement process for the end-line survey should have been initiated much earlier than 2012. Furthermore, the team could have considered using another data source for reporting updates on the results framework much earlier on in the life of the project and validated the reliability of the available institutional data sources. Finally, the procurement and financial reporting processes were excessively delayed throughout project implementation period and while the team made a few changes at restructuring to accommodate this issue more efforts should have been built-in to develop the fiduciary capacity at all levels of implementation teams. Quality of supervision is rated moderately unsatisfactory. (c) Justification of Rating for Overall Bank Performance 22 Rating: Based on the moderately satisfactory rating at quality at entry and a moderately unsatisfactory rating at quality of supervision the overall bank team performance is rated as Moderately Unsatisfactory. 5.2 Borrower Performance (a) Government Performance Rating: Moderately Satisfactory With the implementation of the SWHSM project, the DOH was instrumental in introducing a new strategy to improve maternal and newborn care outcomes in the Philippines. This is a remarkable achievement given the constraints the Government team faced throughout project implementation. Furthermore, the Government identified and made efforts to improve all aspects of the health system to improve the MCP. (b) Implementing Agency or Agencies Performance Rating: Moderately Unsatisfactory The main implementing agencies included the 84 LGUs in the 5 provinces and the DOH. The regional DOH office provided implementation support and oversight. The professional groups, PhilHealth and hospitals were secondary implementing units under the project. The commitment and ownership for the interventions package was notably high. The understanding of the project at most levels of these implementation teams was also high. At the beginning of project implementation, the LGUs were required sign a MOA and open special bank accounts and deposit counterpart funds for the first three months of implementation. While this was a condition of effectiveness of the project, this activity was delayed by more than a year that in turn delayed project launch and the introduction of the project interventions. Moreover, implementation capacity at all levels was quite low when implementing World Bank financed projects using World Bank procedures and processes. This led to many procurement and financial reporting delays at all levels and units that in turn led to delayed implementation throughout the life of the project. (c) Justification of Rating for Overall Borrower Performance Rating: On the basis of a moderately satisfactory rating given for Government implementation and moderately unsatisfactory for delayed implementation by the implementing agencies, the overall rating is Moderately Unsatisfactory. 6. Lessons Learned Ownership of a project by the government and the implementation teams across all levels of regional and sub-regional government is crucial to the success of a project. This was very well demonstrated in this project, as the pilot that was introduced in the project was 23 a package of services the Government wanted to implement and demonstrate to all other stakeholders. The most common reasons for project implementation delays were the procurement system and financial management reporting processes. As this was expected even at time of project design, building in capacity development programs on fiduciary aspects on a continuing basis is essential to address this issue from the beginning of project implementation. The experience from using Performance Based Grants had both positive and negative effects. PBGs helped establish WHTs and other teams as required and they helped create the link between the demand side (community) with the supply side. But managing a PBG within governments system is not easy as most countries have input-based budgeting and also annual cycles. These systems are yet not adapted to manage financial incentives for achieving results. The project faced many issues with regard to making available advance funds for PBGs. Following the restructuring this was changed to a reimbursement scheme that created a newer set of reporting issues. Therefore, much further analysis and understanding along with discussions with auditors and other groups within government is essential before providing funds for incentives. Furthermore, an independent verification system and performance targets were not in place for the PBGs designed under the project. If such mechanisms were utilized the DOH and the LGUs would have been able to link results that would have helped improve the maternal health outcomes. As the Philippines has a highly decentralized health system, implementing a project with one lead agency, in this case the DOH, was not easy as the authority and reporting back mechanisms for the project were different from the usual practice of working. This also led to many delays and if similar projects are designed again this autonomous structure needs to be better incorporated to procurement and financial reporting systems practiced in the country. Early restructuring including cancelling of unwanted resources would have further benefited the implementation of this project and therefore the team should have carried out a more comprehensive restructuring much earlier on in the life of the project. 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners (a) Borrower/implementing agencies Not Available (b) Cofinanciers Not Available (c) Other partners and stakeholders Not available 24 Annex 1. Project Costs and Financing (a) Project Cost by Component (in USD Million equivalent) Actual/Latest Appraisal Estimate Percentage of Components Estimate (USD (USD millions) Appraisal millions) A: Local delivery of the Integrated Women’s Health and 13.40 5.19 39% Safe Motherhood Service Package (WHSM-SP) B: National capacity to sustain 2.50 5.10 204% WHSM services 00 Total Project Costs 15.90 10.29 65% Front-end fee IBRD 0.08 0.08 .00 Total Financing Required 15.98 10.37 65% (b) Project Expenditure by categories Category Amount of Amount of % from Actual Disbursement (in % of % of the loan the loan Appraisal US Dollars) utilization expenditures allocated at allocated allocation (from to be approval after restructured financed (expressed restructuring amount) in US (expressed in Dollars) US Dollars) (1) Goods and 4,000,000 4,800,000 120% 2,205,808.09 46% 100% services other than consulting services (2) Works 1,300,000 1,250,000 96% 933,147.72 75% 100% (3) Consultants 2,700,000 2,670,000 99% 1,508,057.11 56% 100% services (4) Training and 1,700,000 1,500,000 88% 2,132,733.11 142% 100% workshops (5) Performance 3,300,000 5,000,000 151% 2,527,136.17 50% 100% of based grants amounts disbursed (6) Sub project 1,500,000 0 0% 0 0 100% of financing amounts under part disbursed A.1(a)(i) of the project (7) Front end fee 80,000 80,000 100% - - Amount due under section 2.04 of Loan agreement 25 (8) Premia for 0 0 0% 0 0 Amount due interest Rate under caps and Section Interest rate 2.09© of this collars agreement (9) Unallocated 1,420,000 700,000 49% 0 0 DA-B Designated 0 Account DA-C Designated 1,060,874.66 Account Total 16,000,000 16,000,000 - 10,367,756.86 65% (b) Financing Appraisal Actual/Latest Type of Estimate Estimate Percentage of Source of Funds Cofinancing (USD (USD Appraisal millions) millions) Counterpart Borrower 22.00 16.00 73% funds International Bank for Reconstruction Loan 16.00 16.00 100% and Development 26 Annex 2. Outputs by Component These are the LGU specific indicator results for the PDO indicators summarized in the data sheet. Outputs by component follow, thereafter. Original Target Formally Actual Value Values (from Revised Achieved at Indicator Baseline Value approval Target Completion or documents) Values Target Years 80% births delivered in a health facility in each project LGU (defined as a Indicator 7: province) Value quantitative or 42% (DOH data) 80% 87% (DOH data) Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % The average from all 5 Provinces. achievement) Indicator 7A: 80% births delivered in a health facility in Masbate Value quantitative or 35% 80% 73% Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % achievement) Indicator 7B: 80% births delivered in a health facility in Catanduanes Value quantitative or 72% 80% 100% Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % achievement) Indicator 7C: 80% births delivered in a health facility in Albay Value quantitative or 37% 80% 95% Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % achievement) Indicator 7D: 80% births delivered in a health facility in Sorsogon Value quantitative or 53% 80% 94% Qualitative) Date achieved 12/31/2006 09/30/2010 11/30/2013 Comments 27 (incl. % achievement) Indicator 7E : 80% births delivered in a health facility in Surigao del Sur Value quantitative or 48% 80% 87% Qualitative) Date achieved 12/31/2006 09/30/2010 11/30/2013 Comments (incl. % achievement) 40% of deliveries in BEmONCs in each project LGU (defined as Province) Indicator 8: financed by PhilHealth Sponsored Program Value quantitative or 10% 40% 38% Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % achievement) 40% of deliveries in BEmONCs in Masbate is financed by PhilHealth Sponsored Indicator 8A: Program Value quantitative or 3% 40% 14% Qualitative) Date achieved 12/31/2009 09/30/2010 12/31/2012 Comments (incl. % achievement) 40% of deliveries in BEmONCs in Catanduanes is financed by PhilHealth Indicator 8B : Sponsored Program Value quantitative or 1% 40% 19% Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % achievement) 40% of deliveries in BEmONCs in Albay is financed by PhilHealth Sponsored Indicator 8C : Program Value quantitative or 8% 40% 35% Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % achievement) 40% of deliveries in BEmONCs in Sorsogon is financed by PhilHealth Indicator 8D: Sponsored Program 28 Value quantitative or 1% 40% 26% Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % achievement) 40% of deliveries in BEmONCs in Surigao del Sur is financed by PhilHealth Indicator 8E : Sponsored Program Value quantitative or 14% 40% 43% Qualitative) Date achieved 12/31/2006 09/30/2010 11/30/2013 Comments (incl. % achievement) Increase in CPR in each project LGU (defined as province) by 10 percentage Indicator 9: points Value quantitative or 35% 45% 39.4% Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % achievement) Indicator 9A: Increase in CPR in Masbate by 10 percentage points Value quantitative or 33% 43% 33% Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % achievement) Indicator 9B: Increase in CPR in Catanduanes by 10 percentage points Value quantitative or 33% 43% 50% Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % achievement) Indicator 9C: Increase in CPR in Albay by 10 percentage points Value quantitative or 33% 43% 32% Qualitative) Date achieved 12/31/2009 09/30/2010 12/31/2009 Comments (incl. % 29 achievement) Indicator 9D: Increase in CPR in Sorsogon by 10 percentage points Value quantitative or 32% 42% 31% Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % achievement) Indicator 9E: Increase in CPR in Surigao del Sur by 10 percentage points Value quantitative or 44% 54% 47% Qualitative) Date achieved 12/31/2006 09/30/2010 11/30/2013 Comments (incl. % achievement) 100% of BEmONCs in each project LGU (defined as province) are PhilHealth Indicator 10: accredited for its maternal health care package Value quantitative or 9% 100% 86% Qualitative) Date achieved 12/31/2006 09/30/2010 11/30/2013 Comments (incl. % achievement) 100% of BEmONCs in each project LGUs (Masbate) are PhilHealth accredited Indicator 10A: for its maternal health care package Value quantitative or 5% 100% 86% Qualitative) Date achieved 12/31/2006 09/30/2010 11/30/2013 Comments (incl. % achievement) 100% of BEmONCs in each project LGUs (Catanduanes) are PhilHealth Indicator 10B: accredited for its maternal health care package Value quantitative or 0% 100% 90% Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % achievement) 100% of BEmONCs in each project LGUs (Albay) are PhilHealth accredited for Indicator 10C: its maternal health care package Value 5% 100% 74% quantitative or 30 Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % achievement) 100% of BEmONCs in each project LGUs (Sorsogon) are PhilHealth accredited Indicator 10D: for its maternal health care package Value quantitative or 29% 100% 94% Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % achievement) 100% of BEmONCs in each project LGUs (Surigao del Sur) are PhilHealth Indicator 10E: accredited for its maternal health care package Value quantitative or 6% 100% 44% Qualitative) Date achieved 12/31/2008 09/30/2010 11/30/2013 Comments (incl. % achievement) 100% of project LGUs (defined as a province) have passed an ordinance on Indicator 11: contraceptive self- reliance Value quantitative or 36% 100% 80% Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % achievement) 100% of project LGUs (Masbate) have passed an ordinance on contraceptive Indicator 11A: self- reliance Value quantitative or 29% 100% 90% Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % achievement) 100% of project LGUs (Catanduanes) have passed an ordinance on contraceptive Indicator 11B: self- reliance Value quantitative or 100% 100% 100% Qualitative) Date achieved 12/31/2012 09/30/2010 11/30/2013 Comments 31 (incl. % achievement) 100% of project LGUs (Albay) have passed an ordinance on contraceptive self- Indicator 11C: reliance Value quantitative or 22% 100% 100% Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % achievement) 100% of project LGUs (Sorsogon) have passed an ordinance on contraceptive Indicator 11D: self- reliance Value quantitative or 27% 100% 33% Qualitative) Date achieved 12/31/2006 09/30/2010 11/30/2013 Comments (incl. % achievement) 100% of project LGUs (Surigao del Sur) have passed an ordinance on Indicator 11E: contraceptive self- reliance Value quantitative or 0% 100% 100% Qualitative) Date achieved 12/31/2006 09/30/2010 11/30/2013 Comments (incl. % achievement) % of project LGUs (defined as a province) sustaining their enrolment for the Indicator 12: Philhealth sponsored Program to at least 75% of the city and municipal targets Value quantitative or 81% 75% 90% Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % achievement) % of project LGUs (Masbate) sustaining their enrolment for the Philhealth Indicator 12A: sponsored Program to at least 75% of the city and municipal targets Value quantitative or 95% 75% 24% Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % achievement) Indicator 12B: % of project LGUs (Catanduanes) sustaining their enrolment for the Philhealth 32 sponsored Program to at least 75% of the city and municipal targets Value quantitative or 82% 75% 82% Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % achievement) % of project LGUs (Albay) sustaining their enrolment for the Philhealth Indicator 12C: sponsored Program to at least 75% of the city and municipal targets Value quantitative or 72% 75% 67% Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % achievement) % of project LGUs (Sorsogon) sustaining their enrolment for the Philhealth Indicator 12D: sponsored Program to at least 75% of the city and municipal targets Value quantitative or 93% 75% 100% Qualitative) Date achieved 12/31/2006 09/30/2010 11/30/2013 Comments (incl. % achievement) % of project LGUs (Surigao del Sur) sustaining their enrolment for the Philhealth Indicator 12E: sponsored Program to at least 75% of the city and municipal targets Value quantitative or 84% 75% 100% Qualitative) Date achieved 12/31/2006 09/30/2010 11/30/2013 Comments (incl. % achievement) Indicator 13: 100% of BEmONC teams in project LGUs (defined as a province) trained Value quantitative or 36% 100% 106% Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % achievement) Indicator 13A: 100% of BEmONC teams in project LGUs (Masbate) trained Value quantitative or 69% 100% 92% Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 33 Comments (incl. % achievement) Indicator 13B: 100% of BEmONC teams in project LGUs (Catanduanes) trained Value quantitative or 0% 100% 104% Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % achievement) Indicator 13C: 100% of BEmONC teams in project LGUs (Albay) trained Value quantitative or 12% 100% 147% Qualitative) Date achieved 12/31/2009 09/30/2010 11/30/2013 Comments (incl. % achievement) Indicator 13D: 100% of BEmONC teams in project LGUs (Sorsogon) trained Value quantitative or 21% 100% 103% Qualitative) Date achieved 12/31/2006 09/30/2010 11/30/2013 Comments (incl. % achievement) Indicator 13D: 100% of BEmONC teams in project LGUs (Surigao del Sur) trained Value quantitative or 26% 100% 83% Qualitative) Date achieved 12/31/2008 09/30/2010 11/30/2013 Comments (incl. % achievement) 34 Component Description Initiated Current Results Yes/No status and achieved Remarks Component A: Local delivery of the Integrated Women’s Health and safe Motherhood (WHSM) service package (appraisal estimate US $13.4 million; actual US $ 5.19 million). Sub component 1 (a) support the Local Governments in the Yes On-going LGUs have selected Provinces to mobilize networks of established public and private providers to deliver the and are integrated women’s health and safe deploying the motherhood service package (WHSM-SP) different with a focus on maternal care, family teams – planning and STI/HIV control services. The WHT, component activities included establishing B/CEmONC teams for Women’s health, basic obstetric teams, care, comprehensive obstetric care, itinerant adolescent and youth health, itinerant teams; teams, etc. (b) to assist LGUs to develop and No No approach No specific implement cost effective and sustainable developed services approaches to reach three high risk groups: developed for female sex workers, returning overseas the target workers and young adults. groups Sub component 2 to establish and operate reliable and sustainable systems for the delivery of WHSM-SP which included; (a) drug and procurement security , through Yes On-going Contraceptive the provision of goods and services Self-Reliance ordinances issued in all LGUs (i) the establishment of efficient province Yes On-going LGUs and city wide logistics planning, following RA management and procurement systems, 9184 on procurement (ii) the segmentation of local markets for No Not being No market appropriate targeting of subsidized financing undertaken segmentation and free distribution of contraceptives and at LGU level in place (iii) complementary establishment or Yes LGUs expansion of social marketing initiatives for 35 contraceptives; (b) safe blood supply through the provision Yes On-going Blood and services for the setting up of a network banking and of blood service facilities at different levels other related of the health care system. equipment provided to some LGUs (c) behavior change interventions through (i) pilot testing of performance based grants Yes On-going PBGs for to selected LGUs, health service providers WHTs and and users and mothers in place (ii) the provision of goods and services for advocacy, communications and information dissemination. (d) sustainable financing of local WHSM services and related commodities through (i) increased LGU financing and increased Health Almost 100% revenues form PhilHealth benefit payments facilities of health accredited facilities under accredited PhilHealth’s under MCP MCP (ii) application of a market segmentation Yes User fees mechanism that would allow LGU not being beneficiaries to raise user charges from non- implemented poor clients and encourage use of WHSM at LGU level services by eligible poor clients through for non-poor grants and awards clients Component B: National capacity to sustain WHSM services (appraisal estimate US $ 2.5 million; actual US $ 5.10 million). (1) develop, adopt and implement Yes On-going DOH operational and regulatory guidelines for the issuance on provision and use of WHSM services WHSM-SP Operations Manual (2) develop a network of training providers Yes On-going 29 Training that are accredited to provide courses on : (a) Trainings of Centers appropriate deliver y of the integrated B/CEmONC established WHSM – SP ; and (b) team work and teams Training collaboration for the various types of continuing course on 36 WHSM teams B/CEmONC developed and implemented (3) (a) develop a system to monitor and Yes Monitoring Baseline evaluate the implementation of the WHSM – system survey SP and publicly disseminate the monitoring established completed and evaluation results; (b) carry out project but reporting baseline and impact evaluation studies; and delayed (c) support policy and operations research on Only WHSM baseline study completed, the end line and BEmONC functionality assessment were not undertaken (4) Establish and maintain project Yes LGU and Reporting management capacity at the national and at DOH project system in the local level. monitoring place teams RRA process created and being functional implemented Application by all project of Rapid LGUs Results Approach as a management tool implemented at the provincial level 37 Annex 3. Economic and Financial Analysis (including assumptions in the analysis) The welfare economics framework justifies government intervention in reproductive health on the grounds of organization in (i) efficiency and productivity in the use of resources, (ii) equity in the distribution of resources. Efficiency is achieved if consumers and the producers pursued their self-interest in competitive markets. But some conditions are not always met especially in health care markets. Market failure in benefit valuation occurs through; (i) externalities, (ii) public goods, (iii) incomplete information, (iv) information asymmetry. Market failure in cost variation occurs through; (i) taxes and subsidies, (ii) monopoly, (iii) inefficient government service provision. Furthermore, if resources were allocated on the basis of market mechanisms, many poorer people would be unable to achieve the minimally acceptable package of services and leads to an inequitable distribution of services. Therefore to achieve equity, the government’s tendency to intervene to redistribute services is acceptable. Comprehensive efficiency analyses were not carried out during the project period. But a costing analysis had been carried out during midway of project implementation period to identify the cost of expanding the pilot interventions across the country. This assessment had indicated that the pilot was cost effective and recommendations were made for scaling up the SWHSM project intervention to across the country in 2010 at the same time as the batch 2 pilot interventions were introduced to 3 other provinces and therefore much earlier than the pilot introduced through the project was evaluated. No other efficiency assessments were carried out during the project period. The Philippines public expenditure review report published by the World Bank (2011) notes that the Philippines under performs in three key health indicators – life expectancy, child mortality and maternal mortality, compared to similar regional group of countries. Public and private spending for health services is significantly below the regional average but it is noted that use of public health services is pro poor and therefore improving the public health services are most essential to improve the health outcomes of the poor. Furthermore, the public expenditure report also highlights that 80% of public health spending is at the LGU level but inter regional disparities across LGUs in spending is large leading to large disparities in health outcomes in different regions. The SWHSM project selected mainly the Bicol region for demonstrating the pilot package of interventions which had a high poverty headcount of 51.1% and a 9.6% of the share of the poor in 2006. While the SWHSM project aimed to increase the investments in the pilot demonstration provinces, the efficiency of project execution as measured by the speed of disbursement was poor. Actual disbursement significantly lagged behind 38 planned and at 5 years into project implementation only 18% of the funds were disbursed. Majority of the project disbursed in the last two years of project implementation. At restructuring, none of the funds were cancelled. Overall, slow disbursement created an opportunity cost by tying up resources that could have been used by other projects or new activities. The project was efficient in targeting poorer women who would have otherwise never come to a hospital to deliver their baby through the provision of project resources to WHTs through the PBGs. Furthermore the PBGs helped increase the enrollment of the poor for MCP under PhilHealth which helped increase the use of health services for MCP. Analysis is not yet available to quantify the improvements of health outcomes among the poor. The project also turned out to be efficient in being a catalyst for mobilizing other financial and technical resources to further develop Rural Health Units and District hospitals but data in 2013 is not yet available to demonstrate these efforts but the public expenditure review highlights that the poorer people use the LGU managed health facilities more than DOH managed health facilities in regions. Even though minimal effort had been taken to assess the efficiency of the interventions piloted under the project the project interventions package is practiced by many other countries with similar economic status and based on the need and the experience from the project, the interventions package has now been scaled up to across the country. 39 Annex 4. Bank Lending and Implementation Support/Supervision Processes (a) Task Team members Responsibility/ Names Title Unit Specialty Lending Senior Financial Management Ernesto Diaz EAPCO Specialist Teresa Ho Task Team Leader EASHD Task Team Leader Janet Hohnen Consultant Dale Huntington Consultant Noel Sta. Ines Procurement Specialist EAPCO Cynthia F. Manalastas Program Assistant EACPF Parivash Mehrdadi Program Assistant EASHD Thomas Merrick Consultant WBIHD Operations Officer (Social Jose Tiburcio Nicolas EASSD Safeguards) E. Gail Richardson Consultant MNSHD Mario Taguiwalo Consultant Sabrina Terry Program Assistant EASHD Florence Tienzo Health Specialist EASHD Josefo Tuyor Operations Officer (Environment) EASEN Supervision/ICR Preselyn Abella Senior Finance Officer CTRLN Senior Financial Management Agnes Albert-Loth EASFM Specialist Kristine May San Juan Ante Program Assistant EACPF Dominic Reyes Aumentado Senior Procurement Specialist EASR1 Cesar Palma Banzon Program Assistant GSDCS Eduardo P. Banzon Senior Health Specialist EASHH Task Team Leader Jonas Garcia Bautista Consultant EASNS Sadia Afroze Chowdhury Consultant SASHN Rafael A. Cortez Senior Economist (Health) HDNHE Ernesto Diaz Consultant EASHD Timothy Johnston Senior Health Specialist EASHH Gia Mendoza Program Assistant EACPF Kumari Vinodhani Navaratne Senior Health Specialist SASHN EASSO – Jose Tiburcio Nicolas Operations Officer HIS Maria Loreto Padua Senior Social Development Spec EASPS Gerardo F. Parco Senior Operations Officer EASPS Joseph G. Reyes Financial Management Specialist EASOS Roberto Antonio F. Rosadia Health Specialist EASHH Task Team Leader Lilian Loza San Gabriel Program Assistant EACPF 40 Noel Sta. Ines Senior Procurement Specialist EASR1 Tomas JR. Sta.Maria Financial Management Specialist EASFM Florence Tienzo Health Specialist EASHD Fe Timonera E T Consultant CTRLA Josefo Tuyor Senior Environmental Specialist EASDE (b) Staff Time and Cost Staff Time and Cost (Bank Budget Only) Stage of Project Cycle USD Thousands (including No. of staff weeks travel and consultant costs) Lending FY03 97.37 FY04 153.39 FY05 129.66 FY06 0.33 FY07 0.00 FY08 0.00 Total: 380.75 Supervision/ICR FY03 0.00 FY04 0.00 FY05 4.01 FY06 111.63 FY07 44.95 FY08 64.95 Total: 225.54 41 Annex 5. Beneficiary Survey Results Not relevant 42 Annex 6. Stakeholder Workshop Report and Results Not carried out 43 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR Borrower has not completed their project completion report at the time of submission of this ICR. The draft ICR was sent to government for their comments and they only came back with updates to project indicator values. These revised figures were incorporated in the ICR. 44 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders N/A 45 Annex 9. List of Supporting Documents Project Documents: Second WHSMP Aide Memoires – various dates Second WHSMP Completion of the Baseline Survey: Final Report – July 15, 2008 Second WHSMP Consolidated Audit Reports – various dates Second WHSMP Implementation Status and Results Reports – various dates Second WHSMP Interim Financial Reports – various dates Second WHSMP Loan Agreement – June 30, 2005 Second WHSMP Loan Agreement, Amended – September 30, 2010 Second WHSMP Project Appraisal Document Second WHSMP Restructuring Paper – June 23, 2010 Other publications: Gonzales, Glenda, Eichler, Rena and Alix Beith 2010. Pay for Performance for Women’s Health Teams and Pregnant Women in the Philippines: Bethesda, Maryland: Health Systems 20/20, Abt Associates Inc. Huntington, Dale, Banzon, Eduardo, Recidoro, Zenaida. A Systems Approach To Improving Maternal Health in the Philippines. Bulletin of the World Health Organization 2012,90:104-110 Lavado, Rouselle. The Filipino Child Policy Brief No. 1 2010. Philippine Institute for Development Studies. Manila, Philippines. Lavado, Rouselle, Lagrada, Leizel, Ulep, Valerie Gilbert, Tan, Lester. Who Provides Good Quality Prenatal Care in the Philippines? Discussion Paper Series No. 2010-18. Philippine Institute for Development Studies, Manila, Philippines. Manasan, Rosario and Cuenca, Janet. Benefit Incidence of Public Spending on Health in the Philippines. Discussion Paper Series No. 2010-36. Philippine Institute for Development Studies, Manila, Philippines. Ulep, Valerie Gilbert. Are There Improvements in the Delivery of Maternal and Child Health Programs in the Philippines?. Powerpoint presentation. 2013. 46 IBRD 33466R4 I Ilocos X Northern Mindanao 1 2 3 Ilocos Norte Ilocos Sur La Union 58 59 60 Bukidnon Camiguin Lanao del Norte Basco Batan Islands PH I L I PPI NES 4 Pangasinan 61 Misamis Occidental 62 Misamis Oriental 11 SELECTED CITIES CAR Cordillera Admin. Reg. 20ºN 5 Abra XI Davao Reg. Luzon Strait PROVINCE CAPITALS 6 Apayao 63 Compostela Valley 7 Benguet 64 Davao del Norte REGION CAPITALS 8 Ifugao 65 Davao del Sur 9 Kalinga 66 Davao Oriental 10 Mountain Province NATIONAL CAPITAL Babuyan XII SOCCSKSARGEN Islands II Cagayan Valley 67 North Cotabato RIVERS 11 Batanes 68 Sarangani Babuyan Channel 12 Cagayan 69 South Cotabato MAIN ROADS 13 Isabela 70 Sultan Kudarat 14 Nueva Vizcaya RAILROADS 15 Quirino XIII Caraga Laoag City 1 6 71 Agusan del Norte 12 III Central Luzon Kabugao PROVINCE BOUNDARIES 72 Agusan del Sur 16 Aurora 73 Dinagat Islands Bangued 17 Bataan 74 Surigao del Norte Tuguegarao REGION BOUNDARIES Vigan 5 9 18 Bulacan 75 Surigao del Sur 19 Nueva Ecija CAR Tabuk II INTERNATIONAL BOUNDARIES 20 Pampanga ARMM Autonomous Reg. in Bontoc Ilagan 21 Tarlac Muslim Mindanao I 2 10 22 Zambales Lagawe 13 NCR National Capital Reg. 76 77 Basilan Lanao del Sur San Fernando 8 Luzon 125ºE 78 Maguindanao** 3 La Trinidad Cabarroguis 79 Sulu Baguio Bayombong IV-A CALABARZON 80 Tawi-Tawi 7 14 15 23 Batangas Lingayen 24 Cavite 25 Laguna ** Shariff Aguak (Maganoy) and 16 Sultan Kudarat serve as co-capitals 4 26 Quezon of the province. Baler III 27 Rizal Palayan Tarlac 19 IV-B MIMAROPA Iba 21 PHILIPPINES 28 Marinduque 22 San Fernando IV-A 29 Mindoro Occidental 20 18 Polillo 30 Mindoro Oriental Malolos Islands 31 Palawan* Balanga Quezon 17 Pasig 32 Romblon NCR MANILA Antipolo Trece Martires 27 34 V Bicol 24 Santa Cruz Daet V 33 Albay Calamba25 26 34 Camarines Norte 23 35 Camarines Sur Lucena 35 36 Lubang Batangas Catanduanes 36 Catanduanes Islands Pili Virac 37 Masbate Calapan Boac 38 Sorsogon 28 Mamburao Marinduque 30 Legaspi VI Western Visayas 39 Aklan Mindoro Sibuyan 33 Sorsogon Phil i ppi n e Burias 38 40 Antique 29 Sea 41 42 Capiz Guimaras M ind Romblon Ticao Catarman Sea or Tablas Masbate 43 Iloilo o Str 32 Sibuyan 52 Samar 44 Negros Occidental Busuanga 37 ai t Masbate VII Central Visayas 53 Semirara Visayan 45 Bohol Culion Islands Kalibo Catbalogan VIII 46 Cebu Roxas City Sea 47 Negros Oriental Linapacah 39 Naval 49 50 Borongan 48 Siquijor 41 Panay Tacloban Cuyo VIII Eastern Visayas Islands 40 43 51 Leyte 49 Biliran Jordan Cebu Leyte Gulf 50 Eastern Samar San Jose de Iloilo 51 Leyte Buenavista Bacolod 42 46 52 Northern Samar Dumaran 53 Samar Cebu 54 Dinagat 54 Southern Leyte Maasin IV-B VI Negros VII 73 San Jose 10ºN IX Zamboanga Peninsula 44 45 Bohol Siargao 55 Zamboanga del Norte Puerto Princesa Tagbilaran Surigao 56 Zamboanga del Sur 31 74 47 57 Zamboanga Sibugay Mindanao --- Zamboanga City Palawan Dumaguete Siquijor Sea Mambajao 71 XIII 48 Siquijor 59 Camiguin Tandag * Executive Order 429, May 23, 2005, 75 provides for the transfer of Palawan X Butuan Cagayan province (#31) from Region IV to Region VI; Administrative Order 129 holds EO429 in abeyance until an Sulu Sea IX Dipolog Oroquieta de Oro Prosperidad implementation plan is approved 62 72 by the President. Bugsuk 61 Iligan 55 Malaybalay 58 60 Marawi Balabac Pagadian Ipil Tubod 77 Mindanao 63 57 56 64 Nabunturan Tagum Cotabato 67 66 Cagayan Davao Sulu ZAMBOANGA CITY Moro 78 Mati XI Shariff Aguak Kidapawan Isabela Zamboanga Gulf (Maganoy) Digos City ARMM Isulan Davao Basilan 76 70 Koronadal Gulf This map was produced by 69 65 the Map Design Unit of The Jolo Sulu General Alabel World Bank. The boundaries, MALAYS IA M A LAYS IA XII Santos 68 colors, denominations and any other information shown on this map do not imply, on 79 the part of The World Bank 0 50 100 150 Kilometers Tawi-Tawi Group, any judgment on the Sarangani 80 Panglima Celebes Sea legal status of any territory, or any endorsement or 5ºN Sugala acceptance of such 0 50 100 Miles 125ºE boundaries. 120ºE NOVEMBER 2012