Technical Assistance Consultant’s Report

This consultant’s report does not necessarily reflect the views of ADB or the Government concerned, and ADB and the Government cannot be held liable for its contents.

Project Number: 39066 (TA 4647)

Philippines: Health Sector Development Program

Technical Assistance to the Republic of Philippines for the Health Sector Development Program

ADB TA 4647-PHI

FINAL REPORT

June 2006 – August 2007

Prepared by

BERNT ANDERSSON Team Leader, International Consultant Health Sector Reform Specialist

MARIA OFELIA O. ALCANTARA Deputy Team Leader, Health Administration Specialist

This report is submitted by InDevelop, the firm hired by ADB to provide the Technical Assistance to HSDP

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EXECUTIVE SUMMARY In 1999, the Philippine Government launched the Health Sector Reform Agenda (HSRA) to define key reforms and strategies that address inequities and inefficiencies in the health sector. In 2005, the Department of Health defined FourMula One for Health as the implementation framework for the Health Sector Reform Agenda (HSRA). FourMula ONE for Health is directed at achieving goals of better health outcomes, a more responsive health system and equitable health care financing. The Government of the Republic of the Philippines requested the Asian Development Bank (ADB) for assistance to support the implementation of the Health Sector Reform Agenda (HSRA). The goal of the Health Sector development Program (HSDP) is to improve the health status of the population, especially of the poor, and to achieve the health-related Millennium Development Goals (MDGs) of the United Nations. Implementing an integrated set of health sector reforms that benefits the poor will include system-wide changes and the design and implementation of project interventions in selected pilot provinces (Ilocos Norte, Ifogao and Oriental Mindoro) that build on the HSRA. The goal of the TA component is to support the HSDP in capacity building for the key reform policies of FourMula One for Health, and preparation for implementing reforms at the local HSDP project sites of Ilocos Norte, Ifugao and Oriental Mindoro. The capacity building package is focused on the following key reform policies/Administrative Orders of FourMula One for Health: • AO 2006-0017: Incentive Scheme Framework for Enhancing Inter-LGU

Coordination in Health through Inter-local Health Zones (ILHZ) and Ensuring their Sustainable Operations

• AO 2006-0020: Guidelines for Evaluation of the Consumer Participation Strategies in Fourmula One for Health

• AO 2006-0029: Guidelines for Rationalizing the Health Care Delivery System Based on Health Needs

• AO 2006-0022: Guidelines for Establishment of Performance-Based Budget for Public Health

• AO 2006-0023: Implementing Guidelines on Financing Fourmula One for Health Investments and Budget Reforms

• AO 2006-0027: Implementing Guidelines for Performance-Based Budget for DOH Retained Hospitals

• AO 2006-0002: Establishment of Continuing Quality Improvement Programs and Committees in DOH hospitals

• AO 2006-0018: Implementing Guidelines of Philippine National Drug Formulary System

• AO 2006-0009: Guidelines Institutionalizing Drug Price Monitoring System

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The Capacity Building Package that has been developed consists of three components:

a) Policy Dissemination and Advocacy package b) Training package and Technical Assistance packages c) Monitoring, Evaluation and Incentives package

Policies and technical packages have been piloted in three F1 provinces of Ilocos Norte, Ifugao and Oriental Mindoro. The Report briefly describes the processes and the contents of each of the technical packages developed for the basic 7 policy reforms. Strategies for localizing the policy reforms are described in detail in each of the technical consultants’ final reports. A draft final report of the TA was made available for comments on 6 August 2007, 1 month before the end of the assignment. A final workshop was planned for August 29 but requested by ADB to be moved to 4 September. The workshop could not take place due to other activities and commitments of DOH officials. Instead, a final meeting with DOH, ADB and the TA took place on 11 September and the final Report and Capacity Building Package were presented. It was agreed that DOH would evaluate the reports and other deliverables during the following two weeks. Based on the evaluation, reports and other deliverables were revised and submitted to DOH on 1 October. After further evaluation by DOH, the Final Report, Technical Consultants Reports and other deliverables were revised again and final improvements were made by DOH 16 November. The final report is providing a comprehensive document that includes recommendations and plans developed by the individual consultants in line with the deliverables specified in their respective TOR. Each consultant has produced a final technical report based on the individual terms of reference. The team leader has been accountable for the technical quality of all the reports and timely delivery of the reports to the client.

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Table of content

EXECUTIVE SUMMARY

I. BACKGROUND AND RATIONALE 1 II. OBJECTIVES 3 III. METHODOLOGY 3 IV. OUTPUTS

A. Integrated Capacity Building Package 4

B. Advocacy and Policy Dissemination Package 5

C. Training Package 7

C. 1 Inter-Local Health Cooperation 8

C. 2 Consumer Participation 9

C. 3 Optimization of Health Facilities 10

C. 4 Clinical Practice Guidelines and CQI 11 C. 5 Drug Management and Financing 12 C. 6 Performance Based Budget for Public Health 12 C. 7 Performance Budget for Hospitals 13 C. 8 Health Financing and Business Plans 14

D. Indicators, targets and tools: Inputs to

F1 Monitoring and Evaluation System

D. 1 Monitoring and Evaluation for Equity and Effectiveness 15 (ME3) D. 2 Scorecards 17 D.2.1 CHD Scorecard 17 D.2.2 Development partner Scorecard 17 D.2.3 Support to LGU and Hospital Scorecard 19 Development

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E. Incentive Package 19 E.1 We Care4Health Awards 20 E.2 Optimization of Health Facilities 20 E.3 Performance Based Budget for Public Health 21 E.4 Performance Based Budget for Hospitals 21

F. Support to the Program Loan 21

F.1 Baseline Study TOR 22 F.2 Project Administration Management 23 F.3 Training 23 F.4 TOR for incoming consultants 23 F.5 Feasibility Study in Ilocos Norte and Mindoro Oriental 23 G. Project Management and Coordination 23 G.1 Hiring of New TA 4647 24 G.2 Assistance in Finalization of Revised TOR 25 G.3 Preparation of Inception Report 25 H. Other TA Support Activities 26 H.1 Health Financing Reform 26 H.2 Service Delivery Reform 26 H.2.1 Hospital Reform 26 H.2.2 Public Health Reform 27 H.3 Good Governance 27 H.3.1 Local Health System 26 V. RECOMMENDATIONS 29

VI. ATTACHMENTS 35 Attachment 1: TA 4647 Terms of Reference Attachment 2: TA 4647 Team International and Domestic Consultants Attachment 3: Development Partner Report Card - Report Attachment 4: Development Partner Report Card - Examples Attachment 5: Economic Analysis Attachment 6: Feasibility Study Mindoro Oriental and Ilocos Norte Attachment 7: TA 4647 Inception Report Attachment 8: TA 4647 Work Plan Attachment 9: Project Administration Memorandum Attachment 10: CHD Scorecard

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Scope of Work

Terms of Reference for the TA 4647 are attached as Attachment 1. The Terms of reference for the Team Leader and the Deputy Team Leader follow below: International Consultant Health Sector Reform Specialist (team leader) - The consultant will help technically conceptualize and guide the HSRA reform activities under F1, and help accelerate F1 reforms through the HSDP, including the program loan, the investment loan, and the TA. The consultant will have an intermittent contract from inception to the end of the TA, and will have the following roles: (i) oversee and direct the technical work conducted by the TA team; and review all the technical reports ensuring their quality and acceptability before submission to the client; (ii) review, propose, and strengthen reforms under F1. The consultant will (i) provide the technical lead, and will conduct technical discussions with various entities, such as DOH, PhilHealth, Department of Finance, LGUs, and special-purpose entities (SPE1) to monitor the progress of the TA and ensure coherence with medium term plans and F1; (ii) work closely with the team and conduct technical dialogue and activities; review reports of the TA consultants and guide their technical work, assess risks, constraints and bottlenecks, and help resolve these problems; and (iii) liaise with and provide guidance to the deputy team leader; (iv) the consultant will review the current policy and background strategy papers prepared by DOH for F1, and make recommendations on the current needs in the country, particularly needed reforms of the health care financing policies, including implementation and monitoring of reforms (vi)The consultant will participate in the design the performance assessment systems for the donors supporting F1 to be consistent with the F1 Monitoring and Evaluation System; (vii) the consultant will participate in the ADB review missions for the HSDP in the event that such missions take place during the presence of the Team Leader in the Philippines. Health Administration Specialist (deputy team leader) ( 8 person-months). The specialist must be a master’s degree holder in public health or health services administration or any related field, with at least 10 years of relevant experience in program development and implementation in the health sector. The consultant should be well versed in the Philippines health care system. The consultant will have two roles: (i) coordination/administrative, and (ii) technical. In the coordinative and

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administrative, the consultant will (i) manage the day to day operations of the TA and ensure timeliness and integration of all activities and outputs; (ii) liaise with central, provincial, and local governments, private sector, non-government organizations, and the community, and other key technical persons in the country; (iii) assess needs to coordinate, help in planning and monitoring the progress of needs and assignments; (iv) guide the other TA consultants on key issues and on key persons to meet, sources of information; and (v) assist the TA consultants in meeting the objectives of the TA. In the technical role, the consultant will (i) integrate the capacity building activities of all the consultants in an F1 framework; (iii) assist in the project performance, and strengthening implementation; and (iv) monitor the progress of the HSDP investment loan, and address any bottlenecks and constraints. (v)The consultant will design a performance assessment system for the centers for health development of the DOH.

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Acronyms

ADB Asian Development Bank AO Administrative Order BHS Barangay health station BIHC Bureau of International Health Cooperation BLHD Bureau of Local Health Development BLHD CA Cooperating Agencies CB Capacity Building CHD Center for Health Development CMS Communication and Marketing Specialist CO Central Office CPG clinical practice guidelines DHPMS District Health Planning Management Specialist DMFS Drug Management and Financing Specialist DOH Department of Health DTL Deputy Team Leader EC European Commission F1 FourMula One for Health FACO Foreign Assistance Coordinating Office FGD Focus Group Discussion FICO Field Implementation and Coordinating Office FS Feasibility Study GTZ Deutsche Gesellschaft für Technische Zusammenarbeit,

(German Agency for Technical Cooperation) HCF L Health Care Financing Local HCF N Health Care Financing National HF Health Facilities HFMS Hospital Finance and Management Specialist HHRDB Health Human Resource Development Bureau HPDPB Health Policy Development Planning Bureau HRS Human Resource Specialist HSDP Health Sector Development Project HSRA Health Sector Reform Agenda HSS Health Systems Specialist ILHZ Inter-local health zone InDevelop InDevelop Uppsala AB JICA Japan International Cooperating Agency L&D Learning and Development LGU local government unit M & E Monitoring and Evaluation MCH Maternal and Child Health

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MDFO Medium Term Developement Final Outcome MDG Millennium Development Goal ME3 Monitoring and Evaluation for Equity and Effectiveness MES Monitoring and Evaluation Specialist MFO Major Final Outputs MFO Major Final Outputs MOA Memorandum of agreement MTP Medium Term Plans NCHFD National Center for Health Facilities Development NCR National Capital Region NGO non-government organization NHIP national health insurance program PBB Performance Based Budgeting PH Public Health PhilHealth /PHIC Philippines Health Insurance Corporation PHS Public Health Specialist PHS CPG Public Health Specialist Clinical Practice Guidelines PIF Performance Indicator Framework PIPH Province-wide Investment Plans for Health PMGMM Program management Group Membership and Marketing PMU Project management unit POGI Partnership with Organize Group Interface QA Quality Assurance R&R Retooling and Retraining RHU rural health unit SHIS Social Health Insurance Specialist (International) SMCO Sector Management and Coordination Office SPAR TA Technical Assistance TA Team Technical Assistance Team TB Tuberculosis TCG Technical Coordinating Group TL Team Leader TOR Terms of Reference TWG Technical Working Groups UMIS Unified Management Information Systems USAID United States Agency for International Development

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I. BACKGROUND AND RATIONALE

The Philippines has progressed towards realizing its health goals in the past decades although the progress has slowed down during recent years. Vital health indices such as life expectancy, infant, child and maternal mortality rates have improved. Despite the inroads made in the past decades, a number of gaps remain to be filled, the common illnesses of poverty, such as infectious diseases, have not been reduced to acceptable levels. Social and economic changes have created new challenges in terms of degenerative and lifestyle diseases. Further, the organization of the health sector itself suffers from an inappropriate delivery system, inadequate regulatory mechanisms, and inappropriate health care financing schemes. In 1999, the Philippine Government launched the Health Sector Reform Agenda (HSRA) to define key reforms and strategies that address inequities and inefficiencies in the health sector. In 2005, the Department of Health defined FourMula One for Health as the implementation framework for the Health Sector Reform Agenda (HSRA). FourMula ONE for Health is directed at achieving goals of better health outcomes, more responsive health system and equitable health care financing. The Government of the Republic of the Philippines requested the Asian Development Bank (ADB) for assistance to support the implementation of the Health Sector Reform Agenda (HSRA) in April 2004 and in December 2004, ADB approved two loans totalling US$213 million for a health sector development program and investment project loan in support of the HSRA. Also, ADB has provided a grant TA to support the implementation of the Program Loan and the Investment Loan. The goal of the HSDP is to improve the health status of the population, especially of the poor, and to achieve the health-related Millennium Development Goals (MDGs) of the United Nations. Implementing an integrated set of health sector reforms that benefits the poor will include system-wide changes and the design and implementation of project interventions in selected pilot provinces that build on the HSRA.

The goal of the TA component is to support the HSDP in preparation for Health Sector Reform Agenda (HSRA) national implementation plans, particularly capacity building for the key reform policies of FourMula One for Health, and preparation for implementing reforms at the local HSDP project sites. During the initial phase of the TA, the focus was on the policy formulation in support of reforms launched in 1999. Policies were developed under the Program Loan in the areas of Hospital, Public Health, Regulation, Health Financing and Local Health Systems. The incoming phase of the TA shall focus on the capacity building for operationalization of the policies developed and full compliance of the Policy Matrix. To date, the TA has helped the HSRA by developing policies, guidelines, and concepts, which are fundamental for implementing reforms for the health sector and initiated developing capacity building design to operationalize the policies developed at the local levels (Attachment 1: TA 4647 Terms Of Reference). Implementing an integrated set of health sector reforms that benefits the poor will include system-wide changes and the design and

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implementation of project interventions in selected pilot provinces in Ilocos Norte, Ifugao and Oriental Mindoro that build on the HSRA principles.

The current TA is now being aligned towards capacity building for the health sector, to ensure success in the implementation of policies developed and continuing support to the compliance of the Program loan. Capacity building activities will involve policy dissemination and advocacy, training, preparation of DOH technical assistance packages to the health sector, monitoring and evaluation, and designing of incentives for performance.

The overall deliverables of the TA are the (i) preparation of Health Sector Reform Agenda (HSRA) national implementation plans, particularly capacity building for the key reform policies of FourMula One for Health, (ii) preparation for implementing reforms at the local HSDP project sites. The consultants will complete all the technical outputs under the guidance of the international consultant on health sector reform and will report to the Deputy Team Leader for all operations during the period of the TA. The individual consultant’s work plan was developed in close coordination with the DOH counterparts and consolidated to come up with a team implementation plan from August 2006 to March 2007. The plan includes the reporting, workshop, coordinative meetings and field travel schedules and the schedule of activities by reform components and the cross cutting support to implement the TA. The Implementation Plan has been refined in the Inception workshop with the DOH. The Work plan has been modified together with DOH to continue and complete the tasks from February to August 2007. It has been agreed in discussions between the DOH, ADB and the TA team that the continued TA could be better targeted to the current situation in mid-term implementation of the TA by slight revisions of the original TOR. This version of the TOR represents the joint effort to revise the TOR for the period from August 1, 2006 to the end of the TA 4647 (April version of TOR with some minor adjustments). As a consequence of preceding events in the TA implementation and the rescheduling of the overall time frame, ADB and the contractor for the TA services, InDevelop Uppsala AB (InDevelop), have identified and agreed on necessary contract revisions. Such revisions have included: 1. New time frames (assignment ending in end of August 2007) 2. New reporting schedules, (Progress Report, Mid Term Report end May and Final

Report in August according to attached work plan) 3. Specific conditions for fund release from ADB to the contractor. (50% after

delivering Progress Report and 50% after delivering the Mid Term Report) 4. The revision has also settled the time frames for each individual consultant

mentioned in these TOR, except for consultants hired directly by ADB outside the scope of the contract between ADB and InDevelop, who’s TORs have not been revised.

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II. OBJECTIVES A. General:

1. Preparation for Health Sector Reform Agenda (HSRA) national implementation plans, particularly capacity building for the key reform policies of FourMula One for Health,

2. Preparation for implementing reforms at the local HSDP project sites. B. Specific:

1. Provision of capacity building for the health sector to involve policy dissemination and advocacy, training, preparation of DOH technical assistance packages to the health sector, monitoring and evaluation, and designing of incentives for performance.

III. METHODOLOGY

A team of international and domestic consultants has been recruited through an international consulting firm, InDevelop as well as directly by ADB, and includes international experts in health sector reform (team leader), health systems (ADB recruited) and social health insurance (ADB recruited), as well as eleven domestic experts in health administration (deputy team leader): district health planning and management, hospital financial management system, health care finance, public health, PH clinical practice guidelines, drug management and financing, human resource management, monitoring and evaluation, communication and marketing and project administration management (Attachment 2: TA 4647 Team of International and Domestic Consultants). . The TA team has worked in close cooperation with the Department of Health (DOH), Director of the Health Policy Development and Planning Bureau, Bureau of international Health Cooperation and other concern DOH program directors and have receive technical guidance from the project team leader of the Asian Development Bank (ADB)-supported Health Sector Development Program (HSDP). The TA team has also worked closely with the Philippines Health Insurance Corporation (PhilHealth), LGUs, and related agencies and stakeholders. All consultants have worked in close collaboration with ADB, and other development partners supporting the Formula One for Health (F1) such as the European Commission, USAID, German Technical Cooperation, KFW, World Bank, World Health Organization, and others The work of the TA has aligned towards capacity building for the health sector, to ensure success in the implementation of the developed policies as well as to support the local implementation of policies and the investment loan. Capacity building activities have involved policy dissemination and advocacy, training, preparation of

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DOH technical assistance packages to the health sector, monitoring and evaluation, and designing of incentives for performance. The current phase of the TA has focused on the capacity building at the local levels for operationalization of the policies developed and full compliance of the Policy Matrix. The current TA has therefore been aligned towards capacity building for the health sector, particularly capacity building for the key reform policies of FourMula One for Health, to ensure success in the implementation of the policies developed and continuing support to the compliance of the Program loan (Attachment 8: TA 4647 Work Plan). Capacity building activities has involved policy dissemination and advocacy, training, preparation of DOH technical assistance packages to the health sector, monitoring and evaluation, and designing of incentives for performance. The result of the Policy dissemination and Advocacy package would be awareness and determination to implement the 7 basic health reforms. Planning for the implementation should be an integrated part of the provincial and local planning processes, including activities for implementation in the Provincial Investment Plans for Health and in the Local development plans at municipal and inter-local health zone level. As part of the planning for implementation, provincial and local training needs should be assessed and the specific training needs of the province and the LGUs should be identified. The Training package is the third step of the F1 training, the first step being the already existing Introductory course and the second step being the Flagship course. The training package that has been developed by the TA contains integrated 5-day training for the 7 basic health reforms. The development of the technical packages involved the participation of various stakeholders from the fields and the ADB sites, Centers for Health Development, central offices technical staff, the consultants among others. IV. OUTPUTS

A. An Integrated Capacity Building Packages

The goal of the TA component is to support the HSDP in capacity building for the key reform policies of FourMula One for Health, and preparation for implementing reforms at the local HSDP project sites of Ilocos Norte, Ifugao and Oriental Mindoro. During the initial phase of the TA, the focus was on the policy formulation in support of reforms launched in 1999. Policies were developed under the Program Loan in the areas of Hospital, Public Health, Regulation, Health Financing and Local Health Systems. To date, the TA has supported the HSRA by developing policies, guidelines, and concepts, which are fundamental for implementing reforms for the health sector The current phase of the TA has focused on the capacity building at the local levels for

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operationalization of the policies developed and full compliance of the Policy Matrix. The current TA has therefore been aligned towards capacity building for the health sector, particularly capacity building for the key reform policies of FourMula One for Health, to ensure success in the implementation of the policies developed and continuing support to the compliance of the Program loan. Capacity building activities has involved policy dissemination and advocacy, training, preparation of DOH technical assistance packages to the health sector, monitoring and evaluation, and designing of incentives for performance. The capacity building package is focused on the following key reform policies/Administrative Orders of FourMula One for Health: • AO 2006-0017: Incentive Scheme Framework for Enhancing Inter-LGU

Coordination in Health through Inter-local Health Zones (ILHZ) and Ensuring their Sustainable Operations

• AO 2006-0020: Guidelines for Evaluation of the Consumer Participation Strategies in Fourmula One for Health

• AO 2006-0029: Guidelines for Rationalizing the Health Care Delivery System Based on Health Needs

• AO 2006-0022: Guidelines for Establishment of Performance-Based Budget for Public Health

• AO 2006-0023: Implementing Guidelines on Financing Fourmula One for Health Investments and Budget Reforms

• AO 2006-0027: Implementing Guidelines for Performance-Based Budget for DOH Retained Hospitals

• AO 2006-0002: Establishment of Continuing Quality Improvement Programs and Committees in DOH hospitals

• AO 2006-0018: Implementing Guidelines of Philippine National Drug Formulary System

• AO 2006-0009: Guidelines Institutionalizing Drug Price Monitoring System The Capacity building Package that has been developed consist of three components:

a) Policy dissemination and advocacy package b) Training package and a Technical Assistance packages c) Monitoring, Evaluation and Incentives packages

B. Advocacy and Dissemination Packages To use the Capacity building package in the best way, the DOH is recommended to start by using the Policy dissemination and Advocacy package to create awareness and willingness among Provincial Governors and Local Chief Executives to implement the basic 7 reforms and the Provincial DOH Representatives and LGU health workers as well as Regional, Provincial and Municipal Development Council members would be targeted. The implementor of the campaign should be the Center for Health

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Development and the Provincial Governor, preferably through a working group (TWG) or Local Implementation and Coordination Team (LICT) established for the F1 local health sector reform. The duration of the campaign, which was linked to the ADB loan, is estimated to be 3 to 9 months until local issuances have been passed for all F1 Basic 7 Policies in three pilot F1 provinces of Ilocos Norte, Ifugao and Oriental Mindoro. Thus the result of the Advocacy and Dissemination packages would be awareness and determination to implement the 7 basic health reforms. Planning for the implementation should be an integrated part of the provincial and local planning processes, including activities for implementation in the Provincial Investment Plans for Health and in the Local development plans at municipal and inter-local health zone level. It was agreed to work with a limited number of administrative orders, for (1) interlocal health zones, (2) performance based budgeting for health, (3) health financing, (4) drug reforms, (5) performance based budgeting for public hospitals, (6) clinical practice guidelines and (7) consumer participation. A campaign was designed based on the goal to promote the localization of F1 health reform, specifically these 7 sets of reform, positioned and branded as the Basic 7 F1 Health Reforms or the first set of integrated health reforms that an LGU needed to put in place to be able to improve over all health planning and management, health outcomes and services and attract health investments for better health facilities. The team agreed that the campaign tag: Tulong-tulong. Sulong sa Kalusugan actively motivated and described the process we wanted to achieve. This was however changed to ”Localize Health Reform. DOH it Na!” for greater alignment with current DOH health promotion strategies. The objective of the dissemination and advocacy campaign was to Inform and persuade local chief executives to champion the issuance and implementation of 7 Fourmula 1 administrative orders. Specific objectives were: (1) Create top of mind awareness that the first step to local health reform is to adopt the integrated Basic 7 Reforms; (2) promote the key messages/benefits of the F1 Basic 7 Policies to primary and secondary markets; and (3) gain positive support and endorsements from local chief executives & opinion leaders for localizing F1 Basic 7 Policies Once the LGU passage of the Basic 7 policy issuances had been achieved, it is suggested that the campaign would need to shift into another campaign strategy to market how to implement the new processes outlined in the reforms. The primary target audience were the local municipal chief executive and local health opinion leaders. Secondary audiences were the local health staff and workers. Social Marketing Strategies were to choose municipalities that are most ready to adopt the health reforms (demand driven), to break up the Basic 7 package and prioritize what policies to first promote depending on the specific needs of the LGU and to

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prioritize and decide on and promote a single, doable behaviour in clear, simple terms. Social Marketing Strategies were to choose municipalities that are most ready to adopt the health reforms (demand driven), to break up the Basic 7 package and prioritize what policies to first promote depending on the specific needs of the LGU and to prioritize and decide on and promote a single, doable behaviour in clear, simple terms. Message Strategies are to show the “Before” and the “After”, what will happen with the adoption of the F1 Basic 7 policies, develop two sets of materials namely: 1) technical and 2) popular to match the profile of the LGU target audience. Printed Materials on Advocacy and Dissemination Package developed by the TA are:

• Information Folder • F1 Basic 7 Brochure • Technical Briefs for each of the Basic 7 Administrative Orders (AOs) – “Policy

Notes” in 2 versions: Technical & Popular • Web Page • Power point Templates for Presentations to special audiences

C. Training Packages As part of the planning for implementation, provincial and local training needs should be assessed and the specific training needs of the province and the LGUs should be identified. The Training package for the basic 7 policy reforms is the third step of the F1 training, the first step being the already existing Introductory course for Health Sector reform and the second step being the Flagship course. The training package that has been developed by the TA contains integrated 5-day training. The training course can be adopted to include only those components that are relevant according to the training needs assessment and will then be appropriately shorter than 5 days. It is important that the training is linked to the provincial and local plans for the implementation of the 7 basic reforms. The staff sent to the training should have an active role and responsibility for the implementation of the components of the basic 7 health reforms. The objective of the training is to strengthen their capacity to implement the reform components. To facilitate this, the training starts with the participants relating their own experiences and the session ends with providing participants an opportunity to im with their own implementation planning for each component of the course. After the conclusion of the training, participants will return and continue their work together with the implementation of the 7 basic health reforms in accordance with their action plan. The TA has identified training institutions in the three provinces of Ilocos Norte, Ifugao and Oriental Mindoro. Criteria for identifying training institutions in other provinces have been developed. However, to systematize and standardize the training an institution will be identified and provided capacity to undertake the training. The institution shall formulate a business plan to institutionalize and sustain the training.

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The training packages, developed by the TA are:

Experience-based - participants will be engaged in examining past experiences and cases that will either highlight the relevance and impetus of the AO/policy or provide insights on workable strategies and lessons learned in policy implementation.

Action/solution-oriented - to empower the participants to fulfill their roles in the process of policy implementation, this training will guide the participants on how to apply the AO guidelines into concrete plan of actions.

Proactive - participants will be challenged to identify their strengths and opportunities (institution) for increasing effectiveness of policy implementation and incorporate them into their action plan. They will also examine their potential problems and identify preventive and contingency measures.

Integrated - the AO discussed in this training all contribute to the achievement of the goals of FourMula One (F1) for Health. Thus, each of the AO will be discussed in relation to the other AO and will always be linked to the F1 principles and components. Further, a Technical Assistance package to assist in the implementation of the basic 7 reforms has been developed by the TA. This technical assistance will complement the training package and will provide consultants to the local level to assist in the implementation of the reforms. As part of the TA-package, a template or draft Terms of Reference (TOR) for succeeding technical assistance has also been developed. The training module follows the following format and design:

o Module Starter o Current scenario/concerns –Where are we? o Objectives of the AO –Where do we want to be? o AO implementing Guidelines and Concepts –‘vehicles’ for change o Roles of key players –drivers of the change process o Summary in relation to F1 components o Application/Group Integration –how do we get there?

Below is the brief description of each of the training packages developed:

C.1 Inter-Local Health Zones

Independent good performance of public hospitals, health centres, and barangay health stations is not enough to build a strong public health system nationwide. Often, the challenge to address health issues requires a well-coordinated and reliable collaborative effort of health service providers from adjacent municipalities and cities. Increased visibility of common health threats, for instance, goes beyond the capacity of autonomous health entities or local government units (LGU). To protect the health of populations living across several LGUs, decentralized public health networks need to take prompt, unified, and organized action.

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Active inter-LGU cooperation across the nation will definitely pave the way to better health outcomes and more effective and accessible health services for all. The objective of the training package for inter-LGU cooperation is that participants at the end of the session, would be able to achieve the following specific objectives:

1. discuss the rationale, definitions and principles of inter LGU cooperation; 2. explain the guidelines on the F1 ILHZs; 3. explain the indicators of functional inter-local health zones; 4. explain the incentive scheme to promote and sustain ILHZs; and 5. plan the next steps

The training takes participants through the rational and background of inter-LGU cooperation including the DOH Administrative Order 2006-0017, entitled, Incentive Scheme to Enhance Inter-LGU Coordination in Health Operations through Inter-Local Health Zones (ILHZ). After learning about the importance of inter-LGU coordination and the benefits of highly functional Inter-Local Health Zones (ILHZ), the training introduces a tool for assessing ILHZ functionality. At the end of the training, participants are challenged to plan to implement and institutionalize inter-LGO cooperation in their own institutions.

C.2 Consumer Participation Health consumers or individuals or groups who either “directly or indirectly make use of health services” are valuable actors in the implementation of FOURmula One for Health. Their participation is increasingly being recognized as one of the catalysts in reforming the health sector. Empirical evidences showed that their active participation in their own individual care and in the development, monitoring and evaluation of health strategies and programs leads to better health outcomes and more accessible and effective health services. Recognizing these potentials and the direct benefits to consumers, the Department of Health (DOH) created a policy that will support the implementation of consumer participation all over the country. This Administrative Order on Consumer Participation endeavours to provide the mechanisms/strategies to increase consumer participation. Through these strategies, consumers will be gradually considered more as partners for reforms than just passive recipients of health services. The training covers the rationale, the framework used, the implementation strategies and the tool to evaluate the effectiveness of consumer participation. The objectives of the training package are: 1. discuss the rationale, definitions and framework for consumer participation within

the context of F1 Health Sector Reform;

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2. identify the 5 key strategies in promoting community participation; 3. explain the tool in evaluating the effectiveness of consumer participation; 4. plan the next steps in implementing consumer participation in your areas of work. The training takes participants through ddefinitions, such as: a) who are the health consumers, b) what is participation, c) what are the levels of participation and d) what are the degrees of participation. The training also explains the rationale of implementing consumer participation strategies, and the instruments like Consumer Feedback Mechanisms, Increasing Purchasing Power of the Poor, Consumers influence in Provision of Services and Providers, involvement as co-producer and co-financing agent and involvement in Policy, planning, implementation, monitoring and evaluation. A tool is introduced for assessing the current situation of consumer participation.

C.3. Optimization of Health Facilities A large proportion of poor households rely on publicly provided services which are free or low cost but generally considered substantially poorer in quality. At many health centres and barangay health stations, resources are lacking and quality of service is wanting. Larger hospitals with medical specialists are overcrowded and attending mostly to patients that can be treated at lower level hospitals, or at primary medical care centres. Despite the many public and private health facilities and providers, many people find it financially inaccessible due to limited social health insurance. These are just some of the sad pictures of inefficient health care delivery system in the country. These are issues being addressed by F1 health reform initiatives. Specifically, the AO on Optimization of Health Care Facilities endeavours to ensure equitable access to quality health care for every Filipino. The objective of the training package for optimization of health facilities is that participants at the end of the session would be able to achieve the following specific objectives:

1. Conduct a health facility mapping exercise. 2. Conduct a health needs assessment. 3 . Formulate a strategic plan. 4. Develop an action plan. 5. Formulate an investment plan 6. Gain knowledge on the steps of having the plan approved, implemented and evaluated

The training takes participants through the rational and background of the current network of health facilities, with the provision of a rational health delivery system, particularly in the rural areas, posing a difficult challenge to health policy makers and planners. The training is based on the DOH AO 2006-0029, Guidelines for Rationalizing the Health Care Delivery System based on Health Needs, the reports of

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the ADB consultant Jan Both and an the Implementation guidelines developed by the TA. The Training suggest that the Province shall conduct a self- assessment of its current health care needs together with a situational analysis of its health facilities, health providers and resources to benchmark against the standards set by DOH. This will allow the Province to identify the gaps that will have to be addressed with appropriate strategic planning and action plans, taking participants through the following steps: Step1. Health Needs Analysis Step2. Health Resource Analysis Step3. Developing Goals/Objectives Step4. Develop an activity plan for each of the strategies Step 5. Investment plan Step 6. Approval of the plan

C. 4. Clinical Practice Guidelines and Continued Quality Improvement The quality of decision-making in terms of what medications and treatment modalities to give to a patient spells a big difference on the success of health care intervention. More than just the issue of cost efficiency, better health care provides better health outcome. To ensure the implementation of a high standard of quality on effective decision-making in health care, DOH created a policy on Establishing a Continuing Quality Improvement (CQI) Program and Committee in DOH Hospitals. Specifically, this policy advocates for the use of Clinical Practice Guidelines (CPG). CPG is an evidence-based decision support tool on what procedures or services to perform for a particular health problem. When used properly, CPGs can improve health care quality and encourage more efficient use of limited health care resources. The objective of the training package for Continuing Quality Improvement (CQI) Programs and Committees in DOH Hospitals and specifically, the use of Clinical Practice Guidelines (CPG) is that participants at the end of the session would be able to achieve the following specific objectives: 1. For health care providers to learn and apply the concept of quality improvement

with the use of clinical practice guidelines; 2. For participants to express increased appreciation of the value of CPG and

positive inclination in using CPG; and 3. For PHIC and DOH to learn and apply standards of care adopted from CPG. The training takes participants through an introduction to CPG and quality health care, tips on how to make continuous quality improvement work and applying what have been learned through a case analysis.

C. 5. Drug Management and Financing

The timely provision and the proper use of quality and cost-effective essential drugs all

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contribute to an effective health care delivery system. Well-informed health care providers and managers at the different levels of health care play vital roles in achieving this goal. To do their tasks well, they should be very knowledgeable of the drug management process. They should also consistently monitor, evaluate, and improve the following complementary steps of the drug process in their respective hospitals: drug selection, budget allotment, quantification of requirement, procurement, supply management, prescribing, dispensing, and use. Two important DOH policies can serve as guideline in improving drug management process. The Administrative Order (AO) on Institutionalizing and Strengthening the Essential Drug Price Monitoring System provides guidelines for improving access to drugs. On the other hand, the AO on Implementing Guidelines for the Philippine National Drug Formulary System focuses on promoting rational use of drugs. The objectives of the training package are: 1. Discuss the salient provisions of the administrative orders and other government Policy documents on drug management. 2. Describe the steps of the drug management process. 3. Describe the implementing guidelines for drug management. 4. Describe the ‘best practice’ managerial and educational tools for the different

steps (from drug selection to rational drug use) of drug management. The training takes participants through an overview of the drug situation in the Philippines, including common concerns on the national and local drug situation and the strategies recommended by the World Health Organization to improve drug management. The next topic for the training is the Philippine National Drug Policy and other policy documents to ensure drug quality, improve drug access, and promote rational use of drugs. Together with the policy, the managerial and educational tools and interventions for each step of the drug management process (i.e., drug selection, procurement, distribution, and use) were presented and discussed. National and local issues and concerns that hinder rational drug management and the recommendations to address these concerns were discussed by the participants.

C.6. Performance Based Budgeting for Public Health

Public health programs such as those that fight common health treats are more cost effective and benefit a larger segment of the population. However, they are financed by the government which has limited resources. Local and national spending for health should therefore be well-targeted such that they ensure that public health programs are prioritized and managed efficiently. Performance-based budgeting (PBB) can help achieve this. Through this financing mechanism, the limited resources of the government will be allocated not through a fixed annual incremental value but based on performance in achieving well defined outcomes.

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PBB is both a reward mechanism and a financing strategy that encourages judicious spending. As a financing strategy, PBB can very well help achieve F1 health sector reforms. The objectives of the training package are: 1. Explain Performance Based Budgeting; 2. Discuss PBB-PH fund schemes for DOH Central Office, Centers for Health Development and Priority programs for LGU’s; and 3. Compute commodity allocations for LGU’s The training takes participants through what Performance-based Budgeting is, the basis for using PBB, what the AO on PBB contains and the specific objectives of the AO on PBB: to prioritize public health programs over time, to progressively allocate commodities for public health programs and to link budget subsidies of DOH offices to specific outputs and outcomes for targeted reforms in public health programs. The training continues with an exercise to computing commodity requirement in order to familiarize participants with using the guide for setting performance benchmarks for service delivery for priority PH program for provinces and to introduce a mechanism for estimating commodity requirement and allocation for priority PH program for provinces. The training ends with a session for planning of the implementation of the PBB for Public Health.

C.7. Performance Based Budgeting for Hospitals

Performance Based Budgeting refers to the process by which DOH shall divide the hospital MOOE fund into several portions, the releases of which will be based on hospital performance relative to pre-agreed performance measures. This reallocation scheme is meant to contribute to the accomplishment of the following long term goals:

1. The short term goal is to increase improve the quality of hospital services 2. Ensure continued access to hospital services, especially the poor clients 3. Promote the best use of hospital resources 4. Help shift government spending from curative to preventive health

Reward hospitals that show good performance attention and carefulness of hospital chiefs, senior staff (and governing board) in delivering good performance in government hospitals. This will be brought about by linking performance with financing through the consistent implementation of the performance based budgeting process. To do this will require close coordination and vigorous cooperation among the centers for health development and central office and among the technical and financial support services.

The goal of the training is to capacitate participants to use the Guidelines for Performance Based Budgets for Hospitals. At the end of the one-day training, the participants will be able to:

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1. Discuss the steps in conducting the performance based budgeting process. 2. Describe the key performance benchmarks for 2008 to 2010. 3. Explain the self assessment reporting process. 4. Describe the process of submitting a health facility enhancement plan.

The training covers the guidelines to implement the Administrative Order #2006-0027 (Implementing Guidelines for Performance-Based Budgeting for DOH Hospitals). This training is designed for the Center for Health Development to implement the PBB guidelines to DOH retained hospitals.

C.8. Health Financing, Preparing a Business Plan The final training module consistent of pre- and post- tests, Pre-test, a presentation covering the following topics: Rationale for Business Plan for Public Health. (AOs, and Benefits and incentives), Introduction to: what is a Business Plan? What is a Business Plan used for? Who uses Business Plans? Public Health Entrepreneurship, Elements of a Good Business Plan for Public Health (including Discounting, Return on Investments, Cost Effectiveness, Accountability, Accounting, Social Marketing, and Internal and External Audit), Components for a Business Plan for Public Health (as adapted in the Business Plan for Public Health Template), Several Concept Check exercises on the elements of a good business plan, and a Group Exercise. The final training module was initially assessed through the results of the pre- and post- tests. The averaged paired differences showed that there was a 25% increase in acceptability and desire to implement business planning to generate and allocate new revenues for the participant’s public health activities.. During the pilot, the participants were divided into 5 groups for the group exercise. 3 of the groups came up with the correct answer, while the other two did not. This provided an opportunity in object lesson, because the two groups did not follow the principles taught, and consequently, they came up with smaller ending budgets than the other 3 groups.

D. Indicators, Targets and Tools: Inputs to F1 Monitoring and Evaluation System The tasks of the TA has been to formulate a Performance Indicator Framework for Monitoring and Evaluating F1 at the national and LGU sites; Identify sources of data, strategies and methods for gathering data on indicators development; develop a conceptual framework for evaluation of effectiveness and impact of F1 components, activities and interventions. These may include qualitative and quantitative indicator special studies, outside of those identified for routine collection. Evaluation design should also be defined, specifying sample parameters, quantitative and qualitative methods to be used; design needed tools and systems, including recording and reporting forms required, consolidation/summary sheets, etc. Identify relevant stakeholders /offices /units with appropriate function for gathering and handling

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information on identified indicators. Refine and finalize information flows. Pre-test and finalize recording and reporting forms, summary sheets, guide/protocols for interpretation of results, and other tools required; design a validation and verification plan to maintain integrity of M & E System, specifying methods, schedules, and responsible units and develop operational guidelines for validation and verification plan. The consultant shall integrate the performance assessment indicators strategies and tools developed for key F1 policies and stakeholders.

D.1 Monitoring and Evaluation for Equity and Effectiveness(ME3)

A concept paper on Monitoring and Evaluation for Equity and Effectiveness was drafted. The draft concept paper was presented to key DOH personnel during the Orientation-Workshop held in October 2006 for their comments and suggestions on how to improve it.

The draft concept paper included a background on the FourMula One for Health (F1) and its monitoring and evaluation component, which aims to guide the Secretary of Health in assessing how F1 benefits the Filipino people. Goals and objectives of the M&E system were also presented in the concept paper. Various components of the M&E system were discussed in the draft concept paper which includes the performance indicator framework, scorecards, methods for collecting, storing and reporting of results, baseline studies and system of governance. Lastly, phases of activities and timelines were laid out in the draft concept paper. A separate concept paper on the Performance Indicator Framework (PIF) for F1 was drafted. The draft concept paper was also presented during the Orientation-Workshop held in October 2006. The draft concept paper on the PIF included a background on F1 and its goals. In addition, the rationale of the PIF and its objectives were presented in the draft paper. The various components of the PIF were also discussed and included the three major levels such as the final outcomes, intermediate outcomes and major final outputs. Also discussed are performance measures on attainment of goals for the entire country as well as for important equity groups. Measures of performance on individual operations of Local Government Units (LGUs) and hospitals and of coordinative operations of Inter-Local Health Zones (ILHZs) were also briefly articulated in the draft paper. Lastly, a list of targeted activities was included under program of work.

The first draft of the Performance Indicator Framework was likewise presented during the Orientation-Workshop among key DOH personnel in October 2006. The first draft showed the hierarchy of indicators on outcomes and outputs that F1 aims to achieve. The highest level in the hierarchy is the final outcomes which covers F1 goals on improved health status, financial risk protection or fair financing for all, and improved responsiveness of the health system. The second level in the hierarchy is the intermediate outcomes and includes domains in access, efficiency; quality and financial burden (see Annex C for first draft of PIF and list of indicators). The third

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level in the hierarchy is the Major Final Outputs. However, MFOs were not yet included in the first draft of the PIF. An Orientation-Workshop was conducted on October 25-27, 2006 held at the Holiday Inn in Clark, Pampanga. The main participants of the workshop included key personnel of the Department of Health and donors. In particular, DOH participants included the various Technical Working Groups, which were created by the DOH to assist the Task Force on Monitoring and Evaluation in developing performance indicators and targets for F1 and performance scorecards. A workshop design was prepared which included the rationale of the Orientation-Workshop, its objectives; methodologies; expected outputs and program of activities. The general objective of the Orientation Workshop was to organize the work of the DOH Task Force, outside donors and TWGs to provide them with a common perspective and direction for developing the ME3. Likewise, workshop guidelines, methodologies and templates were prepared to provide detailed instructions to guide participants during the workshop. These were presented by the M&E specialist during the workshop proper. Resource persons were invited to give various lecture-discussions (including the M&E specialist) on the following topics: M&E and performance assessment, GoforDev, QIDS, and Major Final Outputs, concept of M&E, scorecards, and data sources. The M&E specialist gave a lecture-discussion on performance goals and presented the draft concept paper on the PIF. The participants of the Orientation-Workshop were divided into groups according to their TWG memberships. The groupings were as follows: FICO Luzon-NCR, FICO Visayas-Mindanao, PSD-Service Delivery, PSD-Regulation, Internal Management Support Team (IMST), and Sectoral Management Coordination Team (SMCT). Three major outputs were expected from each group. The first was their comments and inputs to the draft concept papers on M&E and PIF (Annex G). The second was a draft sectoral and subsectoral performance indicator framework while the third was a draft scorecard (Annex H). The templates that were prepared by the M&E specialist were used to guide the participants in coming up with their workshop outputs. The M&E specialist provided guidance to F1 fellows and TWGs during their weekly meetings as they formulated their subsectoral performance indicator frameworks and as they developed their respective indicators. The M&E specialist provided guidance in planning out the TWGs’ Work plan prior to the national consultative workshop held in December 2006 with major clients. Materials/documents used in guiding the F1 fellows and TWGs were the draft concept papers and draft PIF.

D.2 Scorecards D.2.1 CHD Scorecard The ME3 shall primarily guide the Secretary of Health (SOH) in assessment of how F1 benefits the Filipino people. The ME3 shall also track performance of the health

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system for the use of the SOH and Congress in the context of the F1 implementation. The ME3 system will be guided by a Performance Indicator Framework (PIF) and will be used to measure the performance/compliance of stakeholders in the achievement of F1 goals through scorecards, which includes the Central Level, Regional Level (CHDs and PROs) and LGU scorecards. The CHD shall provide technical assistance to the local levels for the operationalization of health sector reform. The CHD is also task to do regulatory function, monitoring and evaluation and conduct health promotion activities. In the developing of the CHD scorecard, the TA with the M and E task force coordinated with the CHDs. On going discussions and consultations are being undertaken to finalize the CHD scorecard. (See Attachments CHD Scorecard Report) D.2.2 Development Partner Report Card

This conceptual framework was developed with the TWG created for the purpose with the Paris Declaration and the MDG considered (Attachment 3: Development Partner Report Card – Report and Attachment 4: Development Partner Report Card – Examples).

The Development Partner Report Card (DPRC) is being developed as an instrument for dialogue between DOH and development partners, primarily, in this first phase, with the bilateral donors and international organizations like the World Bank, Asian Development Bank and the UN organizations. The card can in a second phase be adopted for the dialogue with other development partners. A process is suggested for further development of the Draft DPRC to be presented in dialogue with the development partners, including a workshop. The aim of DOH is to present a more elaborate DPRC and preliminary data for the JAPI meeting in November this year.

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The purpose are the following: A. Measuring Budget contributions per F1 component B. Final Outcomes in Measuring partners’ commitment to SWAP

1. Reduced transaction costs 2. Efficient donor support, harmonized among donors and aligned to Government

program C. Measuring Commitment to SWAP for Financial Management and Procurement D. Measuring Commitment to SWAP for reporting, monitoring and evaluation.

Below is a portion of the draft partner report card.

Number SWAP Intermediate Outcomes Indicator Scoring

1 Donor support to the health sector has long

term commitment and predictability of

resource flow

Donor committed to 3-5 years

support

�

2 Synchronizing donor support and activities

with the Government budget cycle and

financial year.

Donor support committed and

DOH informed latest Q1 for next

financial year �

3 Donor increasingly use Program Based

Approach (PBA) for their support.

The indicator is use of common

arrangements or procedures, as

percentage of an individual

donors support that goes through

PBA �

4

Timely disbursement of funds and budget

support releases made according to a

schedule decided with the Government, if

requirements are being met

Disbursement schedule agreed

with DOH and disbursements

made according to schedule

�

5

Adopt the use of Government systems to

the extent possible. Where use of current

Government systems is not feasible,

establish jointly with the Government,

additional safeguards and measures in

ways that strengthen rather than

undermine country systems and

procedures.

Donor using or supporting

improvement of Government

Procurement System, to be

acceptable for donor to use

�

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6 Donors use the Government system for

hiring of local experts/consultants.

Fees and contract conditions are uniform

Hiring of local experts subject to

approval of DOH

�

7 Donors ensure that programs they support

are coordinated with the Department of

Health, to enable DOH to have complete

information of all donor support and to

coordinate all donor suport.

Formal agreement exists with

DOH

�

8 Participate in Joint Review

Mission and not requiring own

review �

9

Donor review, monitoring, evaluation, and

reporting processes are harmonized with

procedures and process established for

implementation of the HSRA Utilizing DOH Annual reports and

Score cards for donor support �

10 Provide comprehensive relevant

information regarding resources provided

to Implementing Partners to support the

health sector in the Philippines,

Provide access to expenditure

informationin a timely mannor, at

least on a quarterly basis, on

donor managed funds and

resources in the format to be

jointly decided. �

D.2.3.Support to the Development of the LGU and Hospital Scorecard Technical Assistance and support to the ME3 Task Force was provided by the Hospital Specialist to the development of the Hospital scorecard and other TA member on the LGU scorecard. It is a work in progress.

E. Incentives Earlier experiences of slow implementation of health reforms have led to the realization of the important role of Incentives. The Team has therefore worked with development of incentives for the implementation of the basic 7 health reforms, specifically the WeCare4HealthAward has been developed to stimulate the work of the Inter-Local Health Zones. As part of the TA-package, a template for identifying other incentives has also been developed.

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E.1 WeCare4Health Awards The AO 2006-0017 is the ”Incentive Scheme Framework for Enhancing Inter-LGU Coordination in Health through Inter-local Health Zones (ILHZ) and ensuring their Sustainable Operations”. According to this, DOH shall identify available resources of disposable funds, free goods and free services that can be mobilized and dispensed as incentives to LGUs practising good inter-LGU coordination and establishing functional ILHZ. These incentives are also intended to help promote inter-LGU coordination for achieving full ILHZ functionality. Specifically, the incentive scheme shall be designed to support improvement on coordination for increasing degrees of functionality in the three domains over time. Who may qualify for these incentives:

• All LGUs working as cohesive group; • LGUs coordinating for only some health services; and • Groups of LGUs that improved in functionality ratings

The TA 4647 has suggested a national WeCare4Health Awards (Attachment 5: We Care4Health Awards) as an incentive for doing exemplary interlocal cooperation for health. This award gives recognition to interlocal cooperation that leads to positive health outcomes, continuity of health care, efficient use of resources as well as people participation and empowerment. Transferability and sustainability criteria will also be factored in. The award system is envisioned to be managed by a respected award giving non-government organization that has been into the business of searching for exemplary local government programs and projects. The DOH, through the Bureau of Local Health Development and the CHDs can provide additional incentives to the winners in the form of technical assistance, trainings, additional equipments, commodities and supplies. The funds for these can be accessed from the 3 funds provided for by the Administrative Order 2006-0022 Guidelines for the establishment of Performance Based Budgeting for Public Health.

Likewise, the provincial governments can also provide additional awards to the winners in the forms of recognition, cash, technical assistance and other forms as they may deem fit for their localities. E.2 The Optimization of Health Facilities Plan

The Optimization of Health Facilities Plan will enable the LGU to focus the development of their health system to key facilities. Facilities that show low utilization shall be modified to fit the needs of the community. This plan will be the basis for funding support from the Department of Health and from foreign funding sources. It will also align the investments by the private sector encouraging more development in areas where there are identified service gaps. The operational mechanism envisioned to influence this is through the issuance of certificate of need, the basis of which shall be the optimization plan. The province will also benefit from a more efficient system helping them to conserve operating funds. The surplus fund can be used to expand

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insurance coverage thus helping them for a smooth transition into an insurance financed health delivery system.

E.3 Performance Based Budgeting for Public Health programs Utilizing the different funding schemes for the Performance Based budgeting for Public Health programs, incentives identified for its implementation include the following: 1. Assured continuous supply of priority public health commodities for disease

prevention and disease elimination for local government partners attaining 100% target benchmarks

2. Release of tranche of financial support package for grant programs (EU) for

complete and timely delivery of Service Level Agreement conditionalities for provinces

3. Access to additional funds to augment MOOE and capital outlay for public health

programs for local partners in achieving SLA conditionalities and benchmarks 4. Access to MOOE funds for DOH central offices and CHDs (defined in the

implementation guide) for achieved target and benchmarks 5. Individual recognition and prioritisation for study grant in line with health human

resource development programs for excellent performance in PH for DOH central office and CHDs

E.4 The Performance Based Budgeting for Hospitals The Performance Based Budgeting for Hospitals allows the hospital with good performance to have access to more operating funds. Furthermore, high performing hospitals, which need more developmental funds, can access the health facility enhancement fund. The PBB scores the hospitals performance based on pre-agreed indicators. Hospitals with higher scores can access funds in the Performance Based Operating Fund Pool. The higher the hospital’s scores, the more funds it is allowed to obtain. On the other hand, poor performance results to low scores and less fund access. These unclaimed funds go to a Health Facility Enhancement Fund Pool. Hospitals that garner a score of 95% and above are allowed to submit proposals to be funded out of this pool. The PBB process thus links performance with hospital funding.

F. Support to the Program Loan Continuing support to the compliance of the Program loan by the new TA team was undertaken. The new TA team assisted in the compliance of the program loan in the following areas: The TA team coordinated with the BIHC and the HSDP PMO and provided TA on the following:

• Support to the TOR Baseline Study- accepted by DOH and submitted to

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ADB. • Support to the PAM- Work in progress. Coordination with TA team for

technical input, with BIHC and HSDP PMO for the details esp. on the appendices were undertaken.

• Support to the TOR of incoming consultants for the Project loan-Work in progress. Coordination with HPDPB and BIHC and the TA team was undertaken.

• Support to Social Marketing- Work in progress. Meeting with HSDP PMO and PHIC PMGMM was undertaken.

F.1. Baseline Study TOR

The TA work in close coordination with BIHC and HSDP PMO in the finalization of the Baseline Study TOR. The study is crucial to determine the status and results of the HSDP project especially in the achievement of the goals of the project. The overall goal of the Health Sector Development Project (HSDP) is to improve the health status of the population, especially of the poor, and achieve health-related Millennium Development Goals (MDG) targets. The purpose of the Health Sector Development Project (HSDP) is to increase utilization of affordable and financially sustainable quality health services by the poor based on the progressive implementation of cost-saving and output-enhancing health sector reforms that are guided by the Health Sector Reform Agenda (HSRA). The focus is on results, emphasizing improved access to health services and better outcomes for the poor, and including greater access to essential drugs, strengthened health systems and better management. The Department of Health is currently developing system for F1 Monitoring and Evaluation called the Monitoring and Evaluation for Equity and Effectiveness. This ME3 guided by a performance indicator framework (PIF) shall monitor if F1 is able to accomplish what it has set out to do, and to learn if changes are happening so that more effective interventions can be pursued. A unified baseline study shall be undertaken in the 16 F1 initial provinces to define status of the program and to determine other specific project concerns. The DOH shall tap the developmental partners in the conduct of the baseline study. The ADB supported HSDP shall undertake its study in the provinces of Ilocos Norte, Mindoro Oriental and Ifugao. The design shall be in context of the F1 for Health and the ME3. Various appropriate methodologies in the conduct of the baseline shall be determined to include the Quantitative Service Delivery Survey (QSDS) which can be utilized to investigate the incentives that providers face including institutional, administrative and other factors influencing the over-all performance and the relationship of accountability between policy makers and providers and determine client power to examine the impact of policy and institutional reforms overtime (Attachment 5: Economic Analysis of Bangui DH, Dingras RHU and DH, Nueva Era RHU, Mindoro Oriental Hospital and Mindoro Oriental Financial Analysis).

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F.2 Project Administration Memorandum (PAM) The Project Administration Memorandum (PAM) is intended to provide details of the Project, its description, components, project Inputs, financing plan, procurement management, implementation arrangements, TA support, project monitoring and evaluation, major loan covenants to facilitate the implementation of the HSDP Project. Also, the PAM contains the anticorruption policy of the ADB and auditing requirements. The PAM shall be the primary reference during the project implementation and shall be updated periodically to incorporate significant changes in the project scope and implementation arrangements. The project implementation is subject to the provisions of the applicable Loan Agreement and explains the application of the provisions in the loan agreement.

F.3 Training Assistance to HHRDB for assessment of training program based on the Training Needs Assessment and developing the Template for Training design were undertaken.

F.4 Terms of Reference for incoming consultants

A team of consultants shall be hired to support the HSDP project. The TA 4647 provided support in the formulation of the In-coming consultants’ TOR and the firm that shall managed the TA.

F.5 Conduct of Feasibility Study in the provinces of Ilocos Norte and Mindoro Oriental

A feasibility study for Health Facilities upgrading in Ilocos and Mindoro Oriental was conducted. It aims to determine the technical and economic feasibility of constructing a new provincial hospital and upgrading two existing district/community hospitals in Oriental Mindoro as well the upgrading of six health facilities in the province of Ilocos Norte. The study will also include the analysis of the best scheme of implementing the project in accordance with acceptable technical standards to satisfy the demand, and the optimum timing of its implementation (Attachment 6: Feasibility Study Mindoro Oriental and Ilocos Norte).

G. Project Management and Coordination The TA 4647 program was working closely with the technical partner in HPDPB under the SMCO cluster and BIHC as the TA partner in project management. TA 4647 also worked closely with the HSDP PMO. Consultation and coordination with the DOH BIHC, HPDPB, ADB Investment Loan PMU, Program Director and PHIC were conducted. Presentation of TA4647 was done with SMCT cluster and TCG for the FS study and the capacity building design. Other coordinating and networking activities were as follows:

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Coordination and networking with InDevelop Sweden office for administrative management.

Consultative meetings with ADB conducted to discuss status and issues with the TA team

Coordination with the HPDPB for the technical concerns and BIHC for project

management concerns were undertaken

Consultation with the concerned program office in the DOH and PHIC were conducted

Coordination and consultation with the Local Government Units in the

provinces of Ilocos Norte, Ifugao and Mindoro Oriental were undertaken

Coordination and updating with other Foreign Assisted Projects conducted support to HSRA by EC, USAID Policy and Health Gov, GTZ, and JICA

Regular meetings and coordination with the TA team and with the FS team

were conducted.

G.1. Hiring of the new TA 4647 Team

From June to July 2006, one major tasks of InDevelop was to hire the new TA 4647 team. The Health Administration Specialist / DTL hired in June 2006 facilitated the hiring of the new TA team in close coordination with the Department of health through the SMCO cluster. The Hospital Financial Management Systems Specialist, Public Health Specialist, District Health Planning and Management Specialist, and the Human Resource Management Specialist were on board in August 2006 and the PH Clinical Practice Guidelines Specialist and the Monitoring and Evaluation were on board in September 2006. Approval of the Health Care Finance Specialists, Drug Management and Financial Specialist and Communication and Marketing Specialist was in March 2007. The delay in hiring and the deferment of work of the Hospital Financial Management Systems Specialist, Public Health Specialist, District Health Planning and Management Specialist, and the Human Resource Management was due to contracting issues. The issue was resolved in February 2007 when the Management Director and the Deputy of InDevelop came to the Philippines. The CPG specialist continue to work despite of the contracting issue while the M and E specialist worked for one month to do the initial work for the M and E and latter consultancy was transfer to WHO from ADB using the same TOR to continue the M and E.

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G.2 Assisting the Department of Health in the Finalization of the revised TOR With the FourMula ONE for health (F1) launched in 2005, the TA 4647-PHI support needs to realign its undertaking to support the attainment of the F1 goals. It has been agreed among partners to call upon new set of specialists with revised Terms of Reference. Key policies needed in FourMula ONE have been formulated with the assistance of ADB TA team 4647. The succeeding work of the current TA is now being aligned towards capacity building for the health sector, to ensure success in the implementation of policies developed and continuing support to the compliance of the Program loan. Capacity building activities will involve policy dissemination and advocacy, training, preparation of DOH technical assistance packages to the health sector, monitoring and evaluation, and designing of incentives for performance. Discussion and agreements on the formulation of the revised and new TOR was undertaken in close coordination with the Department of Health through the Health Policy Development Planning Bureau (HPDPB) and Bureau of International Health Cooperation (BIHC) and with the program directors and technical staff. Coordination with the program directors by the respective TA consultants was undertaken as follows: the Hospital Financial Management Systems Specialist with the National Center for Health Facility Development, Public Health Specialist with the National Center for Disease Prevention and Control, District Health Planning and Management Specialist with the Bureau of Local Health Development, Human Resource Management Specialist with Health Human Recourse Development Bureau, the DTL on Health Care Financing Specialist with the HPDPB and Drug Management and Financial Management with the PMU 50. There were additional tasks that were identified to undertake the revised TA to support the CB design in the areas of monitoring and evaluation, dissemination of policies and the need to do CPG baseline study, hence the additional TA for PH Clinical Practice Guidelines, Monitoring and Evaluation and the Communication and Marketing. Consultations with the PhilHealth, HPDPB were undertaken in the finalization of the TOR for the Domestic Consultants. G.3 Preparation of the Inception Report With the new Terms of Reference formulated and required by the DOH, an inception report of the new TA was done and submitted to the Department of Health. The current TA is now being aligned towards capacity building for the health sector to include activities on policy dissemination and advocacy, training, preparation of DOH technical assistance packages to the health sector, monitoring and evaluation, and designing of incentives for performance. In consultation with directors by the TA team and then group consultation with DOH, the Inception report was finalized. An Inception Workshop was conducted by the Incoming Technical Assistance Team ADB TA 4647 to discuss the major milestones undertaken in the previous months and to map out the TA work plan and major benchmarks, deliverables and timelines with their corresponding organic partner bureaus and offices within the Department of Health and PhilHealth. This took place last August 29, 2006. This was participated in by the members of the new ADB TA Team led by Deputy Team Leader and Health Administration Specialist, and several representatives and personnel of the

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Department of Health and PhilHealth. The objectives of the workshop were to discuss the Technical Assistance priorities and create consensus on the past and present status of the TA 4647-PHI Support to the Health Sector Development Program (HSDP) to include Initial and Incoming TA; to present and discuss the work plan from August 2006-March 2007 and create consensus on how to implement the current priorities of DOH and ADB for the TA in light of recent policy developments and the FourMula One for Health; and to determine the project implementation arrangement and achieve agreement on timeliness for the implementation of the project including reporting schedules to DOH and ADB and the conduct of field visits (Attachment 7: TA 4647 Inception Report) H. Other TA support activities H.1 Health Financing Reforms The TA coordinated with PhilHealth and facilitated submission of the documents to comply with the Policy Matrix conditionalities namely:

PhilHealth Board to approve a new premium policy allowing progressive premium structure;

PhilHealth Board approves a progressive premium contribution scheme based on individuals’ capacity to pay for poor households under the poverty line but ineligible for Sponsored Program;

Based on detailed cost database and analysis, PhilHealth Board approved a

revised benefit package;

PhilHealth publishes a performance report on the status of the utilization of the 10 CPGs for quality assurance;

PhilHealth submits a Board-approved Medium Term Plans (MTPs) for 2005-

2012 including actuarial forecast on revenues and payments; and

PhilHealth and organized groups in informal sector develop MOA in all HSDP provinces to implement POGI.

H.2 Service Delivery H.2.1.Hospital Reforms The new TA team continued the work to provide technical support in complying on the following conditionalities of the policy matrix:

DOH designed a UMIS for pilot testing and enters into a MOA with selected hospitals for test

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DOH issued an AO to adopt performance-based allocation of (national) subsidies for 2006

DOH issued AO to state a policy on rationalizing local public hospitals based

on need H.2.2. Public Health Reforms

The new TA team provided technical support in the finalization of the AO on Performance Based Budgeting for Public Health to comply Policy matrix conditionality such as:

DOH developed a framework to establish long term performance-based budgeting for priority public health programs.

H.3 Good Governance

H.3.1. Local Health Systems Reforms The new TA team assisted the DOH in compliance for the following Policy matrix conditionalities namely:

At least three ILHZ business plans in project provinces were developed for 2006

DOH issues an AO to approve incentive schemes supporting sustainable operations of ILHZ

The Deputy Team Leader assisted in the ADB Mission to the Philippines to assess the status of the Program Loan in October 2006. The mission aimed to identify the status of the compliance of the program loan and latter use as basis for the release of the last tranche of the Program Loan to the Government of the Philippines. The DTL provided technical support on the preparation of the technical paper for the mission and facilitated retrieval of necessary documents for the compliance of the policy matrix. Currently the TA is assisting the DOH in the evaluation of the Policies that were formulated during the Program Loan. Moreover, evaluation in areas of status of the policy implementation, defining the gaps and identifying models for operationalization at the local levels were also undertaken. Also, Policy Implementation and Tracking system is being formulated to determine the extent of utilization.

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I. The following the technical reports have been submitted by the Technical Consultants:

o Amelia Torrente Training Package o Marcia Miranda Advocacy and Policy Dissemination Package o Eddie Dorotan Inter-Local Health Zones and

Consumer Participation o Melchor Lucas Performance Based Budgeting for Hospitals and

Optimisation of Health Facilities o Noel Espallardo Clinical Practice Guidelines and

Continuous Quality Improvement o Isidro Sia Drug Management and Pricing o Moises Serdoncillo Performance Based Budgeting for Public Health o Hilton Lam Health Business Plans o Leni Magalit Monitoring and Evaluation

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V. RECOMMENDATIONS

A. Policy dissemination and Advocacy

A detailed Policy dissemination and Advocacy plan needs to be developed by the province to include the subsequent campaigns that should be implemented to launch the Basic 7 reforms. The social marketing strategy should work closely with technical health professionals to identify the Entry reforms or launch reforms which are those reforms that will be advocated for first, based on their capacity to succeed and show how reform works in a province. Advocacy and dissemination campaigns to gain the support of local chief executives should be immediately implemented. The launch campaign needs to be executed over 3 to 9 months, continuing past the point when the ADB loan is received by the province. There needs to be a provincial focal point focused on social marketing and advocacy that is part of the technical working group organized by the province to over see the management of the health policy reforms. Provincial and municipal health information officers and HEPOs need to be skilled and trained in advocacy and social marketing for health policy reform, to include understanding the different administrative orders that are part of the Basic 7 reforms, skills in writing ordinances, public speaking skills for presenting the evidence behind the reform and positively convince mayors and developing a detailed social marketing plan. Once the LGU passage of the Basic 7 policy issuances had been achieved, it is suggested that the campaign would need to shift into another campaign strategy to market how to implement the new processes outlined in the reforms. There is also a need to customize the messages to the unique profile of the LGU and highlight what the LGU should do as mandated in AOs and other general policy directives. For a successful campaign, several channels should be used to reach the target audience namely:

•Local Tri-media for publicity & information features •Promotions & Publicity

•Small Group Presentations

•Personal Advocacy with Local Chief Executives & Local Health Opinion Leaders

•Publicity & local media coverage of training, reports

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B. Training package The Training package for Localizing F1 should be institutionalized as the third must have F1 course that shall complement the first two Strategy Driven Intervention (SDI) courses, namely: (i) Flagship Course for Health Sector Reforms and (ii) Health System Reform Introductory Course. Beginning quarter 4 of 2007 and continuing in 2008, the third F1 course, DOH it na: Localizing F1 Health Reforms, should be conducted first to the three ADB sites, next to the other 16 F1 sites and eventually to the 19 roll-out sites; For 2009, the F1 localization course shall be synchronized with the schedule of the first two SDI courses on F1. A detailed action plan should be prepared for cascading the Strategy Driven Interventions to LGUs to ensure that Local Government Executives and their technical assistants are properly initiated into F1 for Health and become advocates themselves for health reforms. Indigenous People (IP) should be included in implementing health reform policies by extending the Localizing F1 training program to the members of tribal organizations (e.g. Representatives from IP groups in Oriental Mindoro were active participants in the pilot run).

C. Consumer participation

Cities and municipalities should be encouraged to legislate ordinances or resolutions institutionalizing Consumer Participation strategies and mechanisms in all facilities in their localities. Sample ordinances and resolutions should be developed. The organization, training and mobilization of independent consumer groups at the local level should be encouraged. The mass media ( tv, radio, newspapers) could be tapped in raising consumer awareness, feedback and monitoring. D. Interlocal Health Cooperation Provinces should be encouraged to provide Incentives (recognition, cash, technical assistance, etc) to exemplary interlocal health zones in their localities Tap the provincial chapters of the Leagues of Municipalities (LMP) in organizing, strengthening, sustaining and providing incentives to interlocal health zones and formations

E. Optimization of Health Care Facilities A team of consultants should assist in the implementation of the Optimization of Health Care Facilities. It would require a hospital expert, a public health expert and a finance expert to cover the full extent of the Optimization plan. It is also recommended that the DOH impose on the LGUs the use of the Optimization plan as basis for fund support and licensing requirements. A technical assistance schedule will be needed to roll out optimization in the 16 priority areas. The training may be conducted in three clusters and the LGUs given take home assignments to write the first draft of the optimization plan. The team of consultants will then follow-up each province on-site to review and finalize the draft plan. This will be presented to the local chief executive for their comments or approval. Once done the final draft will be submitted to the DOH.

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F. Performance Based Budget for Hospitals (PBB-Hospitals) Since the hospital MOOE budget is still insufficient to meet current levels of operations and a further decrease through a Performance Based Budget for Hospitals (PBB-Hospitals) scheme may further reduce the ability of the hospitals to procure basic requirements, it is recommended that in the initial implementation, a separate budget line item be created which will be subject to the Performance Based Budgeting. This type of arrangement can be done in the next five year while PhilHealth is gradually reaching its goal for universal coverage. Once this goal is reached by PhilHealth, then a proportion of the government budget may be placed under the PBB process.

It is also recommended that the DOH seriously negotiate with DBM to exclude personnel benefits (such as hazard pay and Magna Carta benefits) under the MOOE budget category. The hospitals can only provide these benefits if there are savings from the operations. The hospitals drastically economize their operations so that they can generate savings at the end of the year. This will unduly compromise the care of the patients. It is recommended that they include benefits under Personnel Salaries category. In this way, hospital employee’s benefits will not be dependent upon the hospital’s ability to generate savings from their MOOE. G. Performance Based Budgeting for Public Health The implementation of Performance Based Budgeting for Public Health in the DOH should be preceded by the introduction of performance/results based management training for the senior technical staff (the least). The foundation of performance budgeting is on strategic planning and it would be easier to quantify/qualify performance benchmarks (indicators) if DOH technical will be oriented/trained on this thematic area as part of strategic leadership and management training. Evaluation processes should be developed as part of the M&E system so that performance can be measured at different levels, and evaluation finding disseminated to target users for appropriate actions. In the establishment of PBB-PH, performance and management audit processes should be described and incorporated in subsequent issuances. A training schedule on the PBB guidelines for Finance Office, NCHFD, FICO, CHDs need to be formulated and another schedule for training to disseminate these guidelines to the hospitals. This needs to be done before the next budget cycle so that the scores can be used as the basis for fund allocations. Regarding the HSDP sites, the indicators in the guidelines of the PBB can be used for the monitoring and evaluation of LGU hospitals. The local chief executive and the Provincial Board may use this as basis for their fund allocation.

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H. Philippine National Drug Formulary System and the Essential Drug Price Monitoring System

The Department of Health should facilitate the immediate establishment of the Philippine National Drug Formulary System and the Essential Drug Price Monitoring System. From these 2 systems, the DOH could make available the tools (e.g., formulary, price reference index, etc.) that would guide the local governments in their action to improve access to medicines and in their rational use. System should be in place to assure the active role of local governments in the preparation of the drug list. The guidelines and formulary should be made available electronically, but also in print for those who have no Internet access. The NDP-PMU 50 should be strengthened to be able to systematize and institutionalize the collection (and adoption or development) of prototype interventions and tools to improve drug management (drug selection, procurement, distribution, use) for the different levels of health care delivery by the local governments. These will include training materials and other educational and managerial tools that the stakeholders at the local government urgently need. On drug selection, training modules and operating manuals, as well as the clinical practice guidelines, essential drug list and formulary manual should be provided the local governments for the use of the hospital therapeutics committees. On drug procurement and logistics management, training modules and operating manuals should be updated to reflect the best practices and lessons learned by many loyal goÿÿrnments including those Capiz and Pangasinan On rational drug use, prototype Training modules, technical guidebooks, and IEC packages should be updated. There are many identified stakeholders even at the central government level. One office (and thus its head) should be identified as the orchestrator. The Bureau of Food and Drugs (BFAD) should provide the local governments with list of accredited drug suppliers so the local chief executives would be assured that they are buying quality products. The BFAD shall also be the main stakeholder in the collection of data for the drug price reference index, which should be regularly provided the local governments. The Department of Health, through the Centers for Health and Development, should complement its active provision of guidance and technical materials with an equally active monitoring and giving of due rewards for good performance of the local governments. Local governments should adopt the public health and clinical practice guidelines, essential drug list, and formulary manual produced by the PNDFS in the selection, procurement, and use of drugs. the Operating manuals for the hospital therapeutics committee, for the rural health unit, the botika ng barangay operators should be reproduced or adopted by the local government. Culture-sensitive IEC materials on rational use of drugs and herbal medicines should be produced for different population groups, eg, rural poor, indigenous peoples

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I. Clinical Practice Guidelines Promoting the adoption of Clinical Practice Guidelines recommendations through policy development and implementation may be an effective strategy. A comprehensive framework of research dissemination and utilization that is useful for both health policy and clinical decision-making has been proposed in several reviews. One framework illustrates that the process of the adoption of research evidence into health-care decision-making is influenced by a variety of characteristics related to the individual, organization, environment and innovation. Converting CPG recommendations into policy for implementation is also associated with problems. More often, there are so many policies that health care providers appear bewildered by the number and status of policy items. Processes need to be developed that will engage health care providers identify key policies and promote their implementation. Guideline implementation may require more sustained efforts with multiple strategies, which are reinforced at higher policy levels. In social health insurance programs policies for contracting services is a potential area for CPG implementation. In UK, most NHS Trusts were unable to use contracting and commissioning to improve clinically effectiveness despite their awareness of the policy. Contracting or commissioning is a process of establishing agreements with health care providers. To maximize the contracting process, these agreements can be modified to include conditions on the exact process of care. Reasons identified included the problem of agreeing complex commissioning arrangements to reflect clinical issues, and an unwillingness to use contracting to challenge hospital practice. It is therefore recommended that PHIC should take steps to include CPG implementation as part of the contracting process with health care providers. This can be initially done by linking CPG implementation to the accreditation process of PHIC. Since awareness to the CPG is the first step in the provision of quality care, PHIC must also take steps to educate its accredited health care providers on CPG and quality care and provide appropriate information to them. PHIC must also emphasize that CPG implementation is not a politically driven policy. Strengthening local health systems and improving the delivery of effective interventions is the main objective. To ensure the achievement of this objective, a continuous and sustainable effort of CPG dissemination, implementation, monitoring and evaluation must be done by linking CPG with PHIC Bench book implementation. J. Business Plans for Health

Business Plans for Health as a concept seems to be already well accepted, as evidenced in the very high pre-test scores on the acceptability of Business Planning to generate income for public health activities. Therefore, HSPD should encourage (either through persuasion, providing assistance (technical, financial, or others) capacity building in the form of a training of trainers and a roll out of the training, culminating in series of local government workshops so that the respective health-related local government units can fine-tune and present their outputs to their

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Business Plans to their Local Chief Executives. The modules, while, highly accepted, is still not firmly supported by any specific AO. Therefore, an AO specific on Business Planning for Public Health is recommended. This AO may include references as to what form of Business Enterprises for Public Health the recipients are allowed to take on or create, and may introduce a paradigm shift wherein non-clinicians can be welcome as equals to clinicians in the field of public health, as non-clinicians are envisioned to be the workhorse and champions of business planning for public health.

K. Other recommendations

Further, another AO on Ethics is recommended, as this AO on Ethics can be used to provide guidance to the recipients as they are encouraged to: use public health resources for purposes other than service delivery; and on handling the expected new revenues as a form of public trust. The TL Provided advice on the SWAP process, including a Draft Code of Conduct (COC) based on the Kenya experiences has been provided. The TL has suggested that this COC be adopted to reflect the Philippine context and since the Kenya version has already been approved by the head quarters of major donors also present in the Philippines, it would provide a good base line for discussions.

Prepared by: BERNT ANDERSSON MARIA OFELIA O. ALCANTARA Team Leader Deputy Team Leader

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Attachments

Attachment 1. REVISED TERMS OF REFERENCE FOR ADB TA 4647 as of August 10, 2007

Technical Assistance to the Republic of Philippines for the Health Sector Development

Program

The Philippines has made steady progress in improving its health status in spite of the fact that economic growth has been modest by regional standards and population growth has been high. Poverty, headcounts and economic inequality remain high in the country, and are major determinants of unequal health outcomes. Access to health services is inequitable, because of financial barriers to care for the poor and unequal distribution of health care capacity. In 1999, the Department of Health (DOH) launched the Health Sector Reform Agenda (HSRA) bordering on Hospital, Public Health, Local Health Systems, Health Finance and Health Regulation.

The Government of the Republic of the Philippines has partnered with the Asian Development Bank (ADB) and requested support for the implementation of the Health Sector Reform Agenda. A Technical Assistance (TA) Grant support was provided to provide support for the Policy Loan, the Investment Loan and other start up activities for the Health Sector Development Project. This TA was designed to provide support for HSRA launched in 1999, and being implemented since 2005 under the banner FOURmula ONE for Health. The latter is designed to undertake critical reforms with speed, precision and effective coordination directed at improving the efficiency, effectiveness and equity of the Philippine health system in a manner that is felt and appreciated by Filipinos, especially the poor. FOURmula ONE for Health is directed at achieving the following end goals of better health outcomes more responsive health system and equitable health care financing. The FOURmula ONE for Health pursues critical reforms for more, better and sustained financing, assuring quality and affordability through regulation and ensuring access and availability in service delivery and improving performance and governance.

The reforms will contribute to the national goals of (i) increased financial protection for the poor from the costs of poor health, and (ii) improved public health outcomes, and (iii) increased responsiveness of the health system, especially in

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relation to conditions, diseases and services that are critical for the achievement of the health-related Millennium Development Goals.

Key policies needed in FOURmula ONE have been formulated with the

assistance of ADB TA team 4647 as a result of the work to comply with the conditions of the Policy Matrix for the policy loan.

It has been agreed in discussions between the DOH, ADB and the TA team that

the continued TA could be better targeted to the current situation in mid-term implementation of the TA by slight revisions of the original TOR. This version of the TOR represents the joint effort to revise the TOR for the period from August 1, 2006 to the end of the TA 4647, which is now scheduled to be the end of August 2007. As a consequence of preceding events in the TA implementation and the rescheduling of the overall time frame, the ADB and the contractor for the TA services, InDevelop Uppsala AB (InDevelop), are going to have discussions to identify and agree on the necessary contract variations. Such revisions will have to include new time frames and new reporting schedules, as well as specific conditions for fund release from ADB to the contractor. The revisions will also definitely settle the time frames for each individual consultant mentioned in these TOR, except for consultants hired directly by ADB outside the scope of the contract between ADB and InDevelop, whose TORs have not been revised.

The succeeding work of the TA is now being aligned towards capacity building

for the health sector, to ensure success in the implementation of the developed policies as well as to support the local implementation of policies and the investment loan. Capacity building activities will involve policy dissemination and advocacy, training, preparation of DOH technical assistance packages to the health sector, monitoring and evaluation, and designing of incentives for performance.

A team of international and domestic consultants are implementing the TA. The

team has been recruited through an international consulting firm, InDevelop as well as directly by ADB, and includes international experts in health sector reform (team leader), health systems (ADB recruited) and social health insurance (ADB recruited), as well as eleven domestic experts in health administration (deputy team leader): district health planning and management, hospital financial management system, health care finance, public health, PH clinical practice guidelines, drug management

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and financing, human resource management, monitoring and evaluation, communication and marketing and project administration management. The TA team will work in close cooperation with the Department of Health (DOH), director of the Health Policy Development and Planning Bureau, and Bureau of international Health Cooperation and will receive technical guidance from the project team leader of the Asian Development Bank (ADB)-supported Health Sector Development Program (HSDP). The overall deliverables of the TA are the (i) preparation of Health Sector Reform Agenda (HSRA) national implementation plans, particularly capacity building for the key reform policies of Fourmula One for Health and (ii) preparation for implementing reforms at the local HSDP project sites.

An inception workshop held with the DOH and PHIC in August 2006 shall be the basis of TA implementation with revisions from input of DOH and PHIC during the presentation of the progress report in April 13, 2007. Progress reports are proposed to be delivered in April 2007 and May 2007, but the final reporting schedule will be agreed in the contract variations, as mentioned above. The draft final report of the TA will be made available in July 2007, 1 month before the end of project workshop will be conducted. The draft final report will be revised based on comments submitted by ADB and the Government. The final report will provide a comprehensive document that includes recommendations and plans developed by the individual consultants in line with the deliverables specified in their respective TOR. Such deliverables are not considered as deliverables of the contractor to ADB, but only as deliverables of the TA team to meet the needs of DOH. The deliverables to ADB are the March progress report the April Mid Term report and the final report. Each consultant is responsible for producing a final technical report based on the individual terms of reference. The team leader will be accountable for the technical quality of all the reports and timely delivery of the reports to the client.

The TA team will work closely with the DOH, Philippines Health Insurance Corporation (PhilHealth), LGUs, and related agencies and stakeholders. All consultants will work in close collaboration with ADB, and other development partners supporting the Fourmula One for Health (F1) such as the European Commission, German Technical Cooperation, KFW, World Bank, World Health Organization, and others.

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A. Consulting Firm 1. International Consultant Health Sector Reform Specialist (team leader) (5 person-months intermittently from August 2006 to end of August 2007, in the Philippines and at home office). The specialist should have at least 10–plus years of international experience in forwarding health sector and health systems reform in many countries. The consultant will help technically conceptualize and guide the HSRA reform activities under F1, and help accelerate F1 reforms through the HSDP, including the program loan, the investment loan, and the TA. The consultant will have an intermittent contract from inception to the end of the TA, and will have the following roles: (i) oversee and direct the technical work conducted by the TA team; and review all the technical reports ensuring their quality and acceptability before submission to the client; (ii) review, propose, and strengthen reforms under F1. The consultant will (i) provide the technical lead, and will conduct technical discussions with various entities, such as DOH, PhilHealth, Department of Finance, LGUs, and special-purpose entities (SPE1) to monitor the progress of the TA and ensure coherence with medium term plans and F1; (ii) work closely with the team and conduct technical dialogue and activities; review reports of the TA consultants and guide their technical work, assess risks, constraints and bottlenecks, and help resolve these problems; and (iii) liaise with and provide guidance to the deputy team leader; (iv) the consultant will review the current policy and background strategy papers prepared by DOH for F1, and make recommendations on the current needs in the country, particularly needed reforms of the health care financing policies, including implementation and monitoring of reforms (vi)The consultant will participate in the design the performance assessment systems for the donors supporting F1 to be consistent with the F1 Monitoring and Evaluation System; (vii) the consultant will participate in the ADB review missions for the HSDP in the event that such missions take place during the presence of the Team Leader in the Philippines. 2. International Health Systems Specialist [ADB recruitment] (6 person- months). The specialist should have at least 10 years of multi-country international experience in health systems development. The consultant shall formulate a Technical Reference Manual for Rationalizing Health Service Delivery Systems based on needs to achieve efficient, quality and appropriate health care. The technical reference manual shall include procedures, standards and protocols for relevant components, elements and strategies which may be helpful for health systems that seek to rationalize health

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service delivery and define mechanism to operationalize the system. The consultant will (i) help central and local governments see the benefit of a rationalized health service delivery system, and (ii) help develop the health service delivery system rationalization strategy and implementation plan under HSRA, especially proposals for each of the HSDP provinces. The consultant will work closely with DOH (bureaus of health policy development and planning, facilities and services, local health development, and Health Program Development) and PhilHealth. 3. Social Health Insurance Specialist [ADB recruitment] (6 person-months). The consultant must have multi-country experience. He/she will (i) propose an improved benefits package for beneficiaries under PhilHealth, especially the indigents and those in the informal sector (generally, an enhanced package of primary care benefits has to be developed under PhilHealth); (ii) assist in developing actuarial forecasts on revenues and payments, and recommend a progressive premium; (iii) assess the beneficiaries’ needs to propose the inclusion of services in the benefits package, and determine the feasibility of implementing the benefits package and its corresponding premium implications; (iv) verify the impact of the package on the beneficiaries; (v) assess and propose improved contractual arrangements (including public and private sectors); (vi) develop a performance monitoring system for the sponsored group; and (vii) document best practices for possible replication in other provinces. The domestic consultant on health finance will work closely with the consultant. B. Domestic Consultants 1. Health Administration Specialist (deputy team leader) (Intermittent from June 2006- August 2007 for 11 person-months). The specialist must be a master’s degree holder in public health or health services administration or any related field, with at least 10 years of relevant experience in program development and implementation in the health sector. The consultant should be well versed in the Philippines health care system. The consultant will have two roles: (i) coordination of TA activities and supervision of administrative staff hired by the contractor to support the TA team, and (ii) technical. In the coordinative role, the consultant will (i) manage the day to day operations of the TA and ensure timeliness and integration of all activities and outputs; (ii) liaise with central, provincial, and local governments, private sector, non-government organizations, and the community, and other key technical persons in the country; (iii) assess needs to coordinate, help in planning and monitoring the progress

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of needs and assignments; (iv) guide the other TA consultants on key issues and on key persons to meet, sources of information; and (v) assist the TA consultants in meeting the objectives of the TA; (vi) guide and supervise the administrative support staff of the TA. In the technical role, the consultant will (i) integrate the capacity building activities of all the consultants in an F1 framework; (iii) assist in the project performance, and strengthening implementation; and (iv) monitor the progress of the HSDP investment loan, and address any bottlenecks and constraints. (v)The consultant will design a performance assessment system for the centers for health development of the DOH. The consultant will complete all the technical outputs with guidance of the international consultant on health sector reform and will report to the Team Leader for all operations during the period of the TA. Before submitting deliverables to clients, they should be submitted to the Team Leader for review. 2. Hospital Financial Management Systems Specialist (Intermittent from August 2006 to August 2007 for 5 person-months). The consultant should be a master’s degree holder in hospital administration and financial management with at least 10 years of relevant work experience in hospital financial management development and implementation.

• The consultant will work with DOH and selected hospitals in the LGUs to provide recommendations on the pilot-testing of the UMIS to strengthen financial management in the hospital operations and management information systems;

• Develop a strategy for transition to effective hospital autonomy for HSDP sites, including advocacy plan and tools;

• The consultant will review and enhance the Administrative Orders on the Performance Based Budgeting (PBB) for Hospital and Rationalization of Health Facilities developed under the Program Loan;

• He/she will design capability building activities for the operationalization of key policies in Fourmula One including the Administrative Orders on the PBB for Hospital and Rationalization of HFs. The capacity building shall include the following: policy dissemination and advocacy design, training design and training module including its technical content, TA package design and indicators, targets and tools as inputs to the F1 Monitoring and Evaluation system and designing of incentives for performance; and

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• Consultant shall input to the rationalization of Health Facilities especially its localization in cooperation with the International Health System Specialist.

The consultant will complete all the technical outputs with guidance of the international consultant on health sector reform and will report to the Deputy Team Leader for all operations during the period of the TA. Before submitting deliverables to clients, they should be submitted to the Team Leader for review. 3. Public Health (PH) Specialists (PH Clinical Practice Guidelines [CPG] Specialist = Intermittent from September 2006 to August 2007 for 5 person-months and 4. Public Health Specialist = Intermittent from August 2006 to August 2007 for 3 person-months). The PH CPG Specialist must have expertise in clinical epidemiology. Knowledge and experience in interrupted time series studies and CPG development and implementation will be preferred. The consultant must have a good track record in its previous undertakings in the last three (3) years with the government and/or private institutions of good reputation and should also be knowledgeable about PhilHealth policies related to CPGs. The PH CPG Specialist will conduct the baseline study for CPG utilization including the following: (i) determine the demographic profile of PhilHealth accredited physicians; (ii) determine the awareness of PhilHealth accredited physicians regarding any CPGs developed by medical societies; (iii) determine the knowledge of PhilHealth accredited physicians regarding the recommendations on the diagnosis and treatment of certain diseases based on guidelines that have been disseminated by PhilHealth; (iv) determine the general attitude of PhilHealth accredited physicians towards clinical practice guidelines developed by medical specialty societies; and (v) provide input to the capacity building design in localizing policies . The capacity building shall include the following: policy dissemination and advocacy design, training design and training module including its technical content, TA package design and indicators, targets and tools as inputs to the F1 Monitoring and Evaluation system and designing of incentives for performance. The gathering of data in private and public hospitals for the CPG baseline study shall be done in Manila, Ilocos Norte and Oriental Mindoro. The consultant shall provide policy recommendations and strategies for implementation and incorporate CPG’s into the PHIC Benchbook implementation.

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The consultant will complete all the technical outputs under the guidance of the international consultant on health sector reform and will report to the Deputy Team Leader for all operations during the period of the TA. The Public Health Specialist must be a Masters Degree holder in Public Health with at least 10 years of work experience in public health and health systems and has experience working with the Department of Health and the Local Government Units. The Public Health Specialist will provide input and recommendations on the capacity building design for the AO on PBB for Public Health. The capacity building shall include the following: policy dissemination and advocacy design, training design and training module including its technical content, TA package design and indicators, targets and tools as inputs to the F1 Monitoring and Evaluation system and designing of incentives for performance; and provide technical assistance in the piloting of the capacity building design. The consultant will complete all the technical outputs with guidance of the international consultant on health sector reform and will report to the Deputy Team Leader for all operations during the period of the TA. Before submitting deliverables to clients, they should be submitted to the Team Leader for review. 5. District Health Planning and Management Specialist (Intermittent from August 2006 to August 2007 for 6 person-months). The specialist must have a master’s degree in health administration, proficiency in decentralized planning and administration, and at least 10 years of relevant work experience in decentralized planning and implementation. The consultant will

• Design capability building activities for the operationalization of key policies in Fourmula One including the Administrative Orders on the framework for Incentive Schemes supporting sustainable operations of ILHZs and Mandating the Consumer Participation strategies for F1 and measuring its effectiveness. The capacity building shall include the following: policy dissemination and advocacy design, training design and training module including its technical content, TA package design and indicators, targets and tools as inputs to the F1 Monitoring and Evaluation system and designing of incentives for performance and provide technical assistance in the piloting of the capacity building design.

The consultant will complete all the technical outputs with guidance of the international

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consultant on health sector reform and will report to the Deputy Team Leader for all operations during the period of the TA. Before submitting deliverables to clients, they should be submitted to the Team Leader for review.

6. Health Care Finance Specialists (National and Local Health Care Finance Specialist= Intermittent from March 2007 to August 2007 for 3 person-months. The Health Care Finance Specialist must have a Master’s degree in health economics or any related field and at least 5 years of relevant work experience in health financing. The consultant will

• review the provincial investment plan for health and other related documents and utilize this as reference in the development of the provincial business plan;

• conduct consultations with the LGUs and key officials at the DOH CO and CHDs in the formulation of the ILHZ business plans, and

• assist the local governments in preparing business plans to support the attainment of functional ILHZs and rationalization of local health care delivery systems in the HSDP project sites by

The consultant will complete all the technical outputs with guidance of the international consultant on health sector reform and will report to the Deputy Team Leader for all operations during the period of the TA. Before submitting deliverables to clients, they should be submitted to the Team Leader for review. 7. Human Resource Management Specialist (Intermittent August 2006- August 2007 for 5 person-months). The consultant should have a master’s degree in organizational behavior in business administration and at least 10 years of relevant work experience in health human resources rationalization and career development strategies. The consultant will work with the Department of Health, PhilHealth and Local Government Units in the HSDP sites. The consultant will

• validate Learning and Development (L&D) needs of LGUs and DOH, • formulate Retooling and Retraining (R&R)/(L&D)/Capability Building (CB) Plans

contained in the Provincial Investment Plans for Health (PIPHs) to include: L&D strategies, L&D policies, L&D packages and course designs, L&D implementers, L&D participants and L&D Investment requirements at the provincial level, and

• develop the training design including the templates, tools, methodology, and

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guidelines for the Training activities on capacity enhancements of implementing key policies of F1;

• Consolidate the inputs and recommendations of the training component of the capacity building design and facilitate the its pilot testing in the ADB sites.

The consultant will complete all the technical outputs with guidance of the international consultant on health sector reform and will report to the Deputy Team Leader for all operations during the period of the TA. Before submitting deliverables to clients, they should be submitted to the Team Leader for review. 8. Drug Management and Financial Specialist (Intermittent from February 2007 to August 2007 for 2 person-months). The consultant preferably will have a master’s degree in public health or health management or in any relevant field with at least 5 years of experience in the field of public health and drug management. The consultant will

• provide recommendations to streamline and improve the efficiency of procurement and propose alternative cost-effective management of procurement to improve affordability and improve logistics arrangements.

• will consolidate the existing drug management and financial policies and identify policies that need to be developed for an effective drug management and sustained financing.

• design capability building activities for the operationalization of key policies for efficient drug management in the HSDP sites. The capacity building shall include the following: policy dissemination and advocacy design, training design and training module including its technical content, TA package design and indicators, targets and tools as inputs to the F1 Monitoring and Evaluation system and designing of incentives for performance. AOs to be included in the capacity building design shall be AOs series 2006-0009 Guidelines Institutionalizing and Strengthening the Essential Drug Price Monitoring Systems (EDPMS) and 2006-0018 Implementing Guidelines for the Philippine National Drug Formulary Systems.

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The consultant will complete all the technical outputs with guidance of the international consultant on health sector reform and will report to the Deputy Team Leader for all operations during the period of the TA. Before submitting deliverables to clients, they should be submitted to the Team Leader for review.

9. Monitoring and Evaluation Specialist (Intermittent from September 2006 to August 2007 for 2 person-months) The consultant must be a master’s degree holder in health administration or relevant field and have working experience in monitoring and evaluation as well as a background in working with the DOH, PHIC and LGUs and other health sector reform stakeholders. The consultant will 1 person month:

• formulate the conceptual framework of the F1 Monitoring and Evaluation • Formulate a Performance Indicator Framework for Monitoring and Evaluating

F1 at the national and LGU sites; • identify sources of data, strategies and methods for gathering data on indicators

development; and • develop a conceptual framework for evaluation of effectiveness and impact of

F1 components, activities and interventions. These may include qualitative and quantitative indicator special studies, outside of those identified for routine collection. Evaluation design should also be defined, specifying sample parameters, quantitative and qualitative methods to be used;

1 person month: Support to Health Sector Development Project Investment Loan: Design an M and E framework and systems for the HSDP project in context of the F1 M and E for Equity and Effectiveness; Pre-test the HSDP M and E tool in the HSDP sites and conduct local consultations on the HSDP M and E design. The consultant will complete all the technical outputs with guidance of the report to the Deputy Team Leader for all operations during the period of the Consultancy. . And closely coordinate with BIHC and HSDP PMO.

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10. Communication and Marketing Specialist (Intermittent from February 2007 to August 2007 for 2 person-month). The consultant should have a Master's Degree in communication or relevant field, with working experience in communication and marketing, as well as a background in working with the DOH and LGUs and other health sector reform stakeholders. The consultant will

• consolidate and integrate the communication and advocacy requirements developed for key F1 policies and stakeholders;

• package the communication and marketing for the dissemination for the capacity building for Fourmula One for Health; and

• develop a communication plan for dissemination and advocacy including identifying the key messages, templates, communication channel and approach to communication and marketing.

• conduct consultations with the national and local level partners in coming up of the dissemination and advocacy package.

• participate and act as facilitator and resource person in the pilot run of the capacity building design for localizing F1 policies.

The consultant will complete all the technical outputs with guidance of the international consultant on health sector reform and will report to the Deputy Team Leader for all operations during the period of the TA. Before submitting deliverables to clients, they should be submitted to the Team Leader for review.

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Attachment 2: TA 4647 Team: International and Domestic InDevelop Uppsala AB

New TA 4647 Team

Consultant Position Name of Consultant International Consultant Health Sector Reform Specialist (team leader) Bernt Anderson

International Health Systems Specialist Jan Both

Social Health Insurance Specialist Ron Hendriks Health Administration Specialist/Deputy Team Leader

Maria Ofelia O. Alcantara Hospital Financial Management Systems Specialist

Melchor Lucas

PH CPG Specialist (PhilHealth) Noel Espallardo

PH Specialist (DOH) Moises Serdocillo District Health Planning and Management Specialist

Eddie Doroton Health Finance Management Specialists

Hilton Lam Human Resource Management Specialist

Amelia Torente Drug Management and Financial Specialist, LGU

Isidro Sia

Monitoring & Evaluation Specialist Lenny Magalit

Communication and Social Marketing Specialist Marcia Feria Miranda

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Attachment 3: Development Partner Scorecard - Report 1. Summery The Development Partner Report Card (DPRC) is being developed as an instrument for dialogue between DOH and development partners, primarily, in this first phase, with the bilateral donors and international organizations like the World Bank, Asian Development Bank and the UN organizations. The card can in a second phase bee adopted for the dialogue with other development partners. A process is suggested for further development of the Draft DPRC presented her, in dialogue with the development partners, including a workshop. The ambition from DOH could be to present a more elaborated DPRC and preliminary data for the JAPI meeting in November this year. 2. Background and Rationale for the Development Partner Report Card

The Philippines has progressed towards realizing its health goals in the past decades although the progress has slowed down during recent years. Vital health indices such as life expectancy, infant, child and maternal mortality rates have improved. Despite the inroads made the past decades a number of gaps remain to be filled, the common illnesses of poverty, such as infectious diseases, have not been reduced to acceptable levels. Social and economic changes have created new challenges in terms of degenerative and lifestyle diseases. Further, the organization of the health sector itself suffers from an inappropriate delivery system, inadequate regulatory mechanisms, and inappropriate health care financing schemes.

In 1999, DOH launched the Health Sector Reform Agenda (HSRA), which defines key reforms and strategies required to address inequity and inefficiency in the health sector, and achieve the millennium development goals. The goal of the HSRA was to improve the health status of all Filipinos through the implementation of reforms in five general areas: public health, hospitals, regulation, financing and local health systems. In 2005, the DOH defined FourMula One for Health (F1) as the implementing framework for the health sector reform. The F1 is designed to undertake critical reforms with speed, precision and effective coordination directed at improving the efficiency, effectiveness and equity of the Philippine health system in a manner that is

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felt and appreciated by Filipinos, especially the poor. FourMula ONE for Health is directed at achieving the end goals of better health outcomes, more responsive health system and equitable health care financing. The FourMula ONE for Health pursues critical reforms for a more, better and sustained financing, assuring quality and affordability through regulation and ensuring access and availability in service delivery and improving performance and governance. The reforms will contribute to the national goals of (i) increased financial protection for the poor from the costs of poor health, and (ii) improved public health outcomes, and (iii) increased responsiveness of the health system, especially in relation to conditions, diseases and services that are critical for the achievement of the health-related Millennium Development Goals.

The DOH recognizes that to achieve these goals there is a need to bring about synergy and coordination of support among the different stakeholders and partners towards a unified health sector policy. Hence, in the recent years, the DOH started a sector-wide approach (SWAp) to health sector reforms. The SWAp works towards reducing fragmentation of support of partners to incrÿÿse impact on heanih se aÿÿ development than when implemeÿÿÿÿ i schidually. SWAp also works at sustaining institutional development by using government systems and procedures instead of the usual project mode of creating parallel implementation structures. Moreover, SWAp reduces the transactions costs of the government in dealing individually with the donors and other partners particularly in the planning and review processes. The SWAp process has just started and setting arrangements to move it forward is called for. This should be guided by the Paris Declaration1 and its emphasis on ownership, harmonization, alignment, managing for results and mutual accountability. Furthermore, the process of internalizing and applying the principles of the Declaration will be gradual, even though all opportunities to make early progress should be used.

3. Framework The PIF is a hierarchy of indicators on outcomes desired and outputs required for the Filipino people. The principles guiding this hierarchy will be: impact on the poor; relevance to health outcome; and measurability. The PIF will guide major stakeholders in monitoring and evaluating the effectiveness and impact of F1 components, activities and interventions at both the national and LGU sites in attaining outputs and outcomes desired for the Filipino people, particularly for the poor. The 1 The ‘Paris Declaration on Aid Effectiveness’ has been formally adopted at the recent High Level Forum

Meeting in Paris (February/March 2005) and has been signed by all donors and developing countries.

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PIF can also be a tool to conveniently integrate or provide a coherent framework for efforts of all stakeholders in meeting F1 goals, as well as monitoring and evaluating such efforts.

There are three levels of indicators in the hierarchy: the Final Outcomes, the Intermediate Outcomes and the Major Final Outputs (MFOs). Indicators for inputs, process and structures, and lower level outputs shall be defined at a later phase, except for some such selected indicators deemed critical in F1 key interventions. Scorecards measure performance on outcomes or outputs valuable to the stakeholders’ clients and convey performance in a manner that clients and stakeholders can easily comprehend. Scorecards for major stakeholders will be done including (a) LGUs (b) DOH Centers for Health Development, (c) DOH Hospitals (d) DOH Central Office and (e) Donors.

The indicators in the scorecards are ideally subsets of the indicators in the PIF (final outcomes, intermediate outcomes, MFOs). The subset includes performance indicators which are within the direct mandate and accountability of the stakeholder, are valuable to clients and easily understood by them, and have substantial effect in attaining key F1 interventions, intermediate outcomes and final outcomes.

Scorecards will utilize color coding scheme to show level of performance that is easily understood by clients. Only three colors will be used to keep the scheme simple and easy to understand. A red color code reflects that there are substantial potential for improvement. A yellow color code shows presence of some weakness in performance that should be addressed to optimize performance. A green color code reflects performance that is up to par or exceeds standards.

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4. Specific goal and objective for Development Partner Report Card (DPRC)

based on the role of development partners Donors become stakeholders when they commit specific support to F1. Such support may be in the form of program assistance, site-specific assistance, F1 pillar assistance or agency-wide assistance. Donor assistance shall be assessed on the basis of health system final and intermediate outcomes it contributes to, and will be monitored on the basis of the F1 policy levers (major final output, inputs, structures, & processes) the assistance produces.

The DPRC measures the content and modalities of development partner support. The content of support should be aligned to and support F1, to the 4 pillars, and the Report card should measure to what degree the development partner supports the F1. The modalities of the development partner support should as much as possible follow the Paris agreement on harmonization and alignment and the report card should measure to what degree this is done. The Report card will thus measure the overall goals of the Sector Development Approach for Health (SDAH) of enhanced government leadership, improved sector policy and strategy focus, more effective use of aid to the health sector and lower transaction cost, and the SDAH specific objectives of establishing a common vision for health reform and development, setting priorities and improve the allocation of resources to achieve those priorities, improving the efficiency and accountability of resource use and rationalizing and improving the coordination of external assistance. It will be an instrument for the Government and Development Partners to move the SDAH forward. The card will be used by the development partners themselves and the government/DOH for measuring progress in harmonization and alignment of development partner support to the F1 and the SDAH. The card will be an instrumental for dialogue and will not be used to compare or rank development partners.

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Final Outcome of alignment to Government programs: In the OECD suggested targets for the Paris Declaration, the target for aid flows to be aligned to national priorities is to halve the proportion of aid flows not reported on Government budget with at least 85% reported on budget by 2010. This could apply also to the support to the health sector in the Philippines. Suggested Intermediate Outcome of alignment to Government programs: The target suggested for 2008 is that 70% of support to the health sector from an individual Development Partner is aligned to the four F1 components. Final Outcome of using SDAH modalities: The target for 2008 is suggested to be differentiated according to what is possible for each individual Development Partner and set in dialogue between DOH and the DP. The following Intermediate Outcomes are suggested to be measured for using SDAH modalities: • To facilitate government planning, donor support to the health sector is

characterized by long term commitment and predictability of resource flow. • Donors synchronize their planning and decision process with the Government

budget cycle and financial year. • Donor increasingly use Program Based Approach (PBA) for their suppoto.

Delinition is that PBAs are a way ofÿÿive usÿÿin developmeÿÿ cooperation based on the principles of co-ordinated support for a locally owned programme of development, such as a national development strategy, a sector programme, a thematic programme or a programme of a specific organisation.

• Timely disbursement of funds according to a schedule agreed with the Government.

• The donor adopt the use of Government systems to the extent possible. Where use of current Government systems is not feasible, the donor establish jointly with the Government, additional safeguards and measures in ways that strengthen rather than undermine country systems and procedures.

• Donors use the Government system for hiring of local experts/consultants. Fees and contract conditions are uniform.

• Donors ensure that programs they support are coordinated with the Department

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of Health, to enable DOH to have complete information of all donor support and to coordinate all donor suport.

• Donor review, monitoring, evaluation, and reporting processes are harmonized with procedures and process established for implementation of the HSRA and the F1 will facilitate the work of DOH.

• DP:s provide comprehensive relevant information to DOH regarding resources provided to support the health sector in the Philippines.

5. Scorcard indictors 5.1 Measuring contributions to F1 Contributions to F1 are defined in the document FOURmula ONE for Health, Strategic Plan of Action for Health Reforms under the Administration of Sec. Francisco T. Duque III. (Attachment 1 to the Guidelines, Annex 1). 5.2 Measuring commitment to SWAP Following the Paris High Level Forum on Aid Effectiveness the partnership of donors and partner countries hosted by the DAC was charged with establishing a methodology for measuring the 12 Indicators of Progress with a view to agreeing on targets for these indicators in time for the September 2005 meeting of the UN General Assembly (UNGA). The Baseline Report2 is annexed and contains the definition of indicators and methodology for measurement. These indicators are not designed to measure individual donor but rather the total aid flow to a country. Some of the indicators has been modified and are used in this Development Partner Report card. For the DPSC, the intermediate outcomes suggested above should be used and the indicators suggested for their measurement is presented in the Guidelines in Annex 1 and in the Attachments 2, 3 and 4 to the Guidelines.. 6. Dissemination Annually to be presented and discussed at JAPI meeting in September/October each year. Also presented and analyzed in the DOH Annual report. 2 Baselines and suggested targets for the 12 Indicators of Progress – Paris Declaration on Aid Effectiveness

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7. Responsibilities Process managed by BIHC. BIHC will designate a team of staff to collect the information, from the three levels of the health system, national (DOH), regional (CHD) and local levels (LGU). 8. Recommendations and next steps

- develop in a process with development partners - use a workshop for getting DP:s involved, for comments and for initial testing

and for agreement on the process - training of the team that will take responsibility for the assessment - develop an Administrative Order on the Development Partner Report Card

Guidelines for the Development Partner Report Score Card

1. Scorcard indictors

1.1 Measuring contributions to F1

Contributions to F1 are defined in the document FOURmula ONE for Health, Strategic Plan of Action for Health Reforms under the Administration of Sec. Francisco T. Duque III. (Attachment 1 to the Guidelines, Annex 1).

1.2 Measuring commitment to SWAP

Following the Paris High Level Forum on Aid Effectiveness the partnership of donors and partner countries hosted by the DAC was charged with establishing a methodology for measuring the 12 Indicators of Progress with a view to agreeing on targets for these indicators in time for the September 2005 meeting of the UN General Assembly (UNGA). The Baseline Report3 is annexed and contains the definition of indicators and methodology for measurement. These indicators are not designed to 3 Baselines and suggested targets for the 12 Indicators of Progress – Paris Declaration on Aid Effectiveness

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measure individual donor but rather the total aid flow to a country. Some of the indicators has been modified and are used in this Development Partner Report card. Indicator for planning phase • To facilitate government planning, donor support to the health sector should be

characterized by long term commitment and predictability of resource flow. The Paris Declaration on Aid Effectiveness Suggested Targets for 12 Indicators of Progress has as one of the indicators percent of aid disbursements released according to agreed schedules in annual or multi-year frameworks4. OECD collects data for this indicator from an analysis of IMF data, as re-ported in various Article IV and other reports, for 20 countries. The data collected reflected originally budgeted (by recipient countries) aid and actual aid disbursements received and reflected project, program, and budget support disbursements. An indicator that can be used and measured for individual donors in one country is presented below. The indicator for this that donors are committed to 3-5 years support. To assess this, the current agreement(s) between the donor and the Government should be consulted. If the donor agreement(s) is/are at least for 3 years with committed funds for at least 3 years, the score is green. If agreement(s) are at least for 2 years, with funds committed for at least 2 years, the score is yellow. With agreements for shorter periods, the score is red. • Donors should synchronize their planning and decision process with the

Government budget cycle and financial year.

The finacial year is equal to the calender year for the GOP. Agreements and fundings commitments should then be per calender year. The indicator for this is that donor support is committed and DOH informed latest Q1 for next financial/calender year. This is when the commitments should be known in order for the GOP to process that information into the GOP budget process. If the donor for the last 2 years have made firm commitments latest Q1, the score is green. If the commitment is only tentative and not supported by a decision by the donor, the score is yellow. If the donor only made firm commitments for one of the last 2 years, 4 Indicator 7, Aid is more predictable

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the score is also yellow. If the donor could not make firm commitments in time any of the last 2 years, the score is red. • Donor should increasingly use Program Based Approach (PBA) for their support.

Definition is that PBAs are a way of engaging in develop-ment cooperation based on the principles of co-ordinated support for a locally owned programme of development, such as a national development strategy, a sector programme, a thematic programme or a programme of a specific organisation. Programme based approaches share the following features: (a) leadership by the host country or organisation; (b) a single comprehensive programme and budget framework; (c) a formalised process for donor co-ordination and harmonisation of donor procedures for reporting, budgeting, financial management and procurement; (d) efforts to increase the use of local systems for programme design and implementation, financial management, monitoring and evaluation. PBA modalities – include: � National support (general budget and balance of pay-ment support). � Sector support (budget support at sector level and projects integrated in sectorwide The indicator is use of common arrangements or procedures (indicator 9 of the OECD indicators) as defined above, as percentage of an individual donors support that goes through PBA. The OECD target by 2010 is 66% of aid flows are provided in the context of programme-based approaches (actually 24% of total aid to the Philippines in 2005 according to the OECD baseline was PBA). Indicators for implementation phase • Timely disbursement of funds according to a schedule agreed with the

Government, will facilitate the execution of programs supported by the donor. The indicator for this is that there is a disbursement schedule agreed with DOH and disbursements are made according to the schedule. If there is a schedule that is actually followed for the disbursements during the last year, the score is green. If there is a schedule, but disbursements are delayed during the last year because requirements have not been met by the GOP, score is yellow. If the donor during the last year has not disbursed funds although requirements have been met by GOP,

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scoring is red. • The donor should adopt the use of Government systems to the extent possible.

Where use of current Government systems is not feasible, the donor should establish jointly with the Government, additional safeguards and measures in ways that strengthen rather than undermine country systems and procedures.

The Paris Declaration on Aid Effectiveness Suggested Targets for 12 Indicators of Progress has as one of the indicators5, percent of donors and of aid flows that use partner country procurement and/or public financial management systems in partner countries, which either: (a) Adhere to broadly accepted good practices or; (b) Have a reform programme in place to achieve these. One indicator that can be used for individual donors is to what extent the donor is using the GOP procurement system, or if support is given to improve Government procurement system, to be acceptable for the donor to use. If more than 75% of goods and services provided through the donor is procured using the Government system, the score is green. If 50-74% is procured through Government system, score is yellow, and if less, the score is red. However, if the procurement is done by the donor procurement system and this system has been harmonized to use the same procedures as the Government system, the score is yellow. • If all donors use the Government system for hiring of local experts/consultants,

this would facilitate coordination of technical assistance and ease the work load of DOH. One uniform system would be used instead of all the different donor systems, rules and procedures. The fees and contract conditions could also be uniform. The objective of this would be to improve the use of what the experts are doing.

The indicator chosen for this is if the work of the expert(s) included in the cooperation with a development partner is being institutionalized. If it has resulted in an Administrative Order or provided substantial input to any other document or process, the score is green or else the score is red. • Donors should ensure that programs they support are coordinated with the

5 Indicator 5(ai): Use of country public financial management systems (percent of aid)

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Department of Health, to enable DOH to have complete information of all donor support and to coordinate all donor suport.

The indicator for this is that a formal agreement exists with DOH for the donor supported programs and the contributions from the donor. If such an agreement exists, the score is green, if not the score is red. Indicators for Monitoring and Evaluation • Harmonizing donor review, monitoring, evaluation, and reporting processes with

procedures and process established for implementation of the HSRA and the F1 will facilitate the work of DOH.

OECD is measuring percent of (a) field missions and/or (b) country analytic work, including diagnostic reviews that are joint. Donor missions to the field are missions undertaken by officials to an aid recipient country and that include a request to meet with officials from the country of destination excluding workshops, conferences, etc. OECD is measuring total aid to a country and not individual donors. One indicator for measuring individual DP:s is that the DP participates in Joint Review Mission and not requiring own review missions. If the donor has participated in the JAPI during the last year and not sent own missions to monitor the support, score is green. If the donor has participated but still has had own missions, score is red. Another indicator is if the DP accept the Annual report from DOH for reporting on the support. If the DOH annual report is sufficien for the donor, the score is green. If the donor require a separate report according to a donor specific format, the score is red. • DP:s should provide comprehensive relevant information to DOH regarding

resources provided to support the health sector in the Philippines is important for DOH for coordination of foreign assistance.

The indicator for this is if the DP provides access to expenditure information in a timely manor, at least on a quarterly basis, on donor managed funds and resources in the format to be jointly decided.

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Data collection Source of data for indicators on outputs and outcomes defined shall be identified. Existing and institutional data sources shall be the first preference to be used for indicators on outputs and outcomes that will be identified.. Additional data sources shall be established as needed. A baseline study shall be conducted on the identified indicators and assigned data source developed. The baseline study shall provide information on (a) status of current donor support, (b) areas that need to be discussed with the donor (c) targets that could be set or revised and (d) assess the strengths and weaknesses of the data sources and the quality of the findings.

The baseline study shall be conducted on the fourth quarter of 2007, covering indicators that have existing and available data sources at that time.

Attachment 4 Development Partner Report Card - Examples

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Developm ent Partner Report Card – Examples

4

5

6 Donors use the Government system for hiring of local experts/consultants. Fees and contract conditions are uniform

Hiring of local experts subject to approval of DOH

7 Donors ensure that programs they support are coordinated with the Department of Health, to enable DOH to have complete information of all donor support and to coordinate all donor suport.

Formal agreement exists with DOH

8 Participate in Joint Review Mission and not requiring own review

9 Utilizing DOH Annual reports and Score cards for donor support

10 Provide comprehensive relevant information regarding resources provided to Implementing Partners to support the health sector in the Philippines,

Provide access to expenditure informationin a timely mannor, at least on a quarterly basis, on donor managed funds and resources in the format to be jointly decided.

Donor review, monitoring, evaluation, and reporting processes are harmonized with procedures and process established for implementation of the HSRA

Timely disbursement of funds and budget support releases made according to a schedule decided with the Government, if requirements are being met

Disbursement schedule agreed with DOH and disbursements made according to schedule

Adopt the use of Government systems to the extent possible. Where use of current Government systems is not feasible, establish jointly with the Government, additional safeguards and measures in ways that strengthen rather than undermine country systems an

Donor using or supporting improvement of Government Procurement System, to be acceptable for donor to use

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Development Partner ScorecardB1. Measuring commitment to SWAP for Financial Management and Procurement

Donor is supporting projects and is managing his funds with own FM system. Procurement using the donor procedures

Donor is suporting broad programs. Funds transferred to the program Project Implementation/Management unit (PI/MU) closely linked to government structure. FM is harmonized to a certain degree with Gov. system. Procurement through the PI/MU with harmonize

Donor is giving budget support. On-budget support through Gov. FM system Gov. is doing procurement through Gov. System.

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Development Partner ScorecardB2. Measuring commitment to SWAP for Reporting, Monitoring and Evaluation

Donor is supporting projects and require specific reporting according to his own format. Donor requires annual bilateral meeting for planning and follow-up, donor missions coming one or several times per year.

Donor is suporting broad programs and has harmonized reporting requirements to largely correspond to Gov. system. Participate in JAPI but still require bilateral annual meeting. Donor missions reduced to not more than 1 per year.

Donor is giving budgesupport and Gov. annreporting is accepted.Donor use JAPI and hno bilateral annual meNo separate donor missions.

Attachment 6: Feasibility Study Mindoro Oriental and Ilocos Norte

HSDP Ilocos Norte –Subproject Appraisal Report 1

UPGRADING OF THE PROVINCIAL HOSPITAL, AND SELECTED DISTRICT HOSPITALS AND RURAL HEALTH

UNITS OF ILOCOS NORTE Province of Ilocos Norte

I. INTRODUCTION

1.1 Provincial Profile Ilocos Norte is located in the northwestern part of Luzon. It has a total land area of 3,622.91 sq. kms. Rugged mountains, which are part of the Cordillera Range, seal the province from Cagayan, Apayao and Abra on the east. A narrow coastal plain connects it the province of Ilocos Sur to the south. The South China Sea lies to the west and the Babuyan Channel forms the northern coast. Except for the coastal plain and the Laoag River lowlands, most of the land is rugged and rocky.

Ilocos Norte has two (2) congressional districts comprising twenty-two (22) municipalities and one component city. Ilocos Norte is a first class province with one first and one third class municipalities. The other municipalities are either classified as fourth class (14) or fifth class (6) municipality.

The population of the province in 2005 was 550,445. The province’s annual population growth rate is 1.37% resulting in an average household size of 4.8 persons, lower than the national average of 5 persons. More than 61% of the population belongs to the economically active population aged 15-64 years. Roughly 91% of the labor force found employment in farming and fishing, manufacturing, commerce and trade, community/public services, cottage industries/handicrafts, financing, insurance, real estate, and other business services. Farming and agriculture are the basic sources of income of Ilokanos followed by fishery, manufacturing, and trading. Mining as an economic activity also abound in the province. Limestone, shale feldspar and mineral ore are being mined extensively. Ilocos Norte is dubbed as the ultimate tourist destination in the north. It boasts of several notable tourist attractions like the sand dunes in Currimao and Laoag City, and beach resorts in the municipality of Pagudpod. The basic literacy rate of the province in 2005 was higher compared with those of the other provinces. There are 484 government and private educational institutions in the province, classified into elementary and secondary schools, colleges and universities, technical and vocational institutions and TESDA administered schools. Malnutrition is commonly observed among pre-school and school-aged children and also among pregnant and lactating women. About 83% and 72% of the total number of households in the province have access to safe water and basic sanitation facilities, respectively. More than half of the families in the province have access to a health facility and this could be attributed to the fact that the province has 26 RHUs and 7 public and 6 private hospitals plus private clinics that abound in the town centers.

HSDP Ilocos Norte –Subproject Appraisal Report 2

Ilocos Norte has network of well-paved highways and arterial roads running throughout the province and connecting to the other provinces of the region and to Metro Manila. Electricity supply is widely available and is supplied and distributed by the National Power Corporation and the local electric cooperative, respectively.

Table 1. Ilocos Norte Provincial Profile, 2005

Fiscal/Financial Profile

LGU Borrower

Income Class

Annual Regular Income

(million)

Local Income

(million)

IRA (million)

Borrowing Capacity (million)

Loan Component

of Sub-Project

(million) Ilocos Norte 1st P559.200 P73.247 P486.953

Dingras 4th P46.678 P15.806 P30.872 Nueva Era 4th P38.171 P4.941 P33.230

Socio-Economic Profile Population Land Area Major Economic Activity

540,445 3,622.91 sq. km. Agriculture 1.2 The Proposed Sub-Projects Ilocos Norte has just completed the formulation of a Medium-Term Provincial

Investment Plan for the Health Sector (PIPH). The province has put on high priority the improvement of the delivery of health services by way of expanding the mandatory enrolment of indigent families with the Philippine Health Insurance Corporation (PhilHealth) and by allocating additional capital expenditures for health infrastructure upgrading and medical equipment acquisition. It has likewise initiated the establishment of inter-local health zones (ILHZs) that would rationalize the delivery of health care services. A chief strategy that will lead to the attainment of the goals enunciated in the PHIP is to improve the capability of the province’s health care providers to deliver to its populace adequate, affordable, timely and cost-efficient health care services.

Under the PHIP, the following table lists down the medical facilities identified as priority medical facilities requiring immediate interventions. The high priority accorded to the hospitals primarily stems from the fact they serve as core referral hospitals in their respective ILHZs.

Table 2. Proposed Sub-Projects, Ilocos Norte

Institution/Location Classification Bed Capacity

2004 Occupancy

Rate Gov. Roque B. Ablan, Sr. Memorial Hospital, Laoag City Tertiary 100 106.31

Bangui District Hospital, Bangui Secondary 25 77.18 Dingras District Hospital, Dingras Secondary 25 61.83 Dingras Rural Health Unit, Dingras Primary n.a. n.a.

Nueva Era Rural Health Unit, Nueva Era Primary n.a. n.a.

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1.3 Sub-Projects’ Objectives

As one of the identified HSDP-recipient provinces, the provincial government, as

well as the municipal governments, believes that accessing the financial assistance provided by the HSDP via the Municipal Development Fund Office is a viable and sustainable strategy to address the problems that resulted from the devolution and to squarely meet the objectives of its PHIP.

a. Gov. Roque B. Ablan Sr. Memorial Hospital (GRBASMH) - The provincial hospital is the designated core referral hospital within the Metro Laoag Inter-Local Health Zone. Upon completion of the planned upgrading and renovation, GRBASMH is envisioned to become a Second Level Referral Hospital that will have facilities and will offer services in accordance with DOH A.O. No. 70-A, series of 2002.

b. Dingras District Hospital – A secondary level health care facility, Dingras

District Hospital is proposed to be transformed into a 60-bed Core Referral and Level 2 Hospital that will support six (6) municipalities within its influence zone.

c. Bangui District Hospital - A secondary level health care facility, Bangui

District Hospital is proposed to be transformed into a 40-bed Core Referral and Level 2 Hospital that will support five (5) municipalities within its influence zone.

d. Dingras Rural Health Unit (RHU) – A primary level health care facility that

was recently accredited by PhilHealth and certified as a “Sentrong Sigla” is to be totally reconstructed to be able to deliver health care services in accordance with the accreditation and certification standards of PhilHealth and the program, respectively.

e. Nueva Era Rural Health Unit (RHU) – A primary level health care that is

proposed to be upgraded into a Lying-In/Birthing clinic in order to provide a wider range of services to the residents of Nueva Era and its neighboring towns.

1.4 Sub-Projects’ Beneficiaries

The implementation of the upgrading and renovation of the five priority medical

facilities will primarily benefit the province’s entire population of 550,447 in approximately 115,000 households. Inhabitants in adjoining provinces like Cagayan Valley and Kalinga are also likely to benefit from these sub-projects given their better proximity to these Ilocos Norte hospitals than to their own provincial/municipal hospitals. More importantly, the beneficial impact of the sub-projects will be greatly felt among those whose access to the better-equipped and adequately-staffed private medical institutions is constrained by their limited financial resources. II. HEALTH CARE SERVICES SUPPLY AND DEMAND ANALYSIS

The current health status of the province’s populace can be best described by certain health indicators. Over the past few years, the health situation in the province has posted slight improvements as shown by all health indices except the CDR. These indices have exhibited decreasing trends.

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Table 3. Health Indices, Ilocos Norte/Laoag City, 5-Year Average (2000 – 2004) and 2005

Health Indicator 5 Year Average (2000 - 2004)

Year 2005

% Increase/ (Decrease)

Region I 2005

Crude Birth Rate 19.95 19.83 (0.60) 20.63 Crude Death Rate 5.47 5.80 6.03 5.26 Infant Mortality Rate 6.72 6.13 (8.77) 10.57 Maternal Mortality Rate 0.13 0.09 (30.76) 0.23

Legend: CBR & CDR = Rate per 1000 pop. IMR & MMR = Rate per 1000 Live Birth

Communicable diseases still top the main causes of morbidity and mortality in the province. Despite modest progress in Infection Diseases Control, pneumonia, tuberculosis and diarrhea remain in the ten (10) leading causes of morbidity and mortality. Non-communicable diseases have progressively crept up in the list of leading causes of death. The challenge is that such diseases require sophisticated technology for diagnosis, management and treatment. TB remains a significant public health threat. In 2005, the TB Case Detection Rate was 30% with a cure rate of 91 %. These numbers are still relatively low by any standards.

Looking into the implementation of the various health programs in the province, the most successful in the province is the Expanded Program on Immunization (EPI). As a result of the implementation of this program, the number of Fully Immunized Children (FIC) in the province has been increasing since 2003. Coverage rate by municipality has also been relatively well distributed.

2.1 Health Care Services Delivery – Supply Analysis a. Primary Health Care Infrastructure and Manpower - Primary health care in

the province, which is very much focused on disease prevention and health education, is delivered by rural health units (RHUs), barangay health stations (BHS) and city health units (CHUs). The table below summarizes the current resources on some of the essential facilities and personnel in the province with respect to the national standards.

Table 4. Health Personnel and Facility to Population Ratios, 2005

Facility/Personnel Current Resource

Standard Ratio Actual Ratio Optimal

Resource Remarks

Rural Health Units 25 1:20,000 1:22,017 28 Deficit Barangay Health Stations 110 1:5,000 1:5,004 110 Within

Standard Municipal Health Officer 24 1:20,000 1:22,935 28 Deficit

Public Health Nurse 32 1:20,000 1:17,201 28 Surplus

Midwives 132 1:5,000 1:4,170 1 Surplus

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The physical conditions of most of these health centers leave much to be desired. The buildings are old and in poor conditions with windows and ceilings already dilapidated. Too often, the buildings are too small to comfortably accommodate patients and to house additional services such as laboratory, birthing and DOTS center. A number of comfort rooms/toilets in these buildings are not functional. In most instances, their equipments are either old or limited. Despite these general observations, all facilities are “Sentrong Sigla” and PhilHealth accredited.

b.. Secondary Health Care Infrastructure and Facilities - Secondary health care

is delivered by 8 public hospitals (i.e., one DOH-retained hospital, one provincial hospital, one city hospital and five districts hospitals) and eleven (11) private hospitals as well as private specialist outpatient clinics. The aggregate hospital bed capacity in the province stands at 635 beds broken down into 410 beds public and 225 beds private. Average occupancy for public hospitals in 2004 was computed at 80.3%. No data for private hospitals was available. Based on 2005 provincial population of 550,447, the derived actual hospital bed to population ratio is 1 per 869 inhabitants or almost 60% below the accepted norm of 1 hospital bed per 500 individuals.

Meanwhile, tertiary health care level is very limited. The DOH hospital has in place the hemodialysis and peritoneal dialysis center. It also has Neonatal Intensive Care Unit (NICU). The Provincial Hospital and a private clinic each have a CT scan. The various hospital equipment and facilities generally required in Orthopedic, Stroke & Cancer Centers are lacking. If these are already available in the province, most of them would be too old and needing immediate replacement.

c. Secondary Health Care/Hospital Manpower - Most medical specialists

available in the province are either working with the DOH-run hospital or with the GRBASMH. Only a limited number of specialists are working in their private practices. The secondary hospitals in Dingras, Marcos, and Bangui have each one surgeon and two general physicians. The public primary hospitals generally have one general physician each.

d. Currently Implemented Hospital Rates – Table 5 lists down the charges or rates that the GRBASMH levy on its users. The rates to a large extent could be considered as the upper limits of the fees being charged by all publicly-run hospitals in the province. No data on private hospital charges are available but hospital staff of GRBASMH, Dingras DH and Bangui DH confided that they could at least be double than government hospital rates.

2.2 Demand/Needs Analysis The future demand for hospital beds in the province can be estimated by applying

the standard bed-to-population ratio to the projected population. Specifically, the number of existing and authorized hospital beds, both public and private, is deducted from the projected hospital bed requirement using the projected population based on historical growth trend and the planning standard of hospital bed per 500 persons.

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Table 5. GRBASMH: Currently Implemented Hospital Rates

Type of Room Available No. of Beds

Daily Charge (PhP)

General Ward 70 P300.00 Private Room 20 P450.00 Nursery 10 P345.00 Suite 4 P1,275.00

Other Facilities/Services Average Charge (PhP) Average Laboratory Charges P60.00 Average X-ray Charges P300.00 Average CT Scan Charges P3,200.00

Over a planning period of ten years (2006 – 2015), the projected hospital bed

requirements of the province would gradually climb up from 1,116 beds in 2006 to 1,227 beds in year 2015 based on an annual population growth rate of 1.37% and current public and private hospital bed numbers of 410 and 225, respectively. The projected hospital bed shortage could therefore run up from 481 beds in 2006 to 626 beds in 2015.

Table 6. Projected Hospital Bed Requirements, Ilocos Norte, 2006-2010

Year Population* Projected Total Bed Requirements**

Additional Hospital Bed Requirements

2006 557,988 1116 481 2007 565,632 1131 496 2008 573,382 1147 512 2009 581,237 1162 527 2010 589,200 1178 543 2011 597,272 1194 559 2012 605,455 1211 576 2013 613,749 1227 592 2014 622,158 1244 609 2015 630,681 1261 626

Note: *Based on average annual population growth rate of 1.37%. **Based on a national standard ratio of 1 hospital bed per 500 individuals.

2.3 Health Care Governance

At present the province has developed 4 Inter-local Health Zones (ILHZ) as shown

below. Each of the 4 ILHZ in the province has an organized and functional ILHZ board acting as the policy-making body and a technical working group as the secretariat.

2.4 Conclusion While the aggregate additional hospital beds of 100 capacities of GRBASMH,

Dingras and Bangui District Hospitals would have a limited impact in easing the projected hospital bed shortage, the implementation of the sub-projects has to be carried out with urgency to address the deteriorating health care services delivery and quality brought about by the dilapidated medical facilities, medical staff and hospital bed shortages.

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Table 7. Inter-Local Health Zones, Ilocos Norte, 2006

ILHZ Core Referral Hospital

Number of Municipalities / City

Service Area Population

Metro Laoag GRBASMH 7 265,608 Great Eastern Dingras DH 6 99,000 Metro Batac MMMH 6 160,154 Double North Bangui DH 5 47,666 Total 22 543,007 III. TECHNICAL ANALYSIS

3.1 Description of Existing Facilities a. Gov. Roque B. Ablan, Sr. Memorial Hospital (GRBASMH) - The Gov. Roque

B. Ablan, Sr. Memorial Hospital (GRBASMH) is licensed by the DOH as a tertiary hospital with a capacity of 100 beds. The provincial hospital is the core referral hospital of the Metro Laoag Interlocal Health Zone (ILHZ). Based on the annual report of the hospital, the occupancy rate of the hospital in 2004 was 106%.

The main hospital building, which houses the medical and surgical wards, operating and delivery rooms, and ICU and administrative offices, is more than 50 years old. Regular maintenance repairs are made by the provincial government so that normal hospital functions are still carried out. Only minor repairs in the main hospital building are needed. Attached to this building is an area occupied by the ER, OPD, Laboratory and Radiological Department. The area is now too congested and does not meet the standard room requirements. Mobility is very difficult because of the large number of people coming in and out of the area.

The existing 2-storey building that functions as a pay ward also needs minor repairs. The existing motor pool and maintenance building, supply, laundry and linen rooms are all in very poor conditions and would require major repairs if not total reconstruction. The existing morgue needs only minor repair. Apparently, the improvement of these facilities is not a priority undertaking of the provincial government under the HSDP. Other fund sources are being considered to finance the reconstruction of said facilities.

There is an on-going construction of building primarily to accommodate the OPD

of the hospital which is funded by Congressional Development Fund (CDF) of Congresswoman I. Marcos. An unfinished 3-storey building that will accommodate an additional pay ward section is awaiting completion.

The hospital has a well functioning drainage system. It is also presently utilizing a 2-chamber septic tank for its waste disposal.

As a tertiary hospital, GRBASMH offers inpatient (100 beds) as well as outpatient services. The hospital has 165 personnel including 26 physicians and 35 nurses. There are four major medical departments: medicine, surgery, pediatrics, obstetrics-gynecology and sub specialties- ophthalmology, orthopedics, clinical pathology, anesthesiology.

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The diagnostic facilities of the hospital consist of a laboratory for most basic laboratory tests like bacteriology and blood chemistry. Its Imaging Department is equipped with one CT scan, one X-Ray machine and one ultrasound machine.

b. Dingras District Hospital - The Dingras District Hospital is located in the

eastern part of Ilocos Norte province, some 16 km from Laoag City and about 4 km away from the centre of the Municipality of Dingras. The hospital is licensed by the DOH as a secondary hospital with a 25-bed capacity under the jurisdiction of the provincial government. In 2004, the recorded occupancy rate was 61%. The limited number of services offered and the dilapidated condition of the facility accounts for the low occupancy rates for the past 4 years.

The functionality of the hospital is very poor because it was originally intended as

a school building. The original location of the hospital was in the center of municipality or near the public market but it was razed down by fire sometime in 1990. Structurally, the condition of the building is also very poor. The Operating and Delivery Room, measuring only 16 square meters or less than half of the internationally accepted standards of 36 square meters, is currently in very bad shape while the ceiling and windows are dilapidated. The hospital’s equipments are mostly antiquated.

The hospital has well-functioning drainage system. It also has a 2-chamber septic

tank for waste disposal. Currently, there are 5 medical doctors manning the hospital, including the director

of the hospital, two permanent plantilla doctors, and two contractual specialist doctors (one anesthesiologist and one general surgeon) .The laboratory provides basic services and has one available x-ray unit. They perform only minor and emergency operations in the hospital (such as appendectomy and the like). Major surgeries such as caesarian sections are referred to the provincial hospital in Laoag City.

c. Bangui District Hospital - The district hospital is located in the northern part of the province, in the municipality of Bangui which is around 66 km from Laoag City. It is the only public hospital operating within the Double North Inter-local Health Zone which covers a catchment area of five nearby municipalities. As such, it is categorized as a core referral hospital.

The hospital is licensed by the DOH as a secondary hospital with a capacity of 25 beds. The hospital building was refurbished about 10 years ago but still makes a good impression. The functionality of the building is also reasonable. The hospital has well-functioning drainage system. It also has a 2-chamber septic tank for waste disposal.

Currently, there are 3 medical doctors in the hospital (1 surgeon and two

physicians) plus one vacant position. There are also visiting specialists (ENT and OB/GYN). Based on the submitted annual report, the occupancy rate of the hospital in 2004 was 77%. This hospital also serves residents of the neighboring towns in the provinces of Cagayan and Kalinga.

d. Dingras Rural Health Unit - The Municipality of Dingras has no owned building for their Rural Health Unit. The RHU is at present occupying the old Dingras District Hospital which was raged by fire some years ago. This facility is already very

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dilapidated and in its very poor condition, in fact should have been declared condemned. Structures are no longer sound due to the fire.

e. Nueva Era Rural Health Unit - The unit is at present functioning as Rural

Health Unit. Municipal government officials would like to upgrade it into a Lying-In/Birthing clinic in order to provide a wider range of services to the residents of Nueva Era and its neighboring towns.

3.2 Description of the Proposed Facilities

The following table describes in brief the proposed civil works for each of the sub-

project.

Table 8. Identified Sub-Projects and Proposed Interventions, Ilocos Norte

Sub-Project/Medical Facility Proposed Scope of Civil Works a. Gen. Roque B. Ablan Sr.

Memorial Hospital • Completion of the unfinished 3-story building to

accommodate an additional 50 beds for pay wards and ICU for surgical and pediatric care;

• Repair/repartitioning of existing OPD, Laboratory and Radiology (471 sq. m.);

• Extension/construction of a 2nd floor for the Laboratory/Radiology Departments to accommodate pay consultation rooms, Doctors’ quarters, and conference rooms (462 sq. m.);

• Construction of SBR waste water treatment plant (100 cu. m/day capacity);

• Construction of Waste Collection Unit, Placenta Pit and Vaults for sharp objects; and

• Repair of existing 2-storey Pay Ward Building. b. Dingras District Hospital • Increase bed capacity from 25 to 60 beds;

• Construction of pay ward building with ramp (F.A. = 795 sq.m.)

• Construction of new Out-Patient Department building (F.A. = 305 sq. m.);

• Completion of the newly improved Delivery and Operating Room (F.A. = 223 sq. m)

• Construction of Dietary/Laundry and Linen Building (F.A. = 390 sq.m);

• Construction of Waste Collection Unit, Placenta Pit and Vaults for sharp objects);

• Canal lining/drainage for new buildings; • Repair of the existing main hospital building (902

sq. m.); • Construction of dormitory building; and • Site development works – road network at the back

portion of the hospital compound.

c. Banqui District Hospital • Increase bed capacity from 25 to 40 beds;

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• Construction of 2-storey Pay Ward and Quarters Building (F.A. = 432 sqm);

• Construction of the Out-Patient Department Building (F.A. = 300 sqm);

• Repair/repartitioning of the existing OPD/ER (F.A. = 200 sqm.);

• Minor repairs on the existing building (F.A. = 500 sqm.);

• Site development works; relocation of existing entrance gate and provision of concrete driveway;

• Construction of Waste Collection Unit, Placenta Pit and Vaults for sharp objects; and

• Construction of canal linings/drainage for the new building.

d. Dingras RHU • Site development; • Construction of a new building (265 sq. m.) to

accommodate standard room areas for Treatment Room, Dental Clinic, Family Planning Clinic, Midwife/Nurses’ Room, Laboratory, Conference Room, RHU Physician’s office, Sanitary Inspector Room, Kitchen, Storage, Nurses’ Station and a Lobby/Waiting area ; and

• Construction of a 3-chamber septic tank, vault for sharp objects, fence and canal lining/drainage.

e. Nueva Era RHU/Lying-in Clinic

• Construction of a new building (510 sq. m.) to accommodate around 8 beds;

• Construction of a 3-chamber septic tank, vault for sharp objects, perimeter fence and canal lining/drainage.

3.3 Civil Works Cost Estimates

The total civil works cost estimates, inclusive of taxes, for the three (3) hospitals managed by the province aggregate to P108.5 million while that of the two (2) RHUs amounts to P16.9 million.

Table 9. Civil Works Cost Estimates of Sub-Projects

Name of Facility CW Cost Estimate Tax (12%) Total Cost 1. Gov. Ablan Memorial Hospital 39,093,200 4,691,184 43,784,384 2. Dingras District Hospital 38,734,100 4,648,092 43,382,192 3. Bangui District Hospital 19,093,000 2,291,160 21,384,160

Total for Hospitals 96,920,300 11,630,436 108,550,736 4. Dingras RHU 4,602,500 552,300 5,154,800 5. Nueva Era Lying In Clinic 10,150,000 1,218,000 11,368,000

GRAND TOTAL 111,672,800 13,400,736 125,073,536

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3.4 Sub-Projects’ Investment Cost Estimates

Meanwhile, Table 10 below itemizes the total investment requirements of each facility. The cost of conducting the Detailed Architectural and Engineering Design (DAED) was estimated at 6% of the total cost of civil works. The cost of equipment, on the other hand, was based on earlier estimates indicated in the PHIP for the province. Consultations with the Provincial Health Office reveal that the equipment cost component will be funded through various grants and that negotiations for grant funding have commenced.

The total investment requirements of the GRBASMH, Dingras and Bangui District

Hospitals amount to P148.7 million. The RHUs’ combined investment requirements amounts to P20.82 million.

3.5 Proposed Implementation Schedules of Sub-Projects

Target commencement date of construction is March 2007 while target completion

dates are June 2008 at the latest for the hospitals and December 2007 for the RHUs.

Table 10. Sub-Projects’ Summary Investment Cost Estimates

Name of Facility Civil Works DAED Equipment Total

Investment Cost

1. GRBASMH 43,784,384 2,627,063 15,324,534 61,735,981 2. Dingras DH 43,382,192 2,602,932 10,845,548 56,830,672 3. Bangui DH 21,384,160 1,283,050 7,484,456 30,151,666 All Hospitals 108,550,736 6,513,045 33,654,538 148,718,319 4. Dingras RHU 5,154,800 309,288 1,030,960 6,495,048 5. Nueva Era RHU 11,368,000 682,080 2,273,600 14,323,680 Grand Total 125,073,536 7,504,413 36,959,148 169,537,047 IV. FINANCING

4.1 Sources and Terms of Financing

Only the civil works components of the sub-projects are proposed for Local Government Finance and Development Project (LOGOFIND) financing where the maximum loan amount depends on the income classification of the LGU-borrower. Since Ilocos Norte, the borrower for the three (3) hospitals is a first-class province, 50% of the total costs of civil works will be financed by a loan with the balance funded by a grant (30%) and equity (20%). In the case of Dingras and Nueva Era, both of which are fourth class municipalities, the financing mix for the civil works component will be 45% loan, 40% grant and 15% equity. The LOGOFIND loans will carry an interest rate of 12@ per annum, fixed during the duration of the loan and payable for fifteen (15) years on a semi-annual basis, including a three (3)-year grace period on the principal.

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Table 11. Sources and Amount of Financing

Hospitals Loan (50%) Grant (30%) Equity (20%) Total GRBASMH 21,892,192 13,135,315 8,756,877 43,784,384 Dingras DH 21,691,096 13,014,658 8,676,438 43,382,192 Bangui DH 10,692,080 6,415,248 4,276,832 21,384,160 Sub-total 54,275,360 32,565,221 21,710,147 130,260,883 RHUs Loan (45%) Grant (40%) Equity (15%) Total Dingras RHU 2,319,660 2,061,920 773,220 5,154,800 Nueva Era RHU

5,115,600 4,547,200 1,705,200 11,368,000

Total 61,710,620 39,174,341 24,188,567 146,783,683

4.2 Disbursement and Amortization Schedules If the sub-projects are granted approval in December 2006, loan disbursements are expected to start in January 2007 and end in June 2008 at the latest. The debt service during disbursements of the loan, which is only composed of interest payments, shall be due on April 2007. Regular amortizations will commence in April 2010.

4.3 Equity Participation The source of equity participation is the 20% Development Fund of the LGUs for 2006 as indicated in the Certification issued by the Local Finance Committees of Ilocos Norte, Dingras and Nueva Era. For all 5 sub-projects, the largest equity outlays are expected in 2007.

V. FINANCIAL ANALYSIS

The financial analysis of public sector projects theoretically is undertaken in order to: (i) ensure its financial sustainability; (ii) determine its financial profitability; and (iii) understand its distributional impact. However, the financial rate of return calculation of upgrading/reconstruction of selected hospitals and rural health units in Ilocos Norte is not undertaken as investments in these activities may be regarded as subsidies or transfer payments to the communities in the service areas which are not meant to be recovered.

The implementation of the sub-projects is primarily anchored on the belief that the

medical facilities requiring upgrading/reconstruction will never be in a financially sufficient situation to operate as stand alone economic enterprises given their social orientations. Notwithstanding the LGUs current inherent right to impose user fees under the Local Government Code, the levying of user fees may still have to be based on the willingness to pay of their target beneficiaries. However, given that the target beneficiaries of these medical facilities belong to the lower income brackets of the population their capacities to generate income enough to recover the investments are limited. Therefore, the financial analysis resorted to in this study focuses on the abilities of the LGUs managing these health facilities to sustain their operations without impairing their fiscal positions.

The procedure employed takes into account the cost and benefit streams of a

“without project” and “with project” scenario. The “without project” scenario assumes

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that the present levels of operation of the sub-projects will generally remain unchanged. The incremental net benefits are then derived when the cost and benefit streams of the “with project” situation are reckoned against those of the former. In both instances, the financial prices used in estimating expenses and revenues of the medical facilities are the average prices obtained from the results of interviews, research from secondary sources and information provided by the DOH, concerned LGUs and other stakeholders.

The different capital and operating expenditure items of the sub-projects

considered in the financial analysis are the construction, operation and maintenance costs based on acceptable engineering and hospital management standards during the entire 15-year economic lives of the sub-projects. On the revenue side, depending on the classification of the sub-projects income flows considered include fees charged for major and minor in-patient operations, minor out-patient operations, Caesarian deliveries, laboratory and radiological procedures, and dental services. Projected user fees are to be locally legislated and are expected not to exceed the rates allowed by DOH and PhilHealth. Likewise included are the capitation funds due to RHUs. All are valued in terms of financial prices.

Based on the foregoing assumptions, the projected cash flows on a “without and

with project” basis of each sub-project were derived. Given their service orientations, the net incremental cash flows expectedly showed up to be negative throughout their 15-year lives implying that the expected revenue flows would be insufficient to cover the increased levels of operating expenditures. This finding, however, does not apply to GRBASMH and Dingras RHU owing to their low investment and operating expenditure requirements relative to their service area populations. VI. ECONOMIC ANALYSIS

The economic analysis employed compares all the sub-projects’ expenditures with the benefits projected to accrue to the sub-projects in economic terms. It examines the sub-projects from the entire economy’s point of view to determine whether or not their implementation (i.e., the incremental investments) will improve the economic welfare of the region. The process requires the use of economic or accounting prices of goods and services, foreign exchange, and the cost of capital and labor.

A Shadow Exchange Rate of 1.2 is applied to all foreign components of goods and

services to translate their values into local terms. Unskilled labor in the locality is also shadow priced at 0.60 of the prevailing wage rate. Furthermore, subsidies and taxes and interest payments are excluded from the analysis. Meanwhile, the discount rate used in the economic analysis is the economic opportunity cost of capital or the social discount rate prescribed at 15% by the NEDA-ICC. All other economic prices of goods and services prices used in the projections are assumed equal to their financial prices.

6.1 Economic Costs

The economic costs of the sub-projects considered in the analysis are the construction, operation and maintenance costs based on acceptable engineering and hospital management standards during the entire 15-year economic lives of the sub-projects. These are the same capital and operating expenditure items used in the financial

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analysis but are now valued in terms of their economic or accounting equivalents using the different conversion factors discussed above.

6.2 Economic Benefits

Only the direct economic benefits accruing from the upgrading/reconstruction of the sub-projects are considered in the economic analysis. These are the user fees that will be levied by the sub-projects on the sub-project beneficiaries, savings in medical expenses, savings in transport cost, and economic benefits derived from reduced morbidity and mortality.

a. Hospital Revenues - Public medical facilities too often are recipients of

subsidies and grants from both local and national governments. This include the annual capitation fund (estimated at P300 per head per year) that public hospitals receive from PhilHealth to fund health care needs of indigents. Regular subsidies are provided by host LGUs. Still another source is the user fee imposed on patients that varies with the health care service or procedure provided. While the capitation fund and other subsidies are considered as revenue flows, they are not considered in the analysis because they are treated as transfer payments. Only the proposed user fees from patients for the different hospital services and procedures are considered as direct economic benefits.

b. Savings in Medical Expenses - Public hospitals almost always have

comparatively lower rates than private hospitals. With improved facilities and services, target beneficiaries would be encouraged to avail of preventive or curative care services in these public hospitals in anticipation of the savings that will be obtained for the same service in privately-run facilities. In this study, room and boarding rates are the only variables considered in computing savings as direct economic benefits. Private hospitals and clinics charge on the average P 675/bed/day compared to the P450/bed/day projected for the sub-projects or a daily savings of P225.

c. Savings in Transportation Expenses - Patients and their caregivers have the

incentive to utilize medical facilities that are nearest to them provided they could be provided the same quality service. The upgrading of GRBASMH and RHUs, for instances, would lure patients to avail of medical care in these public hospitals rather than going to the regional hospital in La Union or Baguio City and to the provincial and private tertiary or secondary hospitals in Laoag City, respectively. As such, the differences in transportation fares also count as benefits directly accruing to the economy.

d. Reduced Foregone Income due to Reduced Morbidity - Based on the

prevailing morbidity rates in the sub-projects’ service areas, the potential impact of the incremental investments on the provincial and district hospitals and selected RHUs in Ilocos Norte could be measured in economic terms by estimating the number of working days saved due to disease avoidance and thereafter valuing the same by the corresponding economic wage rates. It is generally assumed that an individual maybe able to save an average of four (4) working days every year due to improved health.

e. Reduced Foregone Income due to Reduced/Delayed Mortality- Improved delivery of health cares services that comes with upgraded facilities creates opportunities for generating savings from reduced mortality. It is generally assumed that an individual

HSDP Ilocos Norte –Subproject Appraisal Report 15

could gain an average of three additional productive years by impeding death as a result of a fully responsive health care services delivery system.

6.3 Economic Analysis Results Table 12 below enumerates the numerical results of the economic analysis based

on the assumptions detailed above. Except for Dingras DH, all other sub-projects registered Economic Rates of Return (ERRs) that are above the prescribed social discount rate. At this discount rate, their Net Present Values (NPVs) are also positive. Their economic viabilities are reaffirmed by the sensitivity test conducted. With a scenario where a simultaneous increase of 20% in incremental investments and 10% increase in MOOE ensue, the ERRs and NPVs still remain robust.

The case of Dingras DH needs to be qualified. As a stand alone sub-project, it

yielded a negative NPV at the prescribed discount rate. However, given that the Ilocos Norte provincial government would be the sole borrower for the three (3) hospitals, the viability of Dingras DH may be evaluated as part and parcel of the total investment requirement that will be loaned out by the LGU. With this as premise, an aggregate economic analysis of the three (3) hospitals resulted in an ERR and NPV at 15% of 55% and P328,863,268, respectively. A scenario espoused in the PHIP for the province that is worth considering is the possible merger of Dingras DH with the Dona Josefa Edralin Marcos District Hospital with the former as the surviving entity. If this option is pursued by the LGU, the proposed capital expenditures for Dingras DH may in the end proved to be economically justifiable.

Table 12. Economic Analysis Results

Facility ERR (%) NPV @ 15%, PhP ERR(%) NPV @ 15%, PhP

GRBASMH 109 398,840,663 87 344,126,231 Dingras DH (26,017,400) (125,467,716) Bangui DH 36 22,624,363 29 17,691,668 Dingras RHU 58 11,360,805 40 8,087,818 Nueva Era RHU 54 23,214,763 47 21,007,445

6.4 Unquantifiable Benefits/Secondary Effects

The unquantifiable benefits and secondary effects or externalities of the sub-

projects are “internalized” and qualified to the extent possible. The proposed sub-projects affect a large number of people within and outside the regions of location. They have primary and secondary benefits, each of which creates its own multiplier effect. The term “external effects” or “secondary benefits” used in this report is a “catch-all” term to describe the indirect contributions that the sub-projects would generate apart from those reflected in the direct utilization of the sub-projects services output.

The unquantifiable benefits would include improved health status, improved nutrition and reduced morbidity and mortality. Health improvement due to the expanded services delivery of the sub-projects would be positively reflected in terms of increased investment flows to the province, increased employment, better performance of school-age children and enhanced social participation, among others.

HSDP Ilocos Norte –Subproject Appraisal Report 16

VII. ENVIRONMENTAL ANALYSIS

Initial Environmental Examination (IEE) Reports have been prepared in compliance with the requirements of the Philippine Environmental Impact Statement (EIS) System (i.e., Presidential Decree (PD) No. 1586) and Department of Environment and Natural Resources Administrative Order (DAO) No. 2003-30. These will expectedly facilitate issuance of the necessary Environmental Compliance Certificates (ECCs) for the five (5) medical facilities.

On the assumption that the existing medical and health care facilities would not be

improved and no additional upgrading/construction activities will be provided by the provincial and municipal governments, the anticipated environmental, health and economic impacts are: a) the deterioration of delivery of health care services in the area; b) the loss of income and employment and trade opportunities as productivity and commerce decrease due to illness; and c) the higher medical and transportation expenses incurred by local people as they will be forced to avail health care services offered by the private hospitals and/or by the regional hospitals in La Union and Baguio City.

Should the sub-projects be implemented, the short-term effects are usually observed during the construction period. Obstruction due to workers’ and equipment movements within the existing hospital facilities can cause inconvenience to patients, medical staff and visitors. Necessary demolition and repartitioning works within the hospital facilities would require relocation of patients and medical offices such as laboratory, X-ray rooms, doctors’/nurses quarter, etc. The noise caused by construction equipments is bound to be objectionable to the patients and medical staff near the construction site. The demolition and repartitioning works will likely generate dust and particulates within the hospital facilities. Construction of new facilities would require deep excavation which can also pose short-term hazards to the public especially to the children.

The short-term environmental effects can be minimized by proper planning, good

engineering design and systematic construction supervision. Necessary precautions and notices should also be considered during the construction period. Likewise, necessary safety provisions should be incorporated in the construction contacts to ensure that such environmental hazards are controlled or minimized.

The long-term environmental effects of the sub-projects will be felt in terms of a cleaner environment and healthier community. However, operation and maintenance of hospital and health care facilities necessitates proper liquid and solid wastes disposal. The considerable volume of wastewater generated by such facilities generally can cause environmental pollution and pose tremendous risk to public health. Additional clinical wastes will also be generated during the sub-projects’ utilization.

To address these concerns, the health personnel of these facilities should update

their HCWMP to ensure consistency with proper collection, storage, disposal and treatment of clinical wastes as prescribed in the DOH Manual of Health Care Waste Management of 1997. Moreover, the health personnel and staff should be required to undertake trainings/seminars on the proper handling, storage, collection and disposal of hospital and other related health care wastes.

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VIII. SOCIAL ACCEPTABILITY

Proper endorsements, resolutions and certifications and approval of the sub-projects were solicited from the concerned Local Government Units (Sangguniang Panlalawigan, Sanggunian Bayan and Barangay Resolutions). Appendices __ to ___ serve as proof of social acceptability of the sub-projects wherein proper consultations and project presentations were conducted during the formulation and finalization of the FS report. IX. FISCAL IMPACT ANALYSIS

The fiscal analysis looked at sub-projects’ impact on the finances of the host LGUs particularly during the years that personnel services and maintenance and other operating expenses (MOOE) are expected to balloon, and loan repayments and insurance payments become due. From the revenue and expenditure projections, the hospital and RHU revenue accounts generally will not suffice to cover all hospital and RHU expenditure accounts including loan amortizations and insurance premium payments. Provincial and municipal LGUs will have to continue to “subsidize” hospital and RHU operations, at least at their current levels. Notwithstanding these findings, fiscal conditions of the host LGUs are projected to remain “healthy” with the implementation of the sub-projects

A fundamental fiscal impact that can be achieved from the sub-projects is the

effective and enhanced fiscal management and administration system, health sector planning and development, and hospital/RHU management and operations as the implementing LGUs are now guided by the PHIP. These are likely to result in improved health and poverty alleviation in affected areas as the target beneficiaries’ access to upgraded health care services becomes better. In addition, the equity counterpart required by the lender and the implementation by contract rather than by forced account of the civil works components of the sub-projects will promote cost effectiveness as well as cost-efficiency consciousness in project execution among the host LGUs. In the long-term, greater efficiency in the use of local resources will be achieved. X. ASSESSMENT OF LGU READINESS TO IMPLEMENT THE SUB-

PROJECTS 10.1 Institutional Analysis Ilocos Norte has prioritized the improvement in the delivery of health services in

terms of insuring families with the National Health Insurance Program (NHIP) and investing in health infrastructure. This is enshrined in the recently formulated Provincial Investment Plan for Health (PIPH). A companion document is the Ilocos Norte Business Plan for the Health Sector which, among other things, defines the health sector areas requiring additional capital expenditures, possible sources of financing and modalities for fund utilization.

To implement the Plan and its component capital expenditure projects, a Project

Management Committee (PMC) shall be organized. It shall be headed by the Governor with the members coming from the League of Mayors, Sangguniang Panlalawigan, Provincial Health Office, and PhilHealth. The PMC shall be the main implementing entity and shall be tasked to conduct regular monitoring and evaluation to ensure that standards

HSDP Ilocos Norte –Subproject Appraisal Report 18

and schedules are complied with. The Sangguniang Panlalawigan of Ilocos Norte has already issued Resolution No. ________ dated to this effect.

At the municipal LGU levels, the PMC shall be replicated with the creation of the

Project Management Offices (PMOs) headed by the respective Municipal Mayors and members drawn from the Municipal Councils, Municipal Health Offices and local PhilHealth offices To date, the Municipalities of Dingras and Nueva Era have issued Resolution Nos. ______ and _____ dated ___________, 2006 and ______________, 2006, respectively, authorizing the creation of the PMOs.

The host LGUs have likewise committed to issue resolutions/local ordinances that

will update hospital service fees once the construction/reconstruction of the medical facilities are completed.

10.2 Legal Requirements The following resolutions have been issued affirming the interests of the LGUs

authorizing the local chief executives to apply, negotiate and participate in the Health Sector Development program and to borrow funds from the Municipal Development Fund Office of the Department of Finance.

LGU Resolution No. Date Issued

Ilocos Norte Dingras Nueva Era 2006-111 August 14, 2006

Certification from the Local Finance Committee on the Source of Equity have also

been issued details of which are itemized below.

LGU Resolution No. Date Issued Ilocos Norte Dingras Nueva Era

Proofs of ownership of the sites where the sub-projects are located are also listed as follows.

LGU/Hospital/RHU Areas (sq.m.) Tax Declaration No.

6,361.0 023-00055 850.0 026-00110 330.0 026-00102

8,883.0 026-00103 Ilocos Norte/GRBASMH

451.0 026-00108 Dingras/Dingras DH 12,960.0 641955 Bangui/Bangui DH 7,957.0 03-002-00667 Dingras/Dingras RHU 4,901.0 05-002-00071 Nueva Era/RHU 8,415.0 05-001-00601

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XI. RECOMMENDATIONS/CONCLUSION

The upgrading/reconstruction of the Gen. Roque B. Ablan Sr. Memorial Hospital, Dingras and Bangui District Hospitals, Dingras and Nueva Rural Health Units would further spur economic development and rationalize health care services delivery in the region. The long-term economic benefits are foreseen to be resoundingly weightier than the economic costs that would be incurred. Based on the findings and analysis results, the implementation of the sub-projects with civil works financing from the MDFO/DOF and limited equity participation by the host LGUs should be vigorously pursued. Concomitant with this recommendation, the Ilocos Provincial Health Office should promptly consider the possibility of merging the Dingras District Hospital with the Dona Josefa Edralin Marcos District Hospital, with the former as the surviving entity, to ensure its economic viability as a stand alone project.

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Attachment 7: INCEPTION REPORT II

Technical Assistance to the Republic of Philippines for the Health Sector Development Program

ADB TA 4647-PHI I. Introduction

Philippine Health Situation: The health status of Filipinos has slightly improved over the past decades. The progress has, however, slowed down during recent years. Infant mortality and maternal mortality are still higher than in comparable countries. Variations are extreme across different regions and between various population groups within the same region or locality. Poverty remains the major threat in terms of access to essential health services, particularly the increasing disparity in income distribution between the upper income groups and the lower income groups and the continuing disparity between urban and rural areas and among geographical regions of the country. The basic health needs of the population, especially the marginalized sectors and specifically to the poorest of the poor, are not fully met. The total health expenditures of the country depend to a large extent on family out-of-pocket spending, which greatly affects the poor.

There are three major factors that gravely affect the health sector. The first major factor is related to the inappropriate health delivery system. This is a situation where you can see some areas with hospitals that are poorly staffed, poorly equipped, and have low occupancy rates. There is an ineffective mechanism for providing public health programs, partly due to the fragmentation of the primary health care system, and partly due to the institutional deficiencies that lead to low absorptive capacities of public health programs. The second major factor is the inadequate regulatory mechanisms. The improvements in the quality of health care remain wanting in most areas and yet the cost of such care has become exorbitantly high and beyond the reach of ordinary people. This is exemplified in the prohibitive cost of drugs and medicines. The third major factor is related to poor health care financing. There is an inadequate funding for health and there are technical inefficiencies in its allocation and utilization.

Health Sector Reform Agenda. In 1999, the Department of Health initiated a bold move in launching the Health Sector Reform Agenda (HSRA) with five reform

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components; Hospitals, Public Health, Health Regulation, Local Health Systems and Health Financing reforms. The HSRA components are the following:

1. Enhanced social insurance benefits package, a strategy to limit balance-billing and increased enrolment of the indigent and the informal sector in the NHIP, to increase financial risk protection of the poor and sick;

2. Supply side measures to upgrade public health facilities in all communities to meet PHIC’s accreditation standards, and to increase fiscal autonomy for public health facilities;

3. More effective regulation of the private health sector and of drugs and commodities, to improve access to quality services and drugs (including generic drugs) at competitive prices;

4. Stronger results-orientation and coordination between DOH and LGUs in the delivery of public health programs; and

5. Development of structures and processes to increase coordination among neighboring LGUs, the DOH and the private sector in planning local health systems.

FourMula ONE for Health. In 2005, the Department of Health defined FourMula One for Health as the implementation framework for the Health Sector Reform Agenda (HSRA). FourMula ONE for Health is designed to undertake critical reforms with speed, precision and effective coordination directed at improving the efficiency, effectiveness and equity of the Philippine health system in a manner that is felt and appreciated by Filipinos, especially the poor. On the whole, FourMula ONE for Health is directed at achieving the following end goals: better health outcomes, more responsive health system and equitable health care financing. FourMula ONE for Health organizes the critical reform initiatives into four implementation components: Better and sustained Health Financing, Assured quality and affordability through Health Regulation, Assured access and availability in Health Service Delivery and Improved performance in Good Governance. The FourMula ONE for Health intends to implement critical interventions as a single package backed by effective management infrastructure and financing arrangements, offices with clear mandates, performance targets and support, all within well-defined time frames. More importantly, the four implementation components will be managed and financed following a sector-wide approach. This implies that the management perspective covers the entire health

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sector, and that the financing portfolio encompasses all sources.

The end goal of financing reforms under FourMula ONE for Health is to secure more, better and sustained investments in health to provide equity and improve health outcomes, especially for the poor. For health regulation, its main goal is assuring access to quality health products, devices, facilities and services, especially those used by the poor. The FourMula ONE for Health interventions in service delivery are aimed at improving the accessibility and availability of basic and essential health care for all, particularly the poor. This covers all public and private facilities and services. The goal of good governance in health is to improve health systems performance at the national and local levels. FourMula ONE for Health will introduce interventions to improve governance in local health systems, improve coordination across local health systems, enhance effective private-public partnerships, and improve national capacities to manage the health sector. The F1 sites are Capiz, Agusan del Sur, Misamis Occidental, Pangasinan, Ilocos Norte, Ifugao, Nueva Vizcaya, Oriental Mindoro, Romblon, Mountain Province, Oriental Negros, North Cotabato, South Cotabato, Southern Leyte, Biliran and Eastern Samar.

A key feature of the FourMula ONE for Health implementation strategy is the engagement of the National Health Insurance Program (NHIP) as the main lever to effect desired changes and outcomes in each of the four implementation components. This aspect of the health care financing reforms still needs to be further developed.

Critical interventions identified for each component are deemed doable given the available time, human and financial resources. The chosen interventions must be backed by sufficient groundwork and buy-in from implementation partners, especially in the development of reform packages for local implementation. These critical interventions must be able to trigger a chain of reaction that will spur the implementation of other FourMula ONE for Health interventions, within and across the four components. All these are expected to show tangible results within the immediate and medium terms, which in turn generate support and cooperation from the public. The Department of Health shall formulate policies that will support the smooth implementation of the FourMula One for Health especially at the local levels.

In implementing FourMula ONE for Health with local partners, there is a need to track, monitor and evaluate how these interventions improve health systems performance and pursue on building local capacities for technical leadership and

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management The Health Sector Development Project supported by ADB has aligned its support to the FourMula One for Health and the reform agenda as indicated in the Program Loan and the Investment Loan provided by ADB. ADB has provided a grant TA to support the implementation of the Program Loan and the Investment Loan. The initial phase of the TA was focused on the policy formulation in support of reforms launched in 1999. Policies were developed under the Program Loan in the areas of Hospital, Public Health, Regulation, Health Financing and Local health Systems. The incoming phase of the TA will focus on the capacity building for operationalization of the policies developed, on support for Monitoring and Evaluation and on capacity building for F1. The HSDP sites identified were among the identified priority sites for HSRA and the 16 sites of FourMula One for Health. II. The ADB Technical Assistance 4647-PHI

In December 2004, ADB approved two loans totaling US$213 million for a health sector development program and investment project loan in support of the HSRA. The Government will contribute $430,000 equivalent toward the TA's total cost of $1,430,000.

Initial TA 4647

The Government of the Republic of the Philippines requested the Asian Development Bank (ADB) for assistance to support the implementation of the Health Sector Reform Agenda (HSRA) in April 2004. ADB, through the Health Sector Development Program (HSDP), is the first development partner to provide DOH with comprehensive support for implementing reforms in the health sector. The goal of the HSDP is to improve the health status of the poor by promoting cost-effective health interventions with an efficient, rationalized, and integrated health service delivery system. To support the reform process, ADB provided a grant, in the form the TA 4647 to help the Department of Health to develop policies and refine monitoring systems, and to assist local government units (LGUs) in initiating and carrying out reforms. To date the TA has helped the HSRA by developing policies, guidelines, and concepts which are fundamental for implementing reforms for the health sector, under the following original scope of work, to:

1. Streamline mechanisms in core referral hospitals to improve performance;

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2. Improve the quality of public health provision by introducing cost-effective interventions, clinical practice guidelines in health facilities, and piloting programs for public health interventions in LGUs;

3. Provide an integrated framework for a rationalized health system at the LGU level, address priority diseases, and explore measures to improve procurement and deployment of equipment, drugs, and supplies;

4. Pilot a strategy for more cost-efficient procurement of drugs, including standardizing the quality and prices of drugs;

5. Propose new schemes to increase coverage of beneficiaries under the Philippines Health Insurance Corporation; and

6. Propose a mode of financing for capital investment to LGUs.

The TA was particularly expected to accelerate HSRA implementation in up to 5 convergence sites under HSDP namely Ilocos Norte, Ifugao, Nueva Vizcaya, Mindoro Oriental and Romblon. These HSDP sites are included in the FourMula One 16 sites.

The TA consist of two components: (i) a sustained, focused and coordinated support for reforms; and (ii) a series of initiatives to enhance the capacity of local health care systems. The TA Team was composed of the following

1. Hospital Financial Management Systems specialist to provide recommendation on the pilot-testing of the UMIS to strengthen financial management in the hospital operations and management information system;

2. The Public Health Specialist to develop CPG for priority 10 diseases and TB for children in coordination with PhilHealth;

3. The District Health Planning and Management Specialist to provide assistance on developing local health systems;

4. The Health Care Finance Specialist to work on improving coverage and benefits package for indigent;

5. The Human Resource Management Specialist to work on the health human resource master plan; and

6. The Drug Management and Financial Specialist to provide recommendations to streamline and improve the efficiency of procurement and propose alternative

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cost-efficient management of procurement to improve affordability and improve logistics arrangements.

The TA Team was complemented by the Health and Sector Reform Specialist

(International) acting as Team leader and a Health Administration Specialist as Deputy Team Leader, and other International and domestic consultants The TA support was focused on providing policy environment necessary for the implementation of reforms under FourMula One for Health and as defined in the conditionalities under the ADB Program loan. The DOH, PHIC and LGU accomplishments with assistance from TA 4647 are the following:

1. Health Financing:

• PhilHealth submitted a confirmation of the inclusion of allocation of the

Sponsored Program in the 2006 budget to Congress; • PhilHealth submitted their financing plan, which allocates subsidies for the

Sponsored Program in 2006; • PhilHealth conducted a market segmentation study on the informal sector; • PhilHealth developed a monitoring and evaluation system of the Sponsored

Program; • PhilHealth designed an information campaign for the progressive premium; • PhilHealth published a report on status of CPG use in accredited hospitals; and • PhilHealth expanded POGI for national implementation under KASAPI

2. Hospital:

• DOH designed a UMIS for pilot testing and entered into a MOA with selected hospitals for test;

• DOH issued an AO on implementation of continuing quality improvement; • PhilHealth endorsed the CQI as criteria for accreditation of all hospitals; • DOH issued an AO to adopt a policy on governing boards of all public hospitals; • DOH evaluation report on progress and experience of corporatizing the two

selected DOH hospitals done; • DOH issued an AO to adopt performance-based allocation of (national)

subsidies for 2006;

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• DOH implements guidelines on revenue retention for DOH hospitals; • DOH completed human resource assessment for 30% of DOH hospitals; • DOH issues AO to state a policy on rationalizing local public hospitals based on

need; • Provincial ordinances from three HSDP provinces authorizing their (provincial)

hospitals to earn, retain and use their income formulated and issued; and • DOH issues an AO to implement the public and private hospital waste

management guidelines. 3. Public Health:

• DOH issued an AO to adopt the revised expenditures targets for public health

spending and hospital-based services; • DOH developed a framework to establish long term performance-based

budgeting for priority public health programs; • DOH drafted a bill for Congress review to institutionalize long-term

performance-based budgeting for priority public health programs; • DOH revised the Philippines National Drug Formulary to include contraceptives

(pills, injectibles, and IUDs); • DOH issued an AO on partnerships with the private sector for delivery of public

health programs, specifically tuberculosis and family planning; and • DOH and selected private health organizations signed a MOA on public-private

partnerships on tuberculosis and women’s health and safe motherhood programs.

4. Health Regulation:

• DOH drafted a bill for Congress review proposing amendments of the

mandates of DOH regulatory agencies to increase efficiency in health care provision;

• DOH and PHIC reviewed and updated the administrative issuances and circulars on licensing and accreditation standards of health facilities;

• DOH issues an AO on certification mechanism for primary health care services providers based on service capacity and quality;

• DOH issued an AO and new regulations on drug management in order to reduce drug prices;

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• DOH issued an AO and new regulations on drug management in order to reduce drug prices;

• DOH and PHIC established a regularly updated and published drug price reference/monitoring system, involving related public and private agencies, consumer organizations, and the academe, among others;

• DOH and PHIC reviewed and issued Department Orders (DO) and circulars in updating PNDF based on the needs of drug management needs of PHIC benefit packages and LGUs;

5. Local Health System:

• DOH, PHIC and LGUs approved a MOA, which commits to (i) establishing

ILHZs, (ii) enrolling the poor in PHIC indigents program, (iii) setting up enrollment centers, and (iv) upgrading strategic health facilities to meet PHIC accreditation and licensing requirements and DOH certification standards for RHUs and BHSs;

• DOH issued an AO to approve incentive schemes supporting sustainable operations of ILHZs;

• EO 205 (1999) converted to mandates (a) DOH and DILG to form national health planning committee and (b) ILHZ into a Republic Act, DOH submits a draft plan for Congress review;

• LGUs signed a MOA to establish ILHZ in at least three of the 13 areas identified by DOH in five project provinces; and • DOH presented an issue paper on the inappropriateness of licensing ILHZ

and that the proper instrument is for systems accreditation of ILHZ. 6. Governance:

• DOH developed and approved a comprehensive plan for health human resource assessment and capacity development;

• DOH issued the first update of short- and medium-term plans for DOH and project provinces in support of HSRA implementation;

• DOH through a consultation process with relevant stakeholders developed and approved a standard instrument for measuring the effectiveness of consumer participation, and tests; and

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Incoming TA 4647

With the FourMula ONE for health (F1) launched in 2005, the TA 4647-PHI support needs to realign its undertaking to support the attainment of the F1 goals. It has been agreed among partners to call upon new set of specialists with revised Terms of Reference.

Key policies needed in FourMula ONE have been formulated with the assistance of ADB TA team 4647. The succeeding work of the current TA is now being aligned towards capacity building for the health sector, to ensure success in the implementation of policies developed and continuing support to the compliance of the Program loan. Capacity building activities will involve policy dissemination and advocacy, training, preparation of DOH technical assistance packages to the health sector, monitoring and evaluation, and designing of incentives for performance.

A team of international and domestic consultants will implement the technical assistance (TA). There will be 3 international experts: the health sector reform specialist (team leader), health systems and social health insurance. There are nine domestic experts as follows: health administration (deputy team leader): district health planning and management, hospital financial management system, health care finance, public health, drug management and financing, human resource management, monitoring and evaluation and communication and marketing. All consultants will work in close collaboration with DOH, ADB, and other development partners supporting the FourMula One for Health.

The overall deliverables of the TA are the (i) preparation of Health Sector Reform Agenda (HSRA) national implementation plans, particularly capacity building for the key reform policies of FourMula One for Health, (ii) preparation for implementing reforms at the local HSDP project sites. The International Consultant Health Sector Reform Specialist - Team Leader - will help technically conceptualize and guide the HSRA reform activities under F1, and help accelerate F1 reforms through the HSDP, including the program loan, the investment loan, and the TA. The International Health Systems Specialist shall formulate a Technical Reference Manual for Rationalizing Health Service Delivery Systems based on needs to achieve efficient, quality and appropriate health care. The Social Health Insurance Specialist will propose an improved benefits package for beneficiaries under PhilHealth, especially

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the indigents and those in the informal sector, assist in developing actuarial forecasts on revenues and payments, and recommend a progressive premium, assess the beneficiaries’ needs to propose the inclusion of services in the benefits package, and determine the feasibility of implementing the benefits package and its corresponding premium implications.

The domestic team, with the Health Administration Specialist as the deputy

team leader, will coordinate and administer the TA project and provide technical support. The Hospital Financial Management Systems Specialist shall work with DOH and selected hospitals in the LGUs to strengthen the hospital financial management. The consultant will provide capacity building support for the operationalization of the Administrative Orders (AO) on the Performance Based Budgeting for Hospitals and Rationalization of Health Facilities. The PH CPG Specialist will conduct the baseline study for CPG utilization while the Public Health Specialist will formulate an integrated framework for the operationalization of the Performance-Based Budgeting for Public Health and Performance Based Awards. The District Health Planning and Management Specialist shall develop LGUs’ capacity in planning and designing capability building activities for the operationalization of key policies in FourMula One including the Administrative Orders on the framework for Incentive Schemes supporting sustainable operations of ILHZs and the A.O. Mandating the Consumers Participation strategies for F1 and Measuring its effectiveness .The Health Care Finance Specialists shall formulate business plan template and tools, develop the guidelines for the development of the business plans and its operationalization and formulate the business plans for selected HSDP sites. The Human Resource Management Specialist will validate Learning and Development (L&D) needs of LGUs and DOH, formulate Retooling and Retraining (R&R)/Learning and Development (L&D)/ Capability Building (CB) Plan contained in the Province-wide Investment Plans for Health (PIPHs) and develop the training design including the templates, tools, methodology, and guidelines for the Training activities on capacity enhancements of implementing key policies of F1. The Drug Management and Financial Specialist will provide recommendations to streamline and improve the efficiency of procurement and identify policies that need to be developed for an effective drug management and sustained financing. The Monitoring and Evaluation (M & E) Specialist will formulate a Framework for Monitoring and Evaluating F1 at the national and LGU sites levels and design the needed templates, guidelines, and data to operationalize and institutionalized M&E. The Communication and Marketing Specialist will package a

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communication and marketing program for the dissemination of policies for FourMula One for Health.

All the consultants will complete all the technical outputs under the guidance of the international consultant on health sector reform and will report to the Deputy Team Leader for all operations during the period of the TA. See Annex 2 for the details of the Terms of Reference of incoming TA 4647-PHI

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Accomplishments are as follows:

1. Discussion and agreements on the formulation of the revised and new TOR on Public Health completed;

2. Formulation of the implementation plan from August 2006 to March 2007; 3. Inception Workshop conducted; and 4. Continuing work on the compliance of the Program Loan policy matrix on the

following: Health Financing:

• PhilHealth Board to approve a new premium policy allowing progressive premium structure;

• PhilHealth Board approves a progressive premium contribution scheme based on individuals’ capacity to pay for poor households under the poverty line but ineligible for Sponsored Program;

• Based on detailed cost database and analysis, PhilHealth Board to approve a revised benefit package;

• PhilHealth publishes a performance report on the status of the utilization of the 10 CPGs for quality assurance;

• PhilHealth submits a Board-approved Medium Term Plans (MTPs) for 2005-2012 including actuarial forecast on revenues and payments; and

• PhilHealth and organized groups in informal sector develop MOA in all HSDP provinces to implement POGI.

Local Health Systems:

• Formulate business plans for 3 ILHZs Implementation arrangements

The TA will work in close coordination with the Department of Health and other agencies, the Philippines Health Insurance Corporation, local government units, and stakeholders. It will also work in close collaboration with other development partners supporting HSRA. The TA spans 18 months. The initial Phase was implemented from September 2005 to July 2006 and the succeeding phase will continue its implementation with the new Terms of Reference to support FourMula ONE for Health from August 2006 to March 2007. The TA technical advisor will oversee the work of the TA team, and the TA manager will coordinate with the

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Government and other involved stakeholders. The TA team will be guided by the Assistant Secretary for Sectoral Management of the Department of Health (DOH) through the director of the health policy development and planning bureau, and receive technical guidance from the project team leader of the Asian Development Bank (ADB) -supported Health Sector Development Program (HSDP). With the new TOR to provide capacity building for the F1 policies formulated with ADB support, the team will have the same composition with additional specialist required to provide support to the F1, the Monitoring and Evaluation Specialist and the Communication and Marketing Specialist.

The DOH technical coordinating group (TCG) will oversee the progress of the TA, ensure its coherence with government policy and the efficient delivery of the outputs, and guide and review the outputs of consultants. The Government of the Republic of the Philippines and the Asian Development Bank (ADB) partnership will direct the capacity building for the health sector, to ensure success in the implementation of policies developed. Capacity building activities will involve policy dissemination and advocacy, training, preparation of DOH technical assistance packages to the health sector, monitoring and evaluation, and designing of incentives for performance. III. Inception Workshop

An Inception Workshop was conducted by the Incoming Technical Assistance Team ADB TA 4647 to discuss the major milestones undertaken in the previous months as well as to map out their work plan and major benchmarks, deliverables and timelines with their corresponding organic partner bureaus and offices within the Department of Health and PhilHealth. This took place last August 29, 2006 from 9:00 AM to 3:00 PM at the HSDP Conference Room of the Department of Health, Sta. Cruz, Manila. Present were the members of the new ADB TA Team led by Deputy Team Leader and Health Administration Specialist, Dr. Maria Ofelia O. Alcantara and several representatives and personnel of the Department of Health.

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Objective of the Inception Workshop: The objectives of the workshop are the following:

1. To discuss the Technical Assistance priorities and create consensus on the past and present status of the TA 4647-PHI Support to the Health Sector Development Program (HSDP) to include Initial and Incoming TA;

2. To present and discuss the work plan from August 2006-March 2007 and create consensus on how to implement the current priorities of DOH and ADB for the TA in light of recent policy developments and the FourMula One for Health; and

3. To determine the project implementation arrangement and achieve agreement on timelines for the implementation of the project including reporting schedules to DOH and ADB and the conduct of field visits.

Opening Ceremony:

The Inception Workshop began with an Invocation led by Master of Ceremonies and the HR Specialist, Ms. Amelia Torrente. This was followed by Assistant Secretary Mario C. Villaverde’s opening message and remarks. Asec. Villaverde reported on how the Department of Health was able to obtain funding support through loans from the Asian Development Bank for the implementation of all its major policy reforms. He also underscored the role played by the initial TA Team in the development and completion of the policy loan conditionalities entered into by both the Department of Finance through the Department of Health and ADB. He added that the incoming TA team will now be challenged and tasked to facilitate and assist in the operationalization of all the policies instituted through capability development, standards setting and production of implementing rules and regulations and manuals. To set the tone of the workshop, Ms. Torrente requested the participants to briefly make self introductions.

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Discussion on the Inception Workshop: To start the discussion of the TA, Dr. Ofelia Alcantara presented the TA 4647 to include support of TA to the Program Loan and the Investment Loan goals. The accomplishments of the initial TA which are mostly on facilitating compliance to the Program Loan and incoming TA will work on the initial activities for the designing of the capacity building for the policies developed. The new TOR of the TA, the composition of the TA team and the implementation arrangement were discussed. See Annex 4 for the PowerPoint presentation of the TOR of the TA 4647. In order to discuss the implementation schedule, the work plan of the new incoming TA with the revised TOR was presented. The organic partners were requested to make comments and additional inputs on the work plan. See Annex 5 for the PowerPoint presentation on the TA Work plan.

Open Forum: In the open forum, the discussions were on the execution of the plan, logistical support of the TA to include workshops, meetings, field travels among others. Below is the table summary of the discussions during the open forum: Area of Concerns Discussions Agreements

1. Logistic support of the TA

The activities identified for the project will need budgetary support.

DTL to confer with Par of InDevelop on the project operating cost. Budget for travel and field visit of the TA team will be sourced from the TA while the expenses of organic partners will be charged to budgets of their respective offices.

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2. Perfecting the contracts of the TA team

Waiting for InDevelop recommendation and action. The contracts of the TA team are being processed by InDevelop.

DTL to follow-up with Par of InDevelop.

3. Implementation arrangement

It was recommended that the organic partner be always involved in the process and in the implementation of the TA.

The TA team will make sure that the organic partner is always involved in the project implementation.

4. Submission of the final Inception Report

It was suggested that the final Inception Report be circulated to concerned offices and organic partner before the IR will be submitted to ADB.

DTL to circulate the final IR to the concerned offices and organic partner for final comments.

5. Terms of Reference

There were no issues raised on the new terms of reference.

6. Work plan Some modifications in the schedule may occur subject to availability of funding.

DTL to confer with Par of InDevelop for the availability of the funding for operation and expenses.

Synthesis and Next Steps

DTL provided the synthesis of the workshop and discussed the next steps as follows:

• The individual TA consultant will further discuss the schedules and the budgetary requirements to undertake the defined activities to implement the TA.

• To finalize the Inception report integrating comments from the participants by Sept 4, 2006.

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• To circulate the inception Report to the concerned offices and organic partners by September 5, 2006.

• To send Inception Report to the Team Leader on Sept 4 for comments and further instructions.

• To submit Inception Report to ADB on September 5 copy furnished DOH thru the office of Assec Mario Villaverde.

• To target September 8 for the acceptance of DOH on the Inception Report. • DTL to confer with Par of InDevelop of the Operating budget and the

contracts of the TA team.

IV. Implementation plan The individual consultant’s work plan was developed in close coordination with the DOH counterparts and consolidated to come up with a team implementation plan from August 2006 to March 2007. The plan includes the reporting, workshop, coordinative meetings and field travel schedules and the schedule of activities by reform components and the cross cutting support to implement the TA. The Implementation Plan has been refined in the Inception workshop with the DOH.

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Attachment 8: TA 4647 WORK PLAN February 2007-August 2007-11-23

WORK PLAN February 2007-August 2007Budgetary RequirementsAs of Aug 6 2007

ACTIVITIES with MILESTONES: Cost in Philippine Pesos

Reports/Papers:

Workplan TA 4647 Feb - Aug 2007

Monthly TA Progress Report

March 2007 Progress Report

April Mid Year Progress Report

Technical Reports from Consultants 28

Draft Final Report

Final Report to include admin requirements and project closure

Work Shops/Seminars:

Consultative Meeting with DOH and TA Team : Support to Project Loan: PAM, TOR of Incoming Consultants, Social Marketing, Baseline Study, Project Mgt. TA Coordination and technical updating with DOH, PHIC, other TA/CA and LGUs. 150,000.00

Feb Mar Apr May Jun

Duration

Jul

- Policy Forum SGM

Aug

- Donor scorecard small group meeting

- Pharma meeting with BFAD and PMU 50

ACTIVITIES with MILESTONES: Cost in Philippine PesosDuration

- Other meetings/SGM Aug 2007 -Other meetings prior to August 2007

- March 2007 Progress Report TOTAL Consultative Meetings 150,000.00 April 20 Mid Year Progress Report 6,750.00

Pilot test the CB design in Mindoro 313,000.00

Conduct Consultative Meetings/Workshops and document proceedings- HR Stakeholders mini- WS (May 9, 16, 30)

9 16 30 13,000.00

Consultative Meeting on R and R Plan and the CB design

30-31 117,000.00

R&R Plan Stakeholders (June 15) 15 83,500.00

Present results of pilot course run to key stakeholder in DOH and LGU in TCGConsultative workshop on Rationalization of HFs and PBB for Hospt 1 5,000.00

Capacity Building Design workshop/consultation with local in at least 2 ADB sites Ilocos Norte 111,800.00

Capacity Building Design workshop/consultation with local in at least 2 ADB sites Ifugao 55,000.00

Hospital Stakeholders workshop 5,000.00

PH Stakeholders workshop

- Present CB draft to SMCO cluster Meeting

Consolidate the inputs and finalize draft CB design

ACTIVITIES with MILESTONES: Cost in Philippine PesosDuration

District Health Stakeholders workshop

Pharma Stakeholders Workshop

Writeshop Finalization of the CB design after stakeholders mtgs, consultation with ADB provinces, Consultation with Minority GroupsConsultative workshop with stakeholders the Dissemination Package 166,000.00

Consultative Meeting Health Care Financing

Develop the CHD Scorecards workshop with CHD and LGUs 91,000.00

Policy Forum Advocacy and Dissemination workshop 141,000.00

Final Workshop - Pre 5,400.00

- Actual 133,000.00

Orientation of DOH and CHDs on the program managers on the Templates- Training package, M and E and Incentive package and the TA package. 30,500.00

Dissemination and Advocacy workshop and template and tools Orientation 166,000.00

Policy Matrix Evaluation workshop 140,500.00

Orientation of Program Staff on CB Design Tagaytay 140,250.00

CPG Follow-up workshop 137,250.00

Total Workshop 1,907,200.00

Develop the Donor Scorecards workshop 46,250.00

ACTIVITIES with MILESTONES: Cost in Philippine PesosDuration

TA Team Travels to ADB sites with DOH Ilocos 59,840.00

TA Team Travels to ADB sites with DOH Mindoro 201,280.00

TA Team Travels to ADB sites with DOH Ifugao 76,400.00

Contingency Travel 97,080.00

Total Travel 434,600.00

Admin and Finance Specialist support to TA (Done 2 person mos and Person Months required Feb-Aug 2007- 8 person mos) 345,800.00

Total Admin support Miscellaneous 345,800.00

Logistics Support

Office Supplies 50,000.00

USB Flash drive (10) at P2,500 each. 11,000.00

Equipment:

Cellfone P6 T each Cancelled

LCD Multimedia P80T 40,000.00

Laptop (1) 50T 70,000.00

Desk top with printer (3) at 35T each 111,000.00

Scanner printer fax copier (1) 4 n 1 =6T 6,000.00

digicam SONY 7.2 mp 25T (1) Cancelled

Digital photoprinter SONY with LCD P15T Cancelled

Total Equipment Offcie 288,000.00

ACTIVITIES with MILESTONES: Cost in Philippine PesosDuration

Project Management

Communication

Cellcards load P300 per consultant per week 20,000.00

Internet Access P100 per consultant per week 10,000.00

Transportation

Metro Manila 20,000.00

Courier/ Transfer 2,000.00

Contingency 50,000.00

Total Office Miscellaneous 102,000.00

TOTAL for Cash Advance in Peso 3,227,600.00

Attachment 9: Project Administration Memorandum

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Project Administration Memorandum Project Number: 33278-02 Loan Number: 2137 November 2007

PHI: Health Sector Development Project

The project administration memorandum is an active document, progressively updated and revised as necessary, particularly following any changes in project or program costs, scope, or implementation arrangements. This document, however, may not reflect the latest project or program changes.

Asian Development Bank

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CURRENCY EQUIVALENTS (As of November 2007)

Currency Unit – Peso (P) $1.00 = P 43.00

ABBREVIATIONS ADB – Asian Development Bank BIHC – Bureau of International Health Cooperation CHD – Center for Health Development CPG – clinical practice guidelines DOF – Department of Finance DOH – Department of Health DOTS – Directly Observed Treatment Strategy EA – Executing Agency EMP – Environmental Management Plan F1 – FourMula One for Health HSDP – Health Sector Development Project HPDPB – Health Policy Development and Planning Bureau HSRA – Health Sector Reform Agenda ILHZ – interlocal health zone LA – Loan Agreement LGU – local government unit MDFO – Municipal Development Office NGO – non-government organization PHIC – Philippines Health Insurance Corporation (PhilHealth) PMU – Project Management Unit PPMS – Project Performance Monitoring System SOE – statement of expenditures TA – technical assistance TDNA – training and development needs assessment

NOTES (i) The fiscal year (FY) of the Government and its agencies ends on 31 December. (ii) In this report, "$" refers to US dollars.

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TABLE CONTENTS

PREFACE 5

LOAN PROCESSING HISTORY 6

LOGICAL FRAMEWORK OF THE PROJECT PROJECT DESCRIPTION 7-14 A. Project Area and Location B. Objectives and Scope C. Project Components D. Special Features

II. COST ESTIMATES AND FINANCING PLAN 15-16 A. Detailed Cost Estimates B. Financing Plan C. Allocation of Loan Proceeds

III. IMPLEMENTATION ARRANGEMENTS 17-18 A. Executing and Implementing Agencies B. Project Management Organization

IV. IMPLEMENTATION SCHEDULE 18-19

V. COST ESTIMATES AND FINANCING PLAN DURING IMPLEMENTATION 19

VI. CONSULTANT RECRUITMENT 20

VII. PROCUREMENT 20

VIII. DISBURSEMENT PROCEDURES 21

IX. PROJECT MONITORING AND EVALUATION 22 a. Project Performance Monitoring and Evaluation b. Project Reviews

X. REPORTING REQUIREMENTS 22 A. Project Monitoring Report

XI. AUDITING REQUIREMENTS 22

XII. MAJOR LOAN COVENANTS 23-25

XIII. IMPLEMENTATION OF THE ACCOMPANYING TA 25-26

XIV. KEY PERSONS INVOLVED IN THE PROJECT 27-29

XV. ANTICORRUPTION 29

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APPENDICES 1 : Logical Framework of the HSDP Project 2A : PIPH of Ilocos Norte, Oriental Mindoro and Ifugao 2B : Policy Matrix and Its localization 3 : Cost Estimates and Financing Plan 4 : Financial Agreement and Funds Flow 5 : Project Organization Chart 6 : Project Implementation Schedule (June- December 2005) 7 : Project Implementation Schedule (2006-2011) 8A : Training Plan (2005-2011) 8B : Training Development and Needs Assessment Summary Report 8C : Planned Training for year 2007 8D : Training templates 9 : Indicative Consultant Services – Consulting Services 10 : Detailed Costing of Consultants 11 : Schedule for Consultants 12A : Indicative Contract Packages Civil Works 12B : Ilocos Norte Civil Works 12C : MDFO LGU Subproject Proposal Development and Implementation 12D : MDFO Implementation Requirements 13 : Projected list of equipment, contracts and Annual Disbursement Schedule by Year 14 : Sample Progress Report 15 : Project Performance Report 16 : Sample Audit Letter 17 : Terms of Reference and Reporting Schedule for Technical Assistance Consultants

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PREFACE

The Philippines has progressed towards realizing its health goals in the past decades although the progress has slowed down during recent years. Vital health indices such as life expectancy, infant, child and maternal mortality rates have improved. Despite the inroads made the past decades a number of gaps remain to be filled, the common illnesses of poverty, such as infectious diseases, have not been reduced to acceptable levels. Social and economic changes have created new challenges in terms of degenerative and lifestyle diseases. Further, the organization of the health sector itself suffers from an inappropriate delivery system, inadequate regulatory mechanisms, and inappropriate health care financing schemes. In 1999, the Philippine Government launched the Health Sector Reform Agenda (HSRA) to define key reforms and strategies that address inequities and inefficiencies in the health sector. In 2005, the Department of Health defined FourMula One for Health as the implementation framework for the Health Sector Reform Agenda (HSRA). FourMula ONE for Health is directed at achieving goals of better health outcomes, more responsive health system and equitable health care financing.

The Government of the Republic of the Philippines requested the Asian Development Bank (ADB) for assistance to support the implementation of the Health Sector Reform Agenda (HSRA) in April 2004 and in December 2004, ADB approved two loans totaling US$213 million for a health sector development program and investment project loan in support of the HSRA. Also, ADB has provided a grant TA to support the implementation of the Program Loan and the Investment Loan.

The Health Sector Development Program (HSDP) comprised two loans: A Program loan (Loan 2136-PHI) to support the financing of comprehensive sector reforms and a project loan (Loan 2137-PHI) for implementation of the reforms in selected provinces. The goal of the HSDP is to improve the health status of the population, especially of the poor, and to achieve the health-related Millennium Development Goals (MDGs) of the United Nations. Implementing an integrated set of health sector reforms that benefits the poor will include system-wide changes and the design and implementation of project interventions in selected pilot provinces that build on the HSRA.

The Project Administration Memorandum (PAM) is intended to provide details of the Project, its description, components, project Inputs, financing plan, procurement management, implementation arrangements, TA support, project monitoring and evaluation, major loan covenants to facilitate the implementation of the HSDP Project. Also, the PAM contains the anticorruption policy of the ADB and auditing requirements. The PAM shall be the primary reference during the project implementation and shall be updated periodically to incorporate significant changes in the project scope and implementation arrangements. The project implementation is subject to the provisions of the applicable Loan Agreement and explains the application of the provisions in the loan agreement. This PAM is the second edition and revised November 2007.

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LOAN PROCESSING HISTORY

Date(s)

a. Approval of project preparatory technical assistance 19 December 2002

b. Feasibility study February 2004

c. Fact-finding 5-25 April 2004 d. Management Review Meeting (MRM) 1 October 2004 (1st) 16 November 2004 (2nd)

e. Appraisal mission 11 October-15 November 2004

f. Loan negotiations 22 November 2004

g. Board circulation 24 November 2004

h. Board consideration and approval 15 December 2004

i. Loan agreement signing 10 January 2005

j. Loan effectiveness, including conditions (include available dates)12 January 2005

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I. PROJECT DESCRIPTION A. Project Area and Location 1. The Health Sector Development Project (HSDP) plans to cover five provinces in selected pilot local government units (LGUs)1 which have been surveyed and are eligible for project support: three neighboring provinces in the north of Luzon (Ifugao, Ilocos Norte, and Nueva Vizcaya); and two poor island provinces (Oriental Mindoro and Romblon). To date 3 provinces has availed the loan from MDFO; these provinces are Ilocos Norte, Oriental Mindoro and Ifugao. Romblon was not able to acquire the loan as the province has no capacity to take up another loan while Nueva Viscaya declined as the province can provide the necessary budget for upgrading health facility. B. Objectives and Scope 2. In 1999, DOH launched the Health Sector Reform Agenda (HSRA), which defines key reforms and strategies required to address inequity and inefficiency in the health sector, and achieve the millennium development goals. The goal of the HSRA was to improve the health status of all Filipinos through the implementation of reforms in five general areas: public health, hospitals, regulation, financing and local health systems. In 2005, the DOH defined FourMula One for Health (F1) as the approach for the health sector reform. The F1 is designed to undertake critical reforms with speed, precision and effective coordination directed at improving the efficiency, effectiveness and equity of the Philippine health system in a manner that is felt and appreciated by Filipinos, especially the poor. FourMula ONE for Health is directed at achieving the end goals of better health outcomes, more responsive health system and equitable health care financing. The FourMula ONE for Health pursues critical reforms for a more, better and sustained financing, assuring quality and affordability through regulation and ensuring access and availability in service delivery and improving performance and governance. The reforms will contribute to the national goals of (i) increased financial protection for the poor from the costs of poor health, and (ii) improved public health outcomes, and (iii) increased responsiveness of the health system, especially in relation to conditions, diseases and services that are critical for the achievement of the health-related Millennium Development Goals.

3. The goal of the HSDP is to improve the health status of the population, especially of the poor, and to achieve the health-related Millennium Development Goals (MDGs) of the United Nations. Implementing an integrated set of health sector reforms that benefits the poor will include system-wide changes and the design and implementation of project interventions in selected pilot provinces that build on the HSRA. The HSDP will advocate, design, initiate, and evaluate specific interventions in support of the HSRA, at the national level and in the HSDP selected provinces with the objective to translate agreed policy reform into changes in corporate cultures and in concrete improvements of health services, especially for the poor. The Project will improve the efficiency and effectiveness of 1 Clusters of LGUs designated as pilot sites for the HSRA are called convergence sites.

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delivery of health care to the poor by focusing on the investments and HSRA reforms needed to implement a number of clinical practice guidelines (CPGs) critical to the health of the poor. Interventions will support the implementation of these CPGs in selected convergence sites, and in DOH, Philippines Health Insurance Corporation (PHIC) and other agencies at the central and regional levels. The HSRA delineates the range of issues to be addressed to accelerate reduction of poverty caused by and contributing to ill health. 4. HSDP will result in more affordable and better quality health care, and thus increase utilization through cost savings and output enhancing health sector reforms in six areas: (i) rationalizing health care financing and increasing health insurance coverage of the poor; (ii) improving governance, operational efficiency, and service provision of public hospitals; (iii) increasing utilization of improved public health care services; (iv) strengthening regulatory functions for improved quality, efficiency, and safety; (v) promoting service integration in local health systems; and (vi) promoting organizational effectiveness and public accountability in the health sector. The Logical Framework of the HSDP Project is in Appendix 1. C. Project Components 5. The Project consists of five components implemented through two funding streams. DOH will finance consultancy and sector capacity building activity and investments to support F1implementation. The Municipal Development Fund Office (MDFO) will provide finance to LGUs to undertake required civil works and equipment purchase. The integration of activity and outputs across the five components is set out below. a. Health Sector Governance 6. This component will strengthen participating provinces and LGUs to implement the HSRA. Focusing on the promotion of a cross-disciplinary culture promoting efficient and effective care, it will enhance appropriate administrative and clinical skills, encourage adoption of improved clinical protocols (CPGs and clinical pathways), facilitate participation in health management and planning, and strengthen monitoring systems that allow effective oversight. To strengthen DOH, capacity building at all levels will be supported by a master plan, specific staff development activities, fellowships and information campaigns. Crucial expertise in areas like health financing and economics, management, sociology and anthropology, and marketing will be needed at national, provincial, and municipal health offices. The Project will help DOH design and develop a national resource center. The center will be established (i) to provide policy analysis and advice, (ii) to spearhead operations research, and (iii) as a repository of HSRA resource materials. The center will systematically document lessons learned from HSRA implementation in the provinces, as well as compile and disseminate health-related information based on a revamped health information system. Consumer satisfaction surveys, reflecting the perceived quality of services, will be initiated and the results published to support informed choice and foster competition. This component will provide the resources to design the systems for extension of PhilHealth coverage to lower income groups, implemented through the following components. Other activities under this component are more logically discussed

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in relation to the components they support and are set out in the following sections. 7. The Clinical practice guidelines are systematically developed statements based on current professional knowledge designed to influence physicians’ decision making. They are touted as vehicles for improving the quality of health care and decreasing costs and utilization. They are supposed to form the basis for assessing accountability in the delivery of health care services. The most efficient way to promote clinical practice guideline utilization is when it is used to improve the quality of health care. In this project the following conceptual framework for the work plan is recommended: The framework presented below emphasized that clinical practice guidelines are not the intended outcome by itself. The ultimate outcome is the improvement of the physicians’ performance and quality of health care. Clinical practice guidelines are just instruments or tools to achieve a health care objective. Thus clinical practice guideline dissemination and implementation should be the primary focus of clinical practice guideline activities rather than just development. The Technical Assistance Grant provided support in enhancing the CPG utilization by conducting a study on CPG utilization and outcome of the study was utilized by PhilHealth in its policy development on Quality Assurance. The outcome of the study was also integrated in the capacity design for operationalization of HSRA policies. 8. With F1, the approach in good governance was enhanced to improve health systems performance at the national and local levels. FourMula ONE for Health will introduce interventions to improve governance in local health systems, improve coordination across local health systems, enhance effective private-public partnership, and improve national capacities to manage the health sector. The FourMula ONE for Health is geared at Establishing FOUR-IN-ONE Health Development Sites, Developing an LGU FourMula ONE for Health Scorecard, Institutionalizing a FourMula ONE for Health Expanded Professional Career Track. Implementation of the reforms shall be an integrated implementation of FourMula ONE for Health components in appropriately delineated localities or inter-local health zones. Assistance and support will be provided to targeted provinces in the areas of financing, regulation, service delivery and governance to improve local health systems performance. 9. The initial 16 FourMula One for Health sites includes the HSDP sites and has formulated the Province wide Investment Plan for Health. Under F1, the PIPH is the key instrument in forging DOH-LGU partnership to achieve the health sector goals of better health outcomes, more responsive health system and equitable health care financing. As an approach to health reforms, PIPH builds upon lessons from previous DOH efforts to collaborate with LGUs including the convergence site development under the Health Sector Reform Agenda (HSRA) supported by various Sector-wide Development Approach to Health (SDAH) partners. Appendix 2A: PIPH of the HSDP supported Provinces of Ilocos Norte, Ifugao, and Mindoro Oriental.

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b. Regulatory Reforms 10. This component will provide systems to DOH and LGUs to bolster cost-efficiency in the health sector. DOH will institute systems to help LGUs (provinces, municipalities, and villages) increase efficiency and reduce the cost of essential drug purchases, promoting the use of generic drugs. The devolution of some functions of the Bureau of Food and Drugs, such as monitoring and rapid preliminary testing of drug quality, will be piloted in the project area. DOH will help LGUs and Interlocal health zones (ILHZs) to establish already successfully tested mechanisms for the procurement and distribution of pharmaceuticals, such as outsourcing the procurement of drugs and pooled procurement. Activities under the health sector governance component will design and test approaches like social franchising in the pharmaceutical sector, currently tested in more than 10 provinces, which is regarded as appropriate for procurement and distribution of low-cost quality medicines to remote areas and supporting involvement of the private health sector. Activities to enhance proper drug supply management and rational use of drugs shall be promoted to maximize the gains of improved access to low-cost quality drugs. Also under the health sector governance component, DOH will carefully monitor LGUs and ILHZs to ensure satisfactory performance before continuing and extending the new policies. 11. Capability building based on policy reforms and best practices of drug management shall be drawn for the different levels of health care providers and managers responsible for improved access to drugs, assurance of quality, and rational use of drugs. The health care providers and managers shall include those from the level of the regional CHD to the province, municipality and village. The administrative orders on the Philippine National Drug Formulary System and the Essential Drug Price Monitoring System shall form the core of the policy bases for regulatory reforms, but other available pertinent legal documents and recommendations will be used to form a comprehensive approach in formulating effective tools for effective drug management. Where gaps in policy are identified, appropriate recommendations will be made. The TA (4647) grant provided support for the regulatory reforms on the development of the capacity building design for operationalizing the administrative orders on the Philippine National Drug Formulary System and the Essential Drug Price Monitoring System. 12. The main goal of health regulation under FourMula ONE for Health is to assure access to quality and affordable health products, devices, facilities and services, especially those used by the poor and implement two prong strategies namely harmonizing licensing, accreditation and certification (supply side) and issuance of quality seals (demand side). FourMula ONE for Health will harmonize the health regulatory requirements, systems and procedures to become more client-responsive, rational and streamlined. Specific interventions under FourMula ONE for Health regulatory reforms includes establishing a “One-stop Shop” for the licensing of health facilities, automating regulatory systems and processes, integrating accreditation and certification into a unified “seal of approval” , introducing intensive, less frequent and incentive-based regulatory procedures and decentralizing regulatory functions to regional offices and LGUs. Also part of the FourMula ONE regulatory priorities is assuring the availability of low-priced yet quality essential medicines commonly used by the poor through the following

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mechanisms: a) promoting high quality generic pharmaceutical products, b) expanding drug distribution networks (national and local hospital pharmacies, c) Botika ng Barangay, Botika ng Bayan) and d) identifying alternative local and foreign sources of low-priced branded drugs. 13. To support these initiatives, performance will become the basis for resource allocation through the PhilHealth insurance system. Designed under the health sector governance component, other cost-containment measures such as the introduction of competition into the provision of services, guidelines on the procurement of high-end medical equipment, and the provision of expensive health services, will also be implemented to avoid oversupply and cost- inefficiencies. The Project will provide systems to PhilHealth so it may adopt a fee schedule for reimbursement of services and pharmaceuticals, which contains appropriate incentives to make health care service provision more accessible, competitive, and equitable both in public and in private facilities. c. Local Health Sector Reform 14. This component will invest in improved health care systems and facilities at the LGU level, enhancing their sustainability and effectiveness. Project resources will be used to implement an agreed package of CPG-focused interventions in a sequenced manner, based on a business plan and the actual performance of the concerned LGUs. The Project will support the development of systems to administer ILHZs, and establishment of an efficient and effective referral network of health facilities linking primary health care services with hospital services and public health programs. In return for project assistance, the LGUs will have to first ensure the coverage of the local poor under PhilHealth. Enrollment of people in the non-formal sector will be encouraged using a range of locally appropriate incentives, including group enrollment through organized groups. The existing means test will be reviewed to improve targeting of government subsidies. When LGUs meet the coverage conditions, project funds will be released to rehabilitate local primary and secondary health care facilities to conform to licensing and accreditation requirements. The availability of affordable quality drugs is a major problem in the health sector, and the Project will integrate mechanisms for the procurement and management of drugs (logistics management, inventory control, and rational use of drugs) established under the health sector governance and regulatory reform components in every ILHZ. In agreement with the concerned LGUs, the Project has undertaken 13 case studies of ILHZ implementation in Ifugao, Ilocos Norte, Nueva Vizcaya, Oriental Mindoro, and Romblon. ILHZ will involve both public and private health sector providers. Important TA inputs will also be in the field of setting up consumer participation strategies and mechanisms at all levels of facilities and the implementation of incentive schemes for ILHZ functionalities. 15. As the Project concentrates on the needs of the poor, marginalized and vulnerable, specific project activities will focus on building their capacity to help themselves, facilitate their representation in local health boards, and increase their utilization of health services taking advantage of PhilHealth coverage. Information campaigns specifically designed for the poor and marginalized groups will be implemented, explaining PhilHealth benefits besides the traditional health

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information campaigns related to disease prevention and promotion of healthy lifestyle. Through ILHZ outreach activities, community financing to cover health costs not reimbursed by PhilHealth (transport to hospital, outpatient drugs, etc), and group activities in support of health-related activities such as water supply, sanitation, and nutrition-related improvements will be encouraged. The health sector governance component will establish a community-focused database, building on the Department of Interior Local Government initiative started in 2002, to improve identification of poor and vulnerable groups. In F1, the LHS reform is integrated in the Good Governance reforms and will introduce interventions to improve governance in local health systems. The TA grant support to local health system was the development of the capacity building design for operationalizing ILHZ cooperation and incentives and the consumer participation administrative orders.

d. Hospital Reform

6. The objective of this component is to enhance sustainability and efficiency of hospitals by restructuring them into corporations and support participation of the private and nonprofit sector integrated into CPGs. ILHZ and coordination mechanisms have been developed, and hospital financial autonomy and capacity building activities will be undertaken through the governance reform component. Project funds will be used to rehabilitate local public hospitals, with the objectives to (i) provide better quality services, particularly for the poor, and (ii) stimulate healthy competition between public and private health sector providers based on the quality of services offered. Civil works will mainly consist of rehabilitating and upgrading existing health facilities in the HSDP sites. In some cases, hospitals will be expanded and some primary health care facilities will be built in poorly served remote areas (particularly in areas with indigenous people). An initial environmental examination was performed for the civil works to be financed by the HSDP (Appendix 12A). The Project will also finance the procurement of medical and office equipment. Recurrent costs generated by these investments in the local health system will be compensated by efficiency gains and resulting cost savings. The governance component will assist PhilHealth to design benefit packages and systems to reinforce the objectives of hospital reform.

17. The technical assistance for this project will be focused on the rationalization of health facilities and performance-based budgeting. The rationalization process involves the documentation and assessment of health resources against standards or accepted indicators. Based on this, a plan is formulated to optimize their use. When implemented, (1) it will solve barriers to health access by proper placement of health facilities in strategic areas; (2) ensure availability of health services by providing the right inputs (infrastructure, equipment, funds and personnel) in the strategic facilities; (3) and improve efficiency through conscious and careful management of these resources. The third item will be facilitated through the adoption of a performance based budgeting process. This will link hospital performance with financial incentives. Generally, it will divide the Maintenance and Other Operating Expenditure budget of hospitals into portions (i.e. funds for the public health programs, basic allocation fund, and performance based allocation fund-PBOF). The PBOF shall be released to the hospital only upon meeting a pre-agreed set of performance indicators.

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Hospitals that fall short of the performance level will automatically forfeit their PBOF. The funds will go to a common pool where top hospital performers will be able to claim access by submitting a Health Facility Enhancement Plan. The rationalization of health facilities and performance based budgeting process can be done at the local levels. e. Public Health Reform 18. This component will provide cost-efficient systems for effective public health programs integrated into CPGs. The Project will support in particular the implementation of the program against tuberculosis and reproductive health. Program implementation and subsidies will be linked to performance in the ILHZs and project LGUs. For tuberculosis, the Project will strengthen the World Health Organization-recommended DOTS.2 For reproductive health and family planning, the Project will support the implementation of a core package of services developed by DOH under the Second Women’s Health and Safe Motherhood Project. The governance component of the Project will provide systems design and support for effective operation of public health systems at LGU and provincial levels, and for related PhilHealth systems. Introduction of performance based management approach in health shall re-focus health programs to achieving results and better accountability at all levels. Health plans shall be more strategic, integrating measures to improve efficiency to cut wastages and leakages. Management reforms and organizational adaptation shall be encouraged to improve program implementation and monitoring. 19. Clinical practice guidelines can provide a framework for the development of outcome and performance measures that can be used in a process to improve care. The process is referred to as quality improvement and is emphasized in the PHIC Benchbook. Quality improvement is simply a method for continuously finding means and ways to provide better patient care and services. The purpose of implementing CPG and linking it with PHIC Benchbook is to enable the RHU personnel to evaluate their own and their colleague’s performance in terms of compliance to specific guidelines in order to improve quality of care delivered to the patients they serve. An additional objective is to evaluate RHU equipment and facilities that will aid in quality service delivery. Majority if not all of the district hospitals do not have a residency training program because all of the activities are for the provision of health services like emergency care, in-hospital care for secondary cases and maternal and child health. As described in the PHIC Benchbook, the use of one-to-one learning and feedback or mentoring is most appropriate in this setting since it capitalizes on the characteristics of the health care providers such as self-directedness and need to balance learning time and work. It is also suitable in tackling current learning need and linking prior knowledge with new clinical experiences in an environment of friendship, trust and respect. 20. Clinical practice guidelines can also assist the formulation and implementation of health policies like the PHIC Benchbook. Guidelines may be developed for under-recognized health problems, poorly delivered health services and preventive interventions to neglected patients or high risk groups. These

2 Directly Observed Treatment Strategy (DOTS) is the most effective strategy available today for controlling

the tuberculosis epidemic. DOTS combines five elements: political commitment, microscopy services, drug supplies, surveillance and monitoring systems, and use of highly efficacious regimes with direct observation of treatment.

14

guidelines can address equity issues that may best be implemented through policy-mediated interventions. This way, guidelines will actually promote distributive justice and advocate delivery of better services to those who are in need especially those who have poor capacity to pay. In our health care system, there are very limited resources and guidelines that can be used to channel resources to more effective services leading to increase efficiency of health system. 21. In F1 the hospital and public health reforms are integrated as one component in the Health Service Delivery reforms which aimed at improving accessibility and availability of basic and essential health care for all, particularly the poor. The reforms cover all the public and private facilities and services. The main concerns for service delivery are to ensure availability of providers of basic and essential health services in localities, designate providers of specific and specialized services in localities, upgrade health facilities and develop human resources and intensify public health programs in targeted localities. Parallel to ensuring the availability of capable providers of quality basic and specialized health services in strategic locations, the upgrading of hospitals, ambulatory clinics and health centers, as well as the skills development of health professionals in these facilities, will be pursued. F1 will intensify current efforts to reduce public health threats in specific localities to include undertaking disease-free zones initiative, implementing intensified disease prevention and control strategy and enhancing health promotion and disease surveillance. The TA grant supported the operationalization of policy capacity building design of the Performance based Budgeting for public health Administrative Order. d. Special Features 22. The HSDP will implement all proposed policy changes developed under the Program loan. These policies are shown in Appendix 2B. HSDP was designed as a poverty intervention, thus, even if the Project area includes provinces with high and low fiscal capacity, the focus will be on the needs of the poor and marginalized groups with special attention to indigenous people. Evaluation of the Project will be carried out through a set of baseline and end-of-Project surveys, to be undertaken by non-government organizations (NGOs), to be contracted by DOH.

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II. COST ESTIMATES AND FINANCING PLAN

A. Detailed Cost Estimates 23. The adjusted Project costs amount to $13.0 million, with $ 4.380 million accruing to national organizations and $ 6.450 million for LGUs. The remaining $ 2.170 million covers contingencies, interest, and other charges. Detailed adjusted Cost Estimates and Financing Plan for the project is shown in Appendix 3. B. Financing Plan 24. The Project loan of $13 million from ADB’s ordinary capital resources is 56% of the total costs. The loan will have a 26-year term, including a grace period of 6 year, an interest rate determined in accordance with ADB’s LIBOR-based lending facility and a commitment charge of 0.75% per annum. ADB will fund 100% of the foreign exchange cost, totaling 28% of the total project cost, and 40% of the local currency cost. The Government will provide the remaining $10.3 million equivalent as counterpart financing, which accounts for 44% of the total costs. The financing plan is summarized in Table 2.

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Table 2: Financing Plan ($ million)

Source Foreign Exchange

Local Currency

Total Cost

Percent

ADB 6.25 6.75 13.00 56 Government 0.00 10.33 10.33 44 Department of Health 8.88 8.88 Local government

units 1.45 1.45

Total 6.25 17.08 23.33 100 C. Allocation of Loan Proceeds 25. As provided in Attachment to Schedule 3 of the Loan Agreement, the adjusted allocations by component with related percentages of ADB financing is provided in Table 3. Appendix 4 shows the financial arrangement and funds flow.

Table 3: Adjusted Allocation and Withdrawal of Loan Proceeds ($)

Allocation and Withdrawal of Loan Proceeds – Re-Allocated Cost

CATEGORY PERCENTAGE OF ADB FINANCING

Amount Allocated Number Item

Category Sub-

category

Percentage Basis for Withdrawal from the Loan Account

1 Civil Works 4,420,000 65

Percent of total expenditure (65% for Local)

2 Equipment 3,280,000 100 Percent of foreign expenditure

3 Consulting Services

1,070,000 100 Percent of foreign expenditure

4 Training & Workshops

200,000 100 Percent of foreign expenditure

5 Research & Studies

220,000 100 Percent of foreign expenditure

6 Project Management

520,000 100 Percent of foreign expenditure

7

Interest & Commitment Charges

2,170,000 100 Percent of amounts due

8 Unallocated 1,120,000 Amounts due

Total 13,000,000

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III. IMPLEMENTATION ARRANGEMENTS A. Executing and Implementing Agencies 26. DOH will be the Executing Agency for the Project and provide overall

guidance for project implementation. The Bureau of International Health and Cooperation (BIHC) will be responsible for the overall management under the overall guidance of a program inter-agency steering committee, headed by the DOH Secretary. BIHC will be assisted by a team of management implementation consultants to support the implementation of the project.

The role of the different offices:

• Central Office: a. Program directors especially from the National Center for Disease

Prevention and Control and National Center for Health Facilities Development and from PhilHealth from shall provide the technical directions on program concerns with the Health Policy Development and Planning Bureau as the over-all in providing technical and policy directions.

b. The Bureau of Local Health shall provide the technical assistance in the local health systems development.

• Center for Health Development

a. Provide the technical assistance to specific provinces in operationalizing polices for the health Sector Reform and in the implementation of the HSDP project. Technical assistance of CHD shall be in the areas of implementation the Provincial Investment Plan for Health, TA on the rationalization of Health Facilities and Performance Based budgeting, Inter Local Government cooperation and incentives, consumer participation, and drug management.

b. Provide technical assistance to define the package of minimum health care for the LGUs, and strengthen technical and managerial capability at the local level to improve LGU performance

c. Rationalize the role of DOH hospitals to complement health care services provided by the LGUs and private sector and facilitate compliance to accreditation requirements of health facilities, products, and services

d. Provide venue for inter-agency coordination including other layers in the health sector in a given locality

e. Monitor and evaluate LGU performance through the LGU scorecard and develop incentive mechanisms for LGUs towards better performance in the delivery of health care

• Provincial Level

a. At the provincial level, project management units (PMUs) headed by the Provincial Health Officer will be responsible for the implementation of the Project with the governor as the provincial

18

project director, assisted by teams of management and technical consultants.

b. BIHC shall provide support to MDFO with respect to the Sub-loan assessment and administration of subproject loan at the LGU level.

B. Project Management Organization 27. The director of the Health Policy Development and Planning Bureau will be the overall project technical coordinator while the head of the BIHC will be the overall project manager and the DOH-Project Implementation Officer will be the designated project director. The Secretary of Health will chair the steering committee providing overall guidance to the Project. Members will include Department of Finance (DOF), MDFO, PhilHealth, representatives of the private sector (NGOs, professional associations, private health care providers), and consumer groups. 28. The Directors of the Center for Health Development will be the regional project supervisor and will designate the existing Local Health Assistance Division/ Regional project management team as the regional supervisory unit for the Project. The regional project management team will (i) ensure coordination between BIHC at the national level and the project province(s) in their jurisdiction; (ii) provide technical support when appropriate; and (iii) be responsible for monitoring, evaluation and auditing of project activities. 29. In the provinces, the provincial governor will be the project director and the provincial health officer the project coordinator. The provincial steering committee will be comprised of the governor, project coordinator, and chairs of the ILHZ boards. The provincial project coordinator will assign one of his/her permanent staff as provincial project manager assisted by a team of consultants and technical health experts, who will form the provincial PMU, which will be directly responsible for implementation of project activities in the province. The provincial project director will facilitate establishment of an ILHZ, which will have a board and permanent secretariat. Each year, the ILHZ will prepare an operational plan (comprising a plan of action, a program of activities, and a financial plan) that will be submitted to the national BIHC for approval, with a copy to the Health Policy Development and Planning Bureau via the regional health office. The Project Organization Chart is in Appendix 5.

IV. IMPLEMENTATION SCHEDULE 30. For efficient project management an implementation schedule needs to be developed and shall serve as the guide in the execution of the project. Some activities to be undertaken in 2005 are following:

(a) Conduct a baseline survey in the four HSDP provinces (excluding Romblon), (b) Prepare business plan development for LGUs under the four project

sites (business plan has been initiated in the provinces of Ilocos Norte

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and Mindoro Oriental). Romblon province is not found to be credit worthy by DOF, and therefore will not be covered under this Project at this time, and

(c) Rehabilitate the HSRA national resource center.

The Project’s first year implementation plan is in Appendix 6. 31. Project implementation was hindered with the issuance of Executive Order No. 366 on Rationalization on 11 May 2005. Recruitment of new staff–even on a contractual basis–from Government’s budget is not possible under the executive order. In consultation with the Department of Budget and Management, it was agreed that DOH will approach DOF to request ADB for a revision of the financing plan and a reallocation of loan proceeds to accommodate recruitment of staff using loan proceeds. The reallocation will also cover the funding out of the proceeds of the loan under local currency domestic consultants, PMU operation expenses, and research/studies. Appendix 7 provides the Project’s implementation plan from year 2007 to 2008.

32. Training is an important component of the project especially in enhancing the understanding of the health reforms and for capacity building for the implementation of the specific components of the reforms. The DOH has developed a Human Resource Master plan to address concerns in HR management especially in enhancing competency and out-migration. The 25 year strategic plan was developed in three phases with corresponding plan components. The Phase 1 – Short term plan for 2005-2010 will focus on workforce planning implementation (redistribution and rationalization of health workers), management of HRH domestic deployment and international migration and on Institutionalization of HRH Management Units. A Training and Development Needs Assessment (TDNA) was conducted in 2007 and a Retraining and Retooling plan is being developed based on the TDNA results, and validated in the HSDP sites (Ilocos Norte, Mindoro Oriental and Ifugao and some sites in Luzon. Appendix 8A shows the HSDP Training plan 2006-2011, Appendix 8B provide the highlights of the TDNA results and Appendix 8C shows the revised training plan for 2007. The preliminary results of the TDNA has been extracted to provide guidance in the revision of the proposed training for 2007, which now is based on the TDNA, the Human Resources Masterplan and the need for strategy driven training related to the Health Sector Reform agenda and the FourMula One implementation. After validation of the TDNA in June and July 2007, the training program for 2008 – 20011 will be revised. Appendix 8D shows the Course Package Worksheet that has been developed by the TA 4647 to be used for the detailed course planning. In Appendix 9D, the template has been used for the Technical Capability Building on the Harmonized and Streamlined Licensure System for Hospitals and other Facilities for CHD Regulatory Officers.

V. COST ESTIMATES AND FINANCING PLAN DURING IMPLEMENTATION 33. Any change in the financing plan and percentage of cost sharing by all parties requires ADB approval, in accordance with applicable ADB policies and guidelines.

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34. Except as ADB may otherwise agree, the items listed in Table 3 above will be financed out of the proceeds of the Loan on the basis of the percentages set forth in the Table. Any deviation from this Table, if necessary, will have to be approved by ADB, following procedures set forth in ADB Guidelines for the Financial Governance and Management of Investment Projects financed by Asian Development Bank.

VI. CONSULTANT RECRUITMENT

35. To support the implementation of the F1 under the HSDP and in particular to strengthen local capacity in the functioning of ILHZ, the management of hospitals and in increasing access to primary health care including essential quality drugs, DOH will recruit a team of management implementation consultants consisting of experts in health financing, monitoring and evaluation, and good governance and a technical team to provide advisory assistance to the Project. 36. A list of indicative consultant services is in Appendix 9. The technical

advisory group of consultants will include experts in relevant health sector reform areas, particularly with regard to:

1. Improving Health Sector Governance 2. Social Marketing & Health Promotion 3. HR Management 4. Social Health Insurance/Purchasing 5. Social Health Insurance 6. Health Financing 8. Continuous Quality Improvement 9. Health Governance Specialist/Health Systems 10. Health Systems Financing 11. ILHZ Implementation 12. Health and Hospital Management 13. Community Participation 14. Public Health 15. Pharmacology 16. Pharmaceuticals 17. Health Care Financing 18. Public Health Clinical Guidelines and Care Pathways 19. Health Systems Analysis

37. Appendix 10 provides a detailed costing of consulting services. The schedule of consultants is found in Appendix 11.

38. The selection, engagement and services of the consultants are subject to the provisions of the “Guidelines on the Use of Consultants by Asian Development Bank and Its Borrowers” dated April 2002, as amended from time to time.

VII. PROCUREMENT

39. Procurement of goods and services will be done in accordance with ADB’s “Guidelines for Procurement under Asian Development Bank Loans” dated February 1999, as amended from time to time, and following existing standard

21

operating procedures established by BIHC. ADB and Government procedures and rules in calling for tenders, whether for international or local competitive bidding, will be followed. 40. Civil works will be awarded by the LGUs on the basis of local competitive bidding. Contracts of over $2 million will e procured through international competitive bidding. Civil works will be partially funded and contracted by the LGUs. A list of indicative contract packages is in Appendix 12A, Appendix 12B- Ilocos Civil works, Appendix 12C shows the MDFO LGU Proposal Development and Implementation flow and Appendix 12D shows the MDFO Implementation requirements. 41. Procurement of most of the project goods will be consolidated at the national through the BHIC, with a limited number of procurements taking place at the regional or provincial levels. Equipment (medical and non-medical), and supplies will be procured on the basis of international competitive bidding for contracts over $500,000, international shopping and local competitive bidding for contracts between $100,000 and $500,000, or direct purchase. For certain types of specialized medical equipment, international shopping may be appropriate as the number of suppliers in the field is limited. Appendix 13 provides the indicative equipment list.

VIII. DISBURSEMENT PROCEDURES 42. Two imprest accounts will be established for eligible expenditures with the Bangko Sentral ng Pilipinas, one each for DOH and MDFO. The imprest accounts will be managed, liquidated, and replenished in accordance with ADB’s Guidelines on Imprest Fund and Statement of Expenditures (SOE) Procedures. The maximum initial amount to be deposited into the imprest account for the general Project expenditures shall not, in aggregate, exceed $500,000 (DOH) and the maximum initial amount to be deposited into the imprest account for relending purposes shall not exceed $1 million (MDFO). 43. ADB’s SOE procedure may be used for reimbursing eligible expenditures and liquidating or replenishing advances, in accordance with ADB’s “Loan Disbursement Handbook” dated January 2001, as amended from time to time, and detailed arrangements agreed upon between the Government and ADB. Any individual payment to be reimbursed or liquidated under the SOE procedure will not exceed $200,000 per contract. The imprest account and statement of expenditures records will be audited annually separately by auditors acceptable to ADB. 44. MDFO will not disburse any funds for the Subsidiary Loan or Sub loans until the Subsidiary Loan Agreement has been signed between the Government and MDFO, and an implementation agreement, in a form acceptable to ADB, has been signed between ADB and MDFO, and the provincial project coordinators have been officially designated by the LGUs. 45. The projected contract awards by years and the projected annual disbursement schedule by years is in Appendix 14.

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IX. PROJECT MONITORING AND EVALUATION 46. The service delivery, health regulation, health financing and health governance monitoring of project will be done within the framework of the Monitoring and Evaluation (M&E) of F 1, with sets of indicators for the F 1 components. The Project performance monitoring system (PPMS) will contain data and information on each health sector reform area, service delivery, health regulation, health financing and health governance, relevant management data and in particular detailed financial data documenting Project progress and adherence to principles of good governance. Achievement will be checked against performance targets set by DOH at the beginning of each year. Specific monitoring forms will be developed and used to monitor progress and accomplishments. The monitoring system will be designed to enable prompt remedial action. Evaluation of the Project will be carried our through a set of baseline and end-of-Project surveys, to be undertaken by NGOs, to be contracted by DOH. 47. The baseline survey will cover the current status and outcome of the HSRA initiatives in the three provinces to validate the indicative levels of outcome and impact indicators reflected in the HSDP framework. The end-of-Project survey will evaluate the impact of the HSDP on the overall health status in the three provinces at the time.

X. REPORTING REQUIREMENTS 48. Quarterly progress reports will be prepared by every provincial project management team, duly signed and endorsed by the governor as the provincial project director. These teams will be responsible for coordinating project activities and for preparing reports on their status and outcomes. The reports will be furnished simultaneously to BIHC and the DOH regional health office (regional project supervisor), and will be consolidated at the national level. 49. BIHC will prepare its own report on the implementation of national activities funded by the Project. It will prepare a single report on project accomplishments to be submitted quarterly to the project director and subsequently forwarded to ADB. A sample of the HSDP Progress Report is shown in Appendix 15. ADB will update its Project Performance Report (PPR) on a monthly basis. Appendix 16 provides a sample of ADB’s PPR.

XI. AUDITING REQUIREMENTS 50. Project expenditures will be recorded according to the standard requirements of the Commission on Audit. All agencies involved in project implementation will prepare and maintain separate accounts for project-related disbursements. BIHC will consolidate the accounts from the various national

23

offices and provinces and submit them to the DOH Finance Service, which will review the consolidated accounts and, after audit, submit them to DOF and ADB. The audit report will include a statement verifying that funds disbursed by ADB against statements of expenditures have been used for the purpose for which they were provided. Project accounts, together with disbursement documents, will be audited annually by independent auditors acceptable to ADB, and will be submitted to ADB within 6 months of the end of each fiscal year. A separate audit opinion on the imprest account and statement of expenditures procedures should be included in the annual audit report. A sample audit letter is provided in Appendix 17.

XII. MAJOR LOAN COVENANTS

51. The following major covenants embodied in the loan agreement (LA) will be adhered to by the Borrower:

(a) Established, Staffed, and Operating PMU: DOH shall be the Executing Agency and shall provide overall guidance for Project implementation. BIHC shall be responsible for the overall management and coordination of the Project, including recruitment of consultants, organization of capacity building and training activities under the Project, and monitoring and evaluation of the Project. (LA, Schedule 6, para. 1)

(b) The Borrower shall make available, promptly as needed, the funds,

facilities, services, land and other resources, which are required, in addition to the proceeds of the Loan, for the carrying out of the Project.

(LA, Article IV, Section 4.02)

(c) In carrying out of the Project, the Borrower shall cause competent and qualified consultants and contractors, acceptable to ADB, to be employed to an extent and upon terms and conditions satisfactory to the Borrower and ADB. (LA, Article IV, Section 4.03[a])

(d) Fielding of Consultants: The selection. engagement and services of

the consultants shall be subject to the provisions of this Schedule and the provisions of the "Guidelines on the Use of Consultants by Asian Development Bank and its Borrowers" dated April 2002, as amended from time to time, which have been furnished to the Borrower and DOH. (LA, Schedule 5, para. 2)

(e) The Borrower shall cause the Project to be carried out in accordance

with the plans, design standards, specifications, work schedules and construction methods acceptable to ADB. The Borrower shall furnish, or cause to be furnished, to ADB, promptly after their preparation, such plans, designs standards, specifications and work schedules,

24

and any material modifications subsequently made therein, in such detail as ADB shall reasonably request. (LA, Article IV, Section 4.03[b])

(f) The Borrower and ADB shall jointly undertake annual review missions to (i) monitor progress of Project implementation; (ii) identify areas of concern; and (iii) suggest remedial actions, if needed. (LA, Schedule 6, para. 17)

(g) The Borrower shall cause the Project to be carried out with due

diligence and efficiency and in conformity with sound administrative, financial, engineering, and environmental and health practices. (LA, Article IV, Section 4.01[a])

(h) The Borrower shall ensure that the activities of its departments and

agencies with respect to the carrying out of the Project and operation of the Project facilities are conducted and coordinated in accordance with sound administrative policies and procedures. (LA, Article IV, Section 4.04)

(i) The Borrower shall take all action which shall be necessary on its part

to enable SPE to perform its obligations under the Implementation Agreement, and shall not take or permit any action which would interfere with the performance of such obligations. (LA, Article IV, Section 4.05)

(j) The Borrower shall exercise its rights under the Subsidiary Loan

Agreement and shall cause SPE to exercise its rights under the Sub loan Agreements, in such a manner as to protect the interests of the Borrower and ADB and to accomplish the purposes of the Loan. (LA, Article IV, Section 4.06[a])

(k) No rights or obligations under the Subsidiary Loan Agreement shall

be assigned, amended, abrogated or waived without the prior concurrence of ADB. (LA, Article IV, Section 4.06[b])

(l) The Borrower shall ensure that (i) an environmental assessment is

carried out for each Subproject in a participatory manner as part of the planning process of the Subprojects; (ii) based on such environmental assessments, an environmental management plan (EMP); (iii) an environmental impact assessment, where necessary, is undertaken for each Subproject and submitted to ADB for concurrence prior to Subproject approval; (iv) adequate environmental mitigation measures are incorporated into all Subproject design, construction, operation, maintenance and monitoring arrangements in accordance with Borrower's environmental laws, regulations, and standards and ADB's Environment Policy (2002); and (v) mitigation measures and monitoring plans required in the Subproject EMPs are implemented effectively and in a timely manner satisfactory to ADB.

25

(LA, Schedule 6, para. 11)

(m) The Borrower shall enable ADB's representatives to inspect the Project, the goods financed out of the proceeds of the Loan, and any relevant records and documents. (LA, Article IV, Section 4.08)

(n) The Borrower shall ensure that the Project facilities are operated,

maintained, and repaired in accordance with sound administrative, financial, engineering, environmental, and business and maintenance and operational practices. (LA, Article IV, Section 4.09)

(o) The Borrower shall (i) maintain, or cause to be maintained, separate

accounts for the Project; (ii) have such accounts and related financial statements audited annually, in accordance with appropriate auditing standards consistently applied, by independent auditors whose qualifications, experience and terms of reference are acceptable to ADB; (iii) furnish ADB, as soon as available but in any event not later than 6 months after the end of each related fiscal year, certified copies of such audited accounts and financial statements and the report of the auditors relating thereto (including the auditors' opinion on the use of the Loan proceeds and compliance with the covenants of this Loan Agreement, as well as on the use of the procedures for the Imprest Accounts and statement of expenditures, all in the English language; and (iv) furnish to ADB such other information concerning such accounts and financial statements and the audit thereof as ADB shall from time to time reasonably request. (LA, Article IV, Section 4.07[a])

(p) The Borrower shall enable ADB, upon ADB's request, to discuss the

Borrower's financial statements for the Project and its financial affairs related to the Project from time to time with the Borrower's auditors, and shall make necessary arrangements for any representative of such auditors to participate in any such discussions requested by ADB, provided that any such discussion shall be conducted only in the presence of an authorized officer of the Borrower unless the Borrower shall otherwise agree. (LA, Article IV, Section 4.07[b])

(q) In carrying out of the Project and operation of the Project facilities, the

Borrower shall perform, or cause to be performed, all obligations set forth in Schedule 6 to the Loan Agreement. (LA, Article IV, Section 4.01[b])

XIII. IMPLEMENTATION OF THE ACCOMPANYING TECHNICAL

ASSISTANCE 52. The Technical Assistance (TA) for the Support for Health Sector Reform3 will provide support to enhance the implementation of HSRA and increase the

3 TA 4647-PHI was approved on 15 September 2005.

26

utilization of affordable and financially sustainable quality health services by the poor. The TA will help the Government give HSRA in the identified original 5 HSDP sites by streamlining policies, developing guidelines, concepts, and administrative orders; and harmonizing the processes between involved public sectors at the central level. To date TA has particularly accelerated the HSRA implementation in the three HSDP sites. The TA has developed a capacity building design in operationalizing the F1 policies at the local levels. Capacity building activities includes policy dissemination and advocacy, training, preparation of DOH technical assistance packages to the health sector, monitoring and evaluation, and designing of incentives for performance. 53. The TA will be attached to the Undersecretary for External Affairs of DOH, technically led by the Director of the Bureau of Health Policy Development and Planning, and based at the HSRA Resource Center. A technical coordinating group will oversee the progress of the TA, ensure its coherence with government policy, the efficient delivery of the outputs, and guide and review the outputs of consultants. 54. The TA consisted of two components: (i) support for HSRA implementation, and (ii) initiatives to enhance the capacity of the local health care system under HSRA. The TA team has worked closely with the Government and other stakeholders to help strengthen ongoing HSRA activities, through a comprehensive methodological assessment, technical review building on international experiences, preparation of systems, and enhancing implementation capacity. 55. The TA was provided to the project in 18 months intermittent from September 2005-August 2007. A team of international and domestic consultants has implemented the TA components. Consultants for the following areas has been recruited: international experts in health sector reform (team leader), health systems (ADB recruited) and social health insurance (ADB recruited), as well as eleven domestic experts in health administration (deputy team leader): district health planning and management, hospital financial management system, health care finance, public health, PH clinical practice guidelines, drug management and financing, human resource management, monitoring and evaluation, communication and marketing and project administration management. Consultants have been recruited either individually or through a firm, under quality- and cost-based selection, in accordance with ADB’s Guidelines on the Use of Consultants. The consultants’ terms of reference and reporting schedule are in Appendix 18. 56. The total cost of the TA is estimated at $1,430,000 equivalent, comprising $440,000 in foreign exchange and $990,000 equivalent in local currency. ADB will finance $1,000,000 (70%) equivalent, covering the entire foreign exchange cost of $440,000 ad $560,000 equivalent in local currency cost. The Government will finance the balance of the local currency cost, equivalent to $430,000 (30%), through the provision of office space, furniture, counterparts, and workshop facilities.

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XIV. KEY PERSONS INVOLVED IN THE PROJECT

57. The following are the key personnel of the Borrower: Department of Finance

1

Roberto B. Tan

Undersecretary International Finance Group Department of Finance

Tel. No. (632) 523-9911 Fax: (632) 526-9960 E-mail: rbtan@dof.gov.ph

2 Ms. Helen Habulan Executive Director Municipal Development Fund Office Department of Finance

Tel. No. (623) 523-9936 Fax: (632) 523- 9937 E-mail: hhabulan@dof.gov.ph

3 Editha Z. Tan

Director International Finance Group Department of Finance

Tel. No. (632) 5239233 Fax: Email: maria@hotmail.com

4 Ms. Alissa Santiago

Project Officer IV Department of Finance

Tel: (632) 5218791 Fax(632) 5259186 Email:

1. DOH Organic Personnel

1. Usec. Alexander A. Padilla

Project Director TeleFax No.: (632) 711-6061 Trunk Line: (632) 743-8301 Loc.1602/1608 E-mail: aapadilla@co.doh.gov.ph

2. Asec. Mario C. Villaverde

Assistant Project Director TeleFax No.: (632) 781-4362 Trunk Line: (632) 743-8301 Loc.1141/1112 E-mail: mcvillaverde@co.doh.gov.ph

3. Dir. Maylene P. Beltran Project Technical Coordinator TeleFax No.: (632) 711-6736 Trunk Line : (632) 743-8301 Loc.1329/1334 E-mail: mmbeltran@co.doh.gov.ph

4. Dr. Ma. Virginia G. Ala Project Manager TeleFax No. (632) 781-8843 Trunk Line: (632) 743-8301 Loc.1302/1338 E-mail: vgala@co.doh.gov.ph

5. Engr. Bonifacio Magtibay

Assistant Project Manager TeleFax No.: (632) 781-8843/781-8844 Trunk Line: (632) 743-8301 Loc.1306/1352 Email:

6. Dr. Heidi Frances OIC, Assistant Project TeleFax No.: (632) 781-

28

Kawi Manager 8843/781-8844 Trunk Line: (632) 743-8301 Loc.1306/1352 Email: babes10467@yahoo.com

7. Ms. Jocelyn T. Sosito Project Officer for Administrative Concern

TeleFax No.: (632) 781-8843/781-8844 Trunk Line: (632) 743-8301 Loc.1306/1352 E-mail: jocelynsosito@yahoo.com

B. DOH Contractual Staff

8. Ms. Myrna C. Caguioa Project Officer for Financial Concern

TeleFax No.: (632) 781-8843 Trunk Line: (632) 743-8301 Loc.1306/1352 E-mail: mtac_68@yahoo.com

C. Project Staff

9. Ms. Madonna M. Tabalan

Administrative Officer TeleFax No.: (632) 781-8844 Trunk Line: (632) 743-8301 Loc.1306 E-mail: madonna_tabalan@yahoo.com

10. Ms. Nancy Victoria C. Berboso

Administrative Assistant TeleFax No.: (632) 781-8844 Trunk Line: (632) 743-8301 Loc.1306 E-mail: nancyberboso@yahoo.com

11. Ms. Cecilia C. Hernandez

Procurement Officer TeleFax No.: (632) 781-8844 Trunk Line: (632) 743-8301 Loc.1306 E-mail: cel_hernandez66@yahoo.com

12. Ms. Lalaine P. Gonzales

Finance Analyst TeleFax No.: (632) 781-8844 Trunk Line: (632) 743-8301 Loc.1306 E-mail: lpgonzales15@yahoo.com

13. Ms. Emy I. Lopez Finance Analyst TeleFax No.: (632) 781-8844 Trunk Line: (632) 743-8301 Loc.1306 E-mail: mamailopez@yahoo.com

14. Mr. Ramil E. Molit Driver TeleFax No.: (632) 781-8844 Trunk Line: (632) 743-8301 Loc.1306 E-mail:

15. Ms. Marifel M. Santiago

Planning & Monitoring Officer TeleFax No.: (632) 711-6736 Trunk Line: (632) 743-8301 Loc.1325/1327 E-mail: feng1125@yahoo.com

29

16. Mr. Angelito L. Santiago

Information System Analyst TeleFax No.: (632) 711-6736 Trunk Line: (632) 743-8301 Loc.1325/1327 E-mail: aingesantiago@yahoo.com

II. PROJECT CONSULTANT

17. Dr. Ma. Socorro E. Ignacio

Project Operation Specialist TeleFax No.: (632) 781-8844 Trunk Line: (632) 743-8301 Loc.1306 E-mail: chorie_phil@yahoo.com

18. Engr. Romeo Guce Civil Works Specialist TeleFax No.: (632) 781-8844 Trunk Line: (632) 743-8301 Loc.1306 E-mail:

XV. ANTICORRUPTION 58. The Project will comply with ADB’s anticorruption policy and guidelines. that anyone coming across evidence of corruption associated with the project must contact ADB’s Office of the General Auditor, which will investigate such allegations. ADB’s anticorruption policy was explained to the national and the pre-selected local governments, DOH, and PhilHealth during project processing. The anticorruption provisions added to ADB’s Guidelines on the Use of Consultants were also discussed, and the section on fraud and corruption in ADB’s Guidelines for Procurement were emphasized. 59. DOH and the implementing agency will ensure timely submission of project accounts. A strict project performance monitoring system will allow DOH and ADB to confirm the appropriate use of project funds.

Attachment 10: CHD Scorecard

Technical Assistance to the Republic of Philippines for the

Health Sector Development Program ADB TA 4647-PHI

Technical Report

CENTER FOR HEALTH DEVELOPMENT SCORECARD

June 2006 – August 2007

Prepared by

MARIA OFELIA O. ALCANTARA MD, MPH Health Administration Specialist

Deputy Team Leader This report is submitted by InDevelop, the firm hired by ADB to provide the Technical Assistnce to HSDP

EXECUTIVE SUMMARY The Department of Health is currently implementing Fourmula One (F1) for Health F1 is designed to undertake critical reforms that are consistent and contribute to the national goals of increased financial protection for the poor, improved public health outcomes, and increased responsiveness of the health system in relation to conditions, diseases and services that are critical for the achievement of the health – related Millennium Development Goals. The Department of Health (DOH) is now in the process of developing a FOURMULA ONE FOR HEALTH MONITORING & EVALUATION SYSTEM for Equity and Effectiveness (ME3) that seeks to measure results of F1 strategies on Governance, Service Delivery, Regulation and Financing, particularly on how these have benefited the poor. It shall also serve to unify all monitoring and evaluation (M&E) activities within a single framework. The M&E covers Performance Indicator Frameworks and Performance Assessment Scorecards for DOH (Central Office, Centers for Health Development, Hospitals), LGUs, and ODA Donors. This paper shall cover the preliminary work undertaken to develop the Centers for Health Development (CHD) Scorecard. The indicators in the scorecards have substantial effect in attaining key F1 interventions, intermediate outcomes and final outcomes.

The CHD Scorecard reflects the performance of the CHD as an extension of the DOH in its mandate and function of steering and leading the national health system. Performance indicators shall include extent and quality of goods and services desired by the local health systems in the regional coverage area, along the 4 main strategies of F1. Performance indicators shall also include a perspective on incremental improvements observed in the health systems in the region and shall also include indicators on satisfaction of clients with CHD services and products.

The content of the CHD Scorecard was consensually undertaken in a series of workshops participated in by regional directors and selected technical staff from the central office and from the CHD. Baseline and gathering of data shall be piloted to the first batch of F1 sites. Analysis and results of the baseline shall be utilized to enhance further the CHD scorecard. There is a need to finalize the attached draft Administrative order for the CHD scorecard. This draft will be utilized as a working document in the finalization of the Administrative Order.

Table of Contents

Executive Summary

I. Background and Rationale 4 A. Fourmula One for Health & F1 ME3 4

B. Role and Function of the CHD 5

II. Methodology 6

III. Objectives 6

IV. Results 6

A. The CHD Performance Indicator Framework 6

A.1 The Final Outcomes 7 A.2 The Intermediate Outcomes 8 A.3 The Major Final Outcomes 8

A.4 CHD MFO 9 B. CHD PIF 10 B.1 CHD Scorecard Framework 17 C. CHD Scorecard Indicators and Data Source 18 D. Scoring Mechanism 20 E. Implementation Schedule 21 E.1 CHD Scorecard Scoring System 21 E.2 Baseline CHD Scorecard 28 E.3 Piloting 28

V. Recommendations and Next Steps Annex A: Draft AO and References 29 Annex B: Documentation Consultation with Stakeholders 44

Annex C: Documentation Consultative Workshop with CHD 60 Directors

Scope of Work

Health Administration Specialist (deputy team leader) The consultant will have two roles: (i) coordination of TA activities and supervision of administrative staff hired by the contractor to support the TA team, and (ii) technical. In the coordinative role, the consultant will (i) manage the day to day operations of the TA and ensure timeliness and integration of all activities and outputs; (ii) liaise with central, provincial, and local governments, private sector, non-government organizations, and the community, and other key technical persons in the country; (iii) assess needs to coordinate, help in planning and monitoring the progress of needs and assignments; (iv) guide the other TA consultants on key issues and on key persons to meet, sources of information; and (v) assist the TA consultants in meeting the objectives of the TA; (vi) guide and supervise the administrative support staff of the TA. In the technical role, the consultant will (i) integrate the capacity building activities of all the consultants in an F1 framework; (iii) assist in the project performance, and strengthening implementation; and (iv) monitor the progress of the HSDP investment loan, and address any bottlenecks and constraints. (v)The consultant will design a performance assessment system for the centers for health development of the DOH.

The consultant will complete all the technical outputs with guidance of the international consultant on health sector reform and will report to the Team Leader for all operations during the period of the TA. Before submitting deliverables to clients, they should be submitted to the Team Leader for review.

4

CHD SCORECARD FINAL REPORT

I. Background and Rationale For the past few decades, the health of the Filipino people has improved as evidenced by trends in vital health indices. There have been improvements in infant mortality rate, maternal mortality rate, life expectancy and other major health indices. There remain large variations in health status among socio-economic groups, as well as among geographic areas. There continues to be unequal access to health services owing to both financial and physical barriers. Various health facilities continue to have inadequate capacities in meeting the health needs of the people. Other health system concerns include inadequate funding and management systems, lack of coordination and cooperation among local government units, weak and ineffective regulation of the quality and cost of health services and health products, inadequate resources, inefficiently generated and inequitably spent funding. As a strategy for implementing the health sector reforms, the DOH created the FOURmula One for Health (F1). The F1 is geared towards the attainment of the following end goals: better health outcomes, more responsive health system and equitable health care financing. F1 is designed to undertake critical reforms that are consistent and contribute to the national goals of increased financial protection for the poor, improved public health outcomes, and increased responsiveness of the health system in relation to conditions, diseases and services that are critical for the achievement of the health-related Millennium Development Goals. A. Formula One for Health and F1 ME3 The FOURMula One for Health as a strategy is geared towards the attainment of the following end goals: BETTER HEALTH OUTCOMES, MORE RESPONSIVE HEALTH SYSTEM and EQUITABLE HEALTH CARE FINANCING. Fourmula One for Health is designed to undertake critical reforms that are consistent and contribute to the national goals of increased financial protection for the poor, improved public health outcomes, and increased responsiveness of the health system in relation to conditions, diseases and services that are critical for the achievement of the health – related Millennium Development Goals. The F1 reforms will take place at the National level (DOH and Philippine Health Insurance Corporation) and at the local level in the 16 initial sites, and subsequently in the roll – out sites and all other areas. As incorporated in the National Investment Plans and Province – wide Investment Plans for Health (PIPH) for the 16 initial sites. Financial support for national and local level implementation will come from DOH, Local Government Units (LGUs), and ODA donors included in the Sector – Wide Development Approach for Health (EC, ADB, GTZ, WB), and seek to likewise, have all these major stakeholders manage F1 projects and activities in a coordinated manner.

The Department of Health (DOH) is now in the process of developing a FOURMULA ONE FOR HEALTH MONITORING & EVALUATION SYSTEM for Equity and Effectiveness (ME3) that seeks to measure results of F1 strategies on Governance, Service Delivery, Regulation and Financing, particularly on how these have benefited the poor. It shall also serve to unify all monitoring and evaluation (M&E) activities within a single framework. To this end, the DOH has organized a DOH Task Force on ME3, and 6 Technical Working Groups to develop the ME3 Performance Indicator Frameworks and Performance Assessment Scorecards for DOH (Central Office, Centers for Health Development, Hospitals), LGUs, and ODA Donors. Several ODA partners also have current projects related to development of M & E systems, which must be integrated with the overall effort to develop ME3. The ME3 shall primarily guide the Secretary of Health in the assessment of how F1 benefits the Filipino people. The ME3 shall also evaluate the performance of the health system for the use of the Congress in the context of the F1 implementation. The ME3 system will also be used to measure the performance/compliance of all stakeholders for health in the achievement of F1 goals through scorecards, foremost of which are the Central Level, Regional Level and LGU Scorecards. In the development of the CHD scorecard it is important to look at CHD functions, its MFOs and the DOH CO and LGU PIF. B. Role and Function of the CHD As defined and prescribed in the Organizational Performance Indicator Framework (OPIF) and as indicated in the various Department and Administrative Orders of the Department of Health, the CHDs, in order to effectively link the MFOs of the LGUs with the MFOs of the DOH CO, are mandated to undertake the following roles and responsibilities: Table 1

CHD Functions

1. Internal & sectoral planning, human resource dev’t incl support to operations of collaborating centers 2. Enforcement & implementation of regulations, standards & licensing of health facilities 3. Health operations, incl. TB control operations, disease prevention & control, health promotion & other health operations 4. Local health technical assistance incl. local health systems dev’t, provision of logistic support to local health programs & assistance funds to support quality assurance in LGUs

II. Methodology

From August 2006 to August 2007, the Health Planning Administration Specialist/Deputy Team Leader worked with the ADB Technical team, Health Policy and Planning Development Bureau, Bureau of Local Health and Development and the Center for Health Development (Regions Ilocos Region, Calabarzon, CAR and NCR), in conceptualizing the Center for Health Development PIF and Scorecard. Initial step was to define the Center for Health and Development roles and functions and its relation to the OPIF followed with the development of the CHD PIF and the CHD scorecard. The draft was presented to the different stakeholders to include the National DOH Program staff, CHD CAR, NCR, 1, Calabarzon, 7 and 11, Hospitals and LGUs from Ilocos Norte, Mindoro Oriental and Ifugao. The output of the consultation process is in Annex 2. The inputs of the consultation were integrated to the draft and was further presented to the all the CHD Directors and FICO. The CHD is the key office that shall be subjected to the scorecard. The documentation of the consultation with the FICO and CHD Directors is in Annex 3. The next steps is to finalize the CHD PIF and the Scorecard and determine the scoring mechanism and the Consequences. III. Objectives The over all objective of the CHD scorecard is to determine the status of the Regional DOH offices using critical indicators for evaluation in a given period of time. Specifically the CHD scorecard shall define the following:

• The CHD Performance Indicator Framework • The CHD Scorecard Indicators • Data Source and Data Management • Scoring Mechanisms • Incentives and Disincentives

IV. Results A. The CHD Performance Indicator Framework The Performance Indicator Framework is a hierarchy of the indicators that describe outcomes and outputs that F1 seeks to attain. The objectives of the PIF are to set indicators for outputs and outcomes that are important for the health of the Filipinos especially the poor, and to provide a framework that will unify M&E efforts by various stakeholders. The main components of the PIF are the final outcomes, intermediate outcomes and the major final outputs.

Figure 1

Performance Indicator Framework

HEALTH STATUS

Financial Risk Protection Responsiveness

Final

Performance Outcomes

SERVICEDELIVERY

Governance

Financing Regulation

Major Final Outputs

Access Quality Efficiency Financial Burden

Intermediate Performance Outcomes

A.1 The Final Outcomes The final outcomes are the highest level in the PIF and are composed of indicators that reflect results, consequences or outcomes of the health sector. Final outcomes for the health system include a) Health Status, b) Financial Risk Protection (FRP) or Equitable Healthcare Financing and c) Responsiveness of the Health System and Client Satisfaction. These three general final outcomes are based on the F1 end goals, and are in consonance with the health system goals identified by the World Health Organization, the Millennium Development Goals (MDG) and the Medium Term Philippine Development Plan (MTPDP).

Health Status measures the health of the population and includes major health indicators such as mortality and morbidity rates, prevalence of diseases, and others. Financial Risk Protection measures the degree to which citizens are protected from the financial risks of ill health, particularly the poor.

Client Satisfaction is the degree to which citizens are satisfied with the services provided by the health sector. Responsiveness of the Health System is the ability of the health system to respond to the non-health or non-clinical expectations of clients. The CHD is crucial in the attainment of the Final Outcome. CHD shall contribute to the Final Outcome, by providing support to the LGUs and ensuring localization of the policies, standards formulated by the DOH.

A.2 The Intermediate Outcomes The Intermediate Outcomes are the next level in the PIF and are composed of indicators that help determine the level of performance of the final outcomes. The Intermediate Outcomes serve as critical links that connect root causes to final outcomes. Intermediate Outcome indicators include MDG, National Objectives for Health (NOH) and F1 outcomes for a) access, b) efficiency, c) quality, and d) financial impact.

Access refers to the ability of patients to use the services they want to use. Quality refers to the degree to which goods and services perform as desired. Efficiency refers to using resources in the best possible way to achieve goals. Financial impact refers to how much different groups pay to support the health system A.3 The Major Final Outputs The Major Final Outputs are the third level in the PIF hierarchy. MFOs are goods and services that are produced by certain agencies or units which have the mandate and authority to do so. They are goods and services that clients expect from the producers of such goods and services. MFOs are composed of indicators on products, goods and services resulting from the implementation of F1 strategies on service delivery (public health and hospitals), health financing, regulation and governance

A.4 CHD MFO Figure 2

FINAL HEALTH OUTCOMES

INTERMEDIATE OUTCOMES (Clients and Providers)

Access Quality Efficiency Financial Impact

LGU MFOs Service delivery reforms • Public-private

partnership • Inter-local

coordination • Rationalized

healthcare delivery

• Quality seals • Financing and

payment linked to quality service

Regulation reforms • Drug price

reduction • Compliance to

health laws

Financing reforms • Increased

resources for health

• Increased extra-budgetary sources

• Increased enrollment

Governance reforms • Management

systems

CHD Functions CHD Major Final Outputs

Internal & sectoral planning, human resource dev’t incl support to operations of collaborating centers

CHD Plan Regional Investment Health Plan PIPH TA Policy Advocacy Training Services (# Persons trained) Collaborating Center Services

Enforcement & implementation of regulations, standards & licensing of health facilities

Arbitration Services Licensing Services (# Health Facilities Licensed)

Health operations, incl. TB control operations, disease prevention & control, health promotion & other health operations

Policy Advocacy S. Technical Assistance M & E Database Monitoring

Local health technical assistance incl. local health systems dev’t, provision of logistic support to local health programs & assistance funds to support quality assurance in LGUs

Supplemental Logistics Policy Advocacy TA

Policy Advocacy Health facilities direct service delivery

Central Office PIF and MFO

B. CHD PIF The CHD PIF as described by PPAs is shown below:

Programs, Projects, Activities (PPA)

A. SERVICE DELIVERYPolicy Advocacy (Implement with TA Policy Packages) Instrument to use

TA (Implement with TA Packages) Tools: HR, Ordinace, IEC to Implement.

Training Licensing Arbitration M and E Data base M and E Monitoring Direct Services

CHD staff covered with Policy Advocacy % of Provincial LHBs covered by PA

Essential Service Packages for each PPAs. provide technical assistance to define the package of minimum health care for the LGUs. Essential Service Packages for each PPAs

Person Days of CHD Staff Training

No. and % of Activites Benchmark for the Regional Data Base Mangement

No and % of M and E Conducted, No of % of CHD scorecard reported to BLHD

A.1. Public Health Program Development

% PHO staff Covered by PA PBB for Public Health

% LGUs provided with TA on PBB for Public Health

No. of CHD Person Days training on SD Public Health PBB for Public Health

No of Complaints with Timeliness of Arbitration respond with in 15 days. Arbitration report and resolution with in 1 year

No. and % of Activites Benchmark for the Regional Data Base Mangement

No and % of M and E Conducted

1.1. Disease Free Zones % of Provincial LHBscovered by PA

% LGUS/ILHZs provided with TA on the implementation of localized disease control and prevention programs.

No. of CHD Person Days training on SD Dse Free Zone Initiatives

a. Filariasis Elimination

b. Schistosomiasis Elimination c. Rabies Elimination & Control

d. Leprosy Elimination

e. Malaria Control

1.2. Intensified Disease Prevention and Control a. TB Prevention & Control

b. HIV/AIDS Prevention & Control

c. Emerging /Reemerging I f ti C t l d. Dengue Prevention and Control

1.3 Child Health

CHD PIF

a. Vaccine Preventable Diseases

b. Breastfeeding Program

c. IMCI d. Nutrition

1.4. Maternal Health a. BEMOC/ CEMOC

-Facility Mapping to ensure access by all pregnant women to BEMOC/CEMOC

% of Provincial LHBs covered by PA

% of Provinces provided with TA on Mapping and Rational of HF plan.

No. of CHD Person Days training on SD BMOC/CMOC

-Upgrading of Facilities b. Women’s Health Team

c. Contraceptive Self Reliance

d. Other Reproductive Health Programs

1.5. Healthy Lifestyle No. of CHD Person Days training on SD Healthy life Style

A.2. Health Facilities Development Program (National/Local;Public/Private)

% of LHBs provided PA onPBB for Hospital andOptimization of HFs.

% of Provinces providedTA on Optimization of HFsand PBB for Hospitals

No. Of Person Days CHDtraining on SD HospitalsOptimization of HFs andPBB for Hospitals

No of Complaints with Timeliness of Arbitration respond with in 15 days. Arbitration report and resolution with in 1 year

No. and % of Activites Benchmark for the Regional Data Base Mangement

monitoring health caredelivery systems in theircoverage area

% of CHDs staff providedTA on establish a hospitalbased on the criteria forthe establishment of a newhospital (for hospital only)

2.1. Rationalize Local Health Facilities to include BEMOC/CEMOC

% Provinces withRationalize InvestmentPlan

% LGUs/ ILHZ provided TAon the mapping all existinghospitals in the region.

No of establish a database ofall hospitals withcorresponding bed capacities.

- Facility Mapping

- Upgrading Facilities

- Rationalize services in facility

2. HR Provision/Capacity Building

3. Integrate Wellness services in hospital

% Provinces provided TAon Wellness Services.

% of Provinces providedTA on integatingwellness/Public Health inthe Hopsitals

A.3. Strengthen Surveillance and Epidemic Management System (SEMS)

% of Provinces Providedwith SEMS

% CHD staff provided TA inmaking DOH asCoordinating Body in theirregion fro SEMS

% CHD Staff and LGUstrained on SEMS

No. and % of Activites Benchmark for the Regional Data Base Mangement

No of DOH Coordinating Bodyin the region

No of hazard and vulnerabilityassessment conducted

No of advice to the RDCC forhealth emergency concernsprovided.

No of operation center toserve as the regionalrepository of events for thehealth sector.

3.1. Create and strengthen PESU/ILHZ/MESU

% CHD staff provided TA on PESU/ILHZ/MEZU

2. Set up Surveillance Systems

3. Link with Private Sector

A. 4. Strengthening of Disaster Preparedness and Response System (DPRS)

% of Proivnces conductedPA on DPRS

% CHD staff provided TAon making DOH asCoordinating Body in theirregion on DPRS.

% CHD staff and LGUstrained on DPRS

No. and % of Activites Benchmark for the Regional Data Base Mangement

report to the Central DOH(HEMS) for all emergenciesand disasters and anyincident with the potentialof becoming an emergency

No of Services provided duringdisater

% LGUs provided withtechnical assistance onhealth emergencymanagement

document all healthemergency events andconduct researches tosupport policies andprogram development

A.. 5 Health Promotion % LGUs/ILHZs provided TAon HP

% CHD staff and LGUstrained on HP

5.1. Behavior Change Communication/ Advocacy

2. Information Education Campaign/Services

- Localization of IEC Context - Reproduction of localized IEC MessagesA.6. Healthy Lifestyle % of Province Provided

with Healthy Life Style% LGUs and ILHZs provided TA on Healthy Lifestyles

% CHD and LGUs trained on Healthy Life style

B. HEALTH REGULATION All HFs licensed and Monitored

No of Complaints with Timeliness of Arbitration respond with in 15 days. Arbitration report and resolution with in 1 year

No. and % of Activites Benchmark for the Regional Data Base Mangement

No and % of M and E Conducted

B.1 Implement./ Enforce health and health related laws

% of Provinces and LHBsconducted with PA onEnforcements andcompliance to healthrelated laws

% of CHD staff provided TA on Law Enforcement; %LGUs provided TA oncompliance of healthrelated law.

No of MonitoringEnforcements of the Lawand compliance to HealthRelated Laws conducted.

- Milk Code - MBFHS - Asin Law - ECCD - Accreditation of facilities % Provinces and LHB

conducted with PA on CPG and Accreditation

% CHD staff and Provinces provided TA on CQI CPG Utilization facilitate compliance to accreditation requirements of health facilities, products and services

% CHD staff and LGUs trained on CQI CPG Utilization facilitate compliance to accreditation requirements of health facilities, products and services

% of HFs accredited for OPB, MCP nd DOTS

- Licensing of Facilities % Provinces and LHB conducted with PA on Licensing

No and % of HFs licensed No and % of M and E Conducted

B.2. Advocate for legislation of health-related laws at local level

B.3. Carry out decentralized regulatory functions

% Provinces conductedwith PA on decentralizedRegulatory Functons

B.4. improve access to low-cost quality drugs/commodities

% Provices and LHBsconducted with PA onEDPMS and PNDF

% CHD staff provided TAon how to provide TA toLGUs on PNDF andEDPMS; % Provices/ILHZsprovided TA on PNDF andEDPMS.

% CHDs and LGUs trainedon EDPMS and PNDF

No of % of Phramacy/BnBand Botica ng BayanCeertified and Licensed

4.1 Botika sa Baranggay 4.2 Botika ng Bayan

4.3. Health PlusC. HEALTH FINANCING No of Complaints with

Timeliness of Arbitration respond with in 15 days. Arbitration report and resolution with in 1 year

No. and % of Activites Benchmark for the Regional Data Base Mangement

No and % of M and E Conducted

C.1 Expansion of the National Health Insurance Program (NHIP)

% of Proinces and LHBsprovided with PA on NHIPin support of PhilHealthMarketing.

% LGUs/ILHZ provided TAon NHIP

1.1. Universal Coverage

a. . Enrollment of the Poor

b. Enrollment of the Informal Sector

b.1 Advocacy, other initiatives

1.2. PHIC accreditation

1.3. Rational Use of PHIC reimbursementC.2. Local Government Premium Counterpart Secured

% of Provnices and LHBs conducted with PA on Ensuring Premuim conterpart.

C.3. Increased sources of Local Health Financing

% of Provinces conducted PA on Formulation of Business Plans

% ILHZs provided TA on Formulation of Business Plans for PH

% CHD staff and LGUs trained on Formulation of Business Plans

D. HEALTH GOVERNANCE No. Of CHD Person Days training on a. Health Systems Basic Course), b. Health Reforms (Flagship course), c. Masteral, d. PhD e. CB design for Operationalizing Policies)

No of Complaints with Timeliness of Arbitration respond with in 15 days. Arbitration report and resolution with in 1 year

% Health Data from Public and Private Sector Complte and quailty); % activites benchmark for Regional HealthData Mangement

No. Of PWHS data validated and No and % of M and E Conducted

D.1. LGU Sectoral Management % CHD staff and RegionalPartner provided TA on theRegional Implementationand Coordination Team(RICT)

No. Of Person DaysMonitoring

1.1 Local Health Systems Development

% Provinces and LHBs conducted PA on ILHZ Cooperation and Incentives

% ILHZs provided TA on ILHZ Cooperation and Incentives and strengthen the technical and managerial capability at the local level to improve LGU performance.

% CHD staff trained on ILHZ Cooperations and Incentives

No. of ME3 Monitoring Conference/year

designate a point person for GIDA implementation

a. Improved Capacity of Local Health Authority- F1Client Participation

% LGUs provided with TA in installing and assessing consumer participation.

% CHD staff Trained on Consumer Particpation

b. Increased inter-LGU Coordination

% Provinces and LHBs conducted PA on ILHZ Cooperation and Incentives

% ILHZs provided TA on ILHZ Cooperation and Incentives.

% ILHZs provided TA on Best Practice Documentation.

% LGUs provided with TA on GIDA.

1.2. Subnational Human Resource Strengthening

% of PA conducted on ensuring provision of training grants for DOH Rep in order to meet the requirements necessary for the performance of his/her duties and responsibilities

% ILHZs/ Provinces/LGUs providd TA on HHR Strenthening

1.3. Sectoral Development Approach for Health

No and % of CHD Staff provided advocacy on SDAH.

% CHD staff provided TA on the Regional Inverstemnt Plan and PIPH;% LGUs provided TA on SDAH.

Develop Regional Investment Health Plan with Provinces/Cities

% LGUs provided TA on the development and implementation of province-wide plans

% CHD staff provided technical assistance in selecting reform strategies

% CHD staff and LGUs provided TA on on public-private collaboration among LGUs and private partners.

1.4. LGU Scorecard Development/ Implementation

% of LGUs / ILHZs conducted with PA on LGU SC Development and Implemenattion

% CHD staff and LGUs provided TA on LGU SC implemenattion.

% CHD staff Trainied on LGU SC

1.5. Local health Information System Development / Utilization

% LGUs provided with PA on the LHIS

% LGUs provied TA on information management services at the local level

% CHD staff Trainied on LHIS

D.2. Internal Management % CHD staff provided TA on the CHD Plan

No and % of M and E Conducted

% CHD Staff provided TA on improving financial management, procurement, materials and commodities management

% CHD staff provided TA on DOH thrusts/directions, newly signed laws, executive issuances, administrative orders, circulars and other policies that have local health implications

% CHD staff provided TA on how to develop motivational strategies for professional advancement

2.1 Finance Management % CHD staff provided with Finance Management

% CHD Staff Provided TA on Financial Mgt

% CHD Staff Trained on FM

Utilization of HSs

2.2 Procurement Management % CHD Staff Provided TA on Procurement Mgt

% CHD Staff Trained on Procument Mgt

2.3. Logistics Management % of CHD staff provided with Logistics Mangement

% CHD Staff Provided TA on Logistics Mgt

% CHD Staff Trained on Logistics Mgt

2.4. Internal Audit

B.1 CHD Scorecard Framework Scorecards are:

a. A tool for measuring and reporting on performance of stakeholders for outcomes and outputs that can be attributed to them and for which they are accountable for; and

b. Measure performance on outcomes valuable to the stakeholders’ clients and convey performance in a manner that clients and stakeholders can easily comprehend

The indicators in the scorecards are subsets of the PIF. The subset includes performance indicators which are:

Within the direct mandate and accountability of the stakeholders Are valuable to clients and easily understood by them Have substantial effect in attaining key F1 interventions, intermediate

outcomes and final outcomes.

The purpose of the Scorecard are: o Provide accountability to client o Performance benchmarks o Link to financing

CHD SCORECARD FRAMEWORK

Final Outcome Health MDGs Intermediate Outcomes Access, Quality, Financial Burden, Efficiency Major Final Outputs LGU Actions/Decisions on

Service Delivery, Regulation, Financing, Governance CHD Actions/Decisions/Assistance to LGUs The above scorecard framework illustrates the important role and distinct relationship between the CHD and the LGUs in the health system. A harmonious and open relationship is expected to bring about the attainment of the final performance outcomes. The attainment of the said final outcomes which are based on the health related millennium development goals is directly influenced

by the attainment of the intermediate outcomes in terms of access, quality, efficiency and financial burden. With the devolution of health to the LGUs as mandated under the Local Government Code of 1991, the attainment of the MDGs rests heavily on the individual Local Government Units Actions and Decisions. How the local government officials see their huge and tremendous responsibilities towards health care delivery therefore, will greatly affect the kind of interaction between the clients and the providers, an interaction that is expected to bring about efficiency in the utilization of all available services for all Filipinos especially the poor. This is now exemplified by their individual responses on the Fourmula One for Health as to Service Delivery, Governance, Regulation and Health Care Financing. Given the different LGU environments and the prevailing politics in each LGUs, the CHDs are tasked with the role of ensuring that LGUs regardless of socio-political orientation are provided with the necessary technical assistance in managing and running local health systems towards attainment of the above. C. CHD Scorecard Indicators and Data Source At the onset, it has been understood that indicators will not be used in isolation but rather in combinations. Triangulation between related indicators will be adopted. In the selection of indicators, the following basic criteria was followed: a. They should be measurable, actionable and objectively verifiable b. They should be relevant to the issue or concern. c. They should be specific providing the most direct evidence of the result it is

measuring. d. They must be easily understood and accepted by the important stakeholders. e. They should take into consideration issues of practicality. f. As a general rule, they should use current available data sources. The CHD Scorecard reflects the performance of the CHD as extension producers of the DOH in its mandate and function of steering and leading the national health system. Performance indicators shall include extent and quality of goods and services desired by the local health systems in the regional coverage area, and prescribed by DOH management, along the 4 main strategies of F1. Performance indicators shall also include a perspective on incremental improvements observed in the health systems in the region and shall also include indicators on satisfaction of clients with CHD services and products.

CHD Scorecard Indicators

Indicators Service Delivery: 1.Technical Assistance Optimization of HFs, PIPH, Private and Public Partnership Regulatory: 1.Timeliness of “Complaint” Arbitration response with in 15 days. Arbitration report and resolution with in 1 year 2. All HFs licensed and Monitored 3. TA on Regulatory Governance: 1. Develop Regional Investment Health Plan (RIPH)with Provinces/Cities 2. Formulate CHD Plan 3.Training- 3 trainings- Introductory Course, Flagship and Operationalization.

4.Timely delivery of commodities TB DOTS and EPI 5. Logistics Management 6. Regional Data Base Management • LHA Data by Province • Local Health Systems • Disease Surveillance • Disaster Management

7. PFM 8. TA on Governance Financing: 1. CHD Health Accounts 2. TA on Financing

D. Scoring Mechanism Means of scoring shall be based on color coding in relation to the identified indicators as agreed upon by CHD representative and the CHD scorecard taskforce. The table below shows the values that shall be taken into reference in scoring CHD’s performance based on the formulated indicators. Measure for scoring shall be taken from the suggested scoring parameters based on the indicators found in table below. CHD Scorecard Color Coding Scheme

Value of indicator Color Code Interpretation Greater than or equal target

Green

Maintain the level of effort

Below but at least 80% of target Yellow

Increase the level of effort

Less that 80% of target Red

Increase the level of effort and introduce innovations

CHD Scorecard line chart shapes

Shape Interpretation Circle

Square

Diamond

E. Implementation Schedule The target implementation schedule in table 3 below (highlighted in green) was based on the consensus during the consultative workshop done with CHD officials and LGU representatives shall start on the last quarter of 2007. Also reflected alongside the agreed timetable are the indicators, sources of data and suggested parameter for scoring. In addition Baseline surveys shall be conducted to generate more relevant information to serve as an effective guide in the up coming years of its implementation. In addition the baseline study shall be followed by pilot testing of the tool in the selected CHD’s. E.1 CHD Scorecard Scoring System

Principles: • The CHD Scorecard is a report card to LGU and DOH CO (BLHD). • The scoring is by Individual CHD. • Determine the Actual accomplishment versus Target / Yearly

accomplishments compared to previous year. • A score shall be provided by indicator and shall be color coded as follows:

90-100% = Green 75-89 = Yellow <74 = Red

• The CHD scorecard must define the following:

• Objectives - What are the strategies to achieve quality patient care? • Indicators- What to measure? • Measures - How will progress for each particular objective be measured? • Data Source – Where would appropriate data be coming from? • Baseline 2007- Determine what is the baseline of the Indicators? • Targets - What is the target value sought for each measure by year? • Values- What is the score? • Color Code - Color indicator with regards to measured values:

o Above average (green) o Average (amber) o Below average (red)

• Initiatives - What will be done to facilitate the reaching of the target?

Indicators Measurement Data

Source Baseli

ne 2007

Targets by 2010 Progress (2008-2009, 2010)

Values

Color code

Initiatives

SD: 1.Technical Assistance SD Optimization of HFs PIPH Private and Public Partnership

1. No and % of provinces provided TA on: - Optimization of HFs - PIPH - Private and Public Partnership

2. No and % Regional Mapping of HFs by province and level of care (Public and Private)

3. No and % Competencies and capacities

4. No and % of Optimization of HFs Plans/ Rationalized Investment Plans

5. No and % of PIPH formulated

and operational plan for 2009 implemented

6. No and % of 2010 operational

plans formulated and implemented

7. No and % of Regional Private

and Public Partnership (PPP)Plan formulated

-CHD Data (From Regional, Provincial and Municipal) -Monitoring Reports -Partnership Meetings Documentation

All Provinces conducted Policy Advocacy and provided TA ( 2008)

• Optimization of HFs • PIPH • Private and Public

Partnership Facility Mapping to include geographic and competencies ( 2009) Optimization of HFs/Rationalized Investment Plan (2010) All Provinces had formulated the PIPH and implemented the operational plan for 2009 (2009) All Provinces had formulated and implemented 2010 operational plan (2010) PPP Meetings conducted and Regional Plan for PPP formulated (2009)

8. No and % of Private and

Public Partnership Plan Implemented

9. No and % of Private Sector

who has partnered with the Government and involved in Health Planning, Implementation and as Service Providers

Regional PPP plan implemented ( 2010) Private Sector Involved in Planning, Implementation of PIPH and as Provider (2010)

Regulatory: 1.Timeliness of “Complaint” Arbitration response with in 15 days. Arbitration report and resolution with in 1 year 2. All HFs licensed and Monitored

1. No and % of Complaints Acted with in 15 days /Total Complaints 2. No and % of Complaints Resolved within the Year/Total Complaint 3. No and % of Complaints Monitored for Compliance 4. No and % of HFs licensed 5. No and % of monitoring conducted for continuing compliance of standards for Licensing No and % of TA conducted on:

• EDPMS • PNDF

CHD data • Complaints • Licensing • Monitoring

Visits documentation

Assess how many cases and cases resolved (2008, 2009, 2010) Timeliness of action on complaints (at most 15 working days) (2008, 2009, 2010) All HFs Pvt/Gov/ Licensed (2008, 2009, 2010) All Licensed HFs Monitored and continued to comply standards for Licensing All provinces conducted Policy Advocacy and provided with TA on (2008):

3. TA on Regulatory

• CPG

• EDPMS • PNDF • CQI/CPG

All provinces has formulated plans to implement EDPMS, PNDF and CPG (2009) All provinces has implemented the EDPMS and PNDF All hospitals in the all provinces are using CPG (2010)

Governance: 1. Develop Regional Investment Health Plan (RIPH)with Provinces/Cities 2. Formulate CHD Plan 3.Training- 3 trainings-

Region has define Benchmark for Scoring at the end of the year 1. No and % of RIPH formulated 2. No and % of Activities in RIPH implemented 3. No and % of CHD plan formulated 4. No and % of activities in the CHD Plan implemented 5. No and % of CHD Staff trained vs. target on the 3 trainings: • Introductory Course

CHD Data: • Regional

Plans • Monitoring

Report • Training • Data Base • Procurement • Logistics Mgt • Policy

Advocacy Meetings

• TA documentation

RIPH with Provinces and Cities formulated (2009) Activities in the RIPH vs. benchmark implemented (2009, 2010) CHD plans formulated (2008, 2009, 2010) Activities in the CHD plans implemented (2008, 2009, 2010) Targeted Training for CHD staff on the 3 trainings (2008,

Introductory Course, Flagship and Operationalization.

4.Timely delivery of commodities TB DOTS and EPI 5. Logistics Management 6. Regional Data Base Management • LHA Data

by Province

• Flagship Course • CB on Operationalization of

Policies

6. No and % of Issuance of commodities within 2 months to the Provinces 7. No and % of Regional of Logistics Management Plan to include:

• FIFO /FEFO Stockcards • NGAS Compliance • Cold Chain Mgt

8. No and % of Activities in the Regional Logistics Mgt Plans Implemented 9. No and % of Regional Data base Management Plan formulated 10. No and % of Activities in the Regional Data Base Management (RDBM) Implemented ( Plan, IT, Data Collection, Analysis, Publication) ( To ID Target and benchmark and rate every year) 11. No and % of PFM Plan

2009,2010) • Introductory Course • Flagship Course • CB on Operationalization of

Policies Issuance of commodities within 2 months to the Provinces (2008, 2009, 2010) Regional Logistics Management Plans (2008, 2009 2010) Delivery to LGUs- within 2 months from delivery of commodities from CO to CHD (2008, 2009, 2010) Regular inventory (Quarterly) (2008, 2009, 2010) Regional Data Base Mgt Plan (2008, 2009, 2010) Activities vs. benchmark of the RDBM implemented

• Local Health Systems

• Disease Surveillance

• Disaster Management

7. PFM 8. TA on Governance

formulated 12. No and % of Activities in the PFM conducted 13. No and % of Policy Advocacy and TA provided to provinces on:

• ILHZ Cooperation and Incentives

• Consumer Participation 14. No and % of Provinces with Plans on:

• ILHZ Cooperation and Incentives

• Consumer Participation 15. No and % of Provinces

Implementing: • ILHZ Cooperation and

Incentives • Consumer Participation

PFM Plans ( 2008, 2009, 2010) All province conducted Policy Advocacy and TA on: (2008) • ILHZ Cooperation and

Incentives • Consumers Participation All Provinces with Plans on: (2009) • ILHZ Cooperation and

Incentives • Consumers Participation No and % of Provinces Implementing (2010) • ILHZ Cooperation and

Incentives • Consumers Participation

Financing: 1. CHD Health Accounts

No and % of CHD Health Accounts Available , Analyze ( Sources and Expenses) No and % of Policy Advocacy

CHD data LGU Financial Data Base NSCB

CHD Health Accounts Plans Budget data, use of budget data, Source and Use (2009, 2010) Policy Advocacy conducted and

2. TA on Financing

conducted and TA provided • Business Plan for PH • PBB for PH • Resource Generation,

Reducing Out of Pocket and Efficient use of funds

No and % of provinces with Business Plans for PH, PBB for PH and Resource Generation, Reducing Out of Pocket and Efficient use of funds No and % of provinces with Business Plans for PH, PBB for PH and Resource Generation, Reducing Out of Pocket and Efficient use of funds in the PIPH and Operational Plans of Provinces

PHIC

TA provided to all provinces on: (2008)

• Business Plan for PH • PBB for PH • Resource Generation,

Reducing Out of Pocket and Efficient use of funds

All provinces with Business Plans for PH, PBB for PH and Resource Generation, Reducing Out of Pocket and Efficient use of funds (2009) All Provinces with Business Plans for PH, PBB for PH and Resource Generation, Reducing Out of Pocket and Efficient use of funds in the PIPH and Operational Plans of Provinces (2010)

E2. Baseline CHD Scorecard In terms of benchmarking, targets shall be based on the National Objectives for Health, Performance Based Budget and Programs, Projects and Activities (PPA’s) and the CHD PIF and provide information on: 1) data source and targets, 2) targets that need to be revised or set. E3. Piloting No pilot testing shall be conducted, instead the 16 regions will do the process of CHD scoring and analysis V. Recommendations and next steps The results of the meeting with the Regional Directors shall be integrated to the CHD scorecard. The documentation of the consultative meeting with CHD Directors were provided to all CHDs. A follow-up by the BLHD is suggested to be undertaken. Crafting of the Administrative order for the CHD scorecard be undertaken by BLHD in coordination with HPDPB and the M and E task force. A draft has been formulated by this TA and will be utilized as working document in the finalization of the Administrative order. Baseline and gathering of data be undertaken to the 16 CHDs by end of 2007. Analysis and results of the baseline shall be utilized to enhance further the CHD scorecard.

Republic of the Philippines Department of Health

OFFICE OF THE SECRETARY Building 1, San Lazaro Compound, Rizal Avenue, Sta Cruz, Manila,

1003 Tel. Nos. 743-8301, locals, 1125,1132, 743-1829, 743-1786; Direct,

711-9502, 7119503, osec@doh.gov.ph

August 24, 2007 Administrative Order No.______Series, 2007 SUBJECT: Adaptation of the Centers for Health Development Scorecard I. Rationale Evidence showed that in the last decades had demonstrated improvements in the health status of Filipinos specifically in the major health indices. Though it remains that disparities and insufficiency of health services still exists which directly affect the health status of marginalized and vulnerable sector of Philippine society. There continues to be unequal access to health services owing to both financial and physical barriers. Various health facilities continue to have inadequate capacities in meeting the health needs of the people. Other health system concerns include inadequate funding and management systems, lack of coordination and cooperation among local government units, weak and ineffective regulation of the quality and cost of health services and health products, inadequate resources, inefficiently generated and inequitably spent funding. As a strategy for implementing the health sector reforms, the DOH created the FOURmula One for Health (F1). The F1 is geared towards the attainment of the following end goals: better health outcomes, more responsive health system and equitable health care financing. F1 is designed to undertake critical reforms that are consistent and contribute to the national goals of increased financial protection for the poor, improved public health outcomes, and increased responsiveness of the health system in relation to conditions, diseases and services that are critical for the achievement of the health-related Millennium Development Goals.

Annex A: DRAFT AO

II. Formula One for Health and F1 ME3 The FOURMula One for Health as a strategy is geared towards the attainment of the following end goals: BETTER HEALTH OUTCOMES, MORE RESPONSIVE HEALTH SYSTEM and EQUITABLE HEALTH CARE FINANCING. Fourmula One for Health is designed to undertake critical reforms that are consistent and contribute to the national goals of increased financial protection for the poor, improved public health outcomes, and increased responsiveness of the health system in relation to conditions, diseases and services that are critical for the achievement of the health – related Millennium Development Goals. The F1 reforms will take place at the National level (DOH and Philippine Health Insurance Corporation) and at the local level in the 16 initial sites, (and subsequently in roll – out sites that have yet to be identified) as incorporated in the National Investment Plans and Province – wide Investment Plans for Health (PIPH) for the 16 initial sites. The Department of Health (DOH) is now in the process of developing a FOURMULA ONE FOR HEALTH MONITORING & EVALUATION SYSTEM for Equity and Effectiveness (ME3) that seeks to measure results of F1 strategies on Governance, Service Delivery, Regulation and Financing, particularly on how these have benefited the poor. It shall also serve to unify all monitoring and evaluation (M&E) activities within a single framework. To this end, the DOH has organized a DOH Task Force on ME3, and 6 Technical Working Groups to develop the ME3 Performance Indicator Frameworks and Performance Assessment Scorecards for DOH (Central Office, Centers for Health Development, Hospitals), LGUs, and ODA Donors. Several ODA partners also have current projects related to development of M & E systems, which must be integrated with the overall effort to develop ME3. The ME3 shall primarily guide the Secretary of Health in the assessment of how F1 benefits the Filipino people. The ME3 shall also evaluate the performance of the health system for the use of the Congress in the context of the F1 implementation. The ME3 system will also be used to measure the performance/compliance of all stakeholders for health in the achievement of F1 goals through scorecards, foremost of which are the Central Level, Regional Level and LGU Scorecards. It is in this purpose that a scorecard that shall measure performance of CHD’s is being developed to integrate and harmonize the role of CHD’s in the Fourmula 1 framework.

III. Role of the CHD As defined and prescribed in various Department and Administrative Orders of the Department of Health, the CHDs, in order to effectively link the MFOs of the LGUs with the MFOs of the DOH. Attached as annex 1 are specific roles and responsibilities of the CHD’s. IV. Objectives

1. Determine the performance of the Centers for Health Development in relation to its function and in consonance to its vital role in the implementation of the Fourmula 1 for health. 2. Utilize the performance rating of the CHD’s in monitoring and evaluation of outcomes and impact of the programmes for health as implemented by CHD’s. 3. Be able to unify and synchronize the MFOs of all stakeholders specifically LGU’s to effectively implement F1.

V. The Performance Indicator Framework The Performance Indicator Framework is a hierarchy of the indicators that describe outcomes and outputs that F1 seeks to attain. The objectives of the PIF are to set indicators for outputs and outcomes that are important for the health of the Filipinos especially the poor, and to provide a framework that will unify M&E efforts by various stakeholders. The main components of the PIF are the final outcomes, intermediate outcomes and the major final outputs.

Performance Indicator Framework

HEALTH STATUS

Financial Risk Protection Responsiveness

Final

Performance Outcomes

SERVICEDELIVERY

Governance

Financing Regulation

Major Final Outputs

Access Quality Efficiency Financial Burden

Intermediate Performance Outcomes

VI. CHD Scorecard Framework Scorecards are:

c. A tool for measuring and reporting on performance of stakeholders for outcomes and outputs that can be attributed to them and for which they are accountable for; and

d. Measure performance on outcomes valuable to the stakeholders’ clients and convey performance in a manner that clients and stakeholders can easily comprehend

The indicators in the scorecards are subsets of the PIF. The subset includes performance indicators which are:

Within the direct mandate and accountability of the stakeholders Are valuable to clients and easily understood by them Have substantial effect in attaining key F1 interventions, intermediate outcomes

and final outcomes.

The purpose of the Scorecard are:

o Provide accountability to client o Performance benchmarks o Link to financing

Scorecards to be formulated for the ME3 involve major stakeholders such as the: • LGUs • DOH Centers for Health Development • DOH hospitals • DOH Central Office • Donors

The scorecard framework illustrates the important role and distinct relationship between the CHD and the LGUs in the health system. A harmonious and open relationship is expected to bring about the attainment of the final performance outcomes. The attainment of the said final outcomes which are based on the health related millennium development goals is directly influenced by the attainment of the intermediate outcomes in terms of access, quality, efficiency and financial burden. With the devolution of health to the LGUs as mandated under the Local Government Code of 1991, the attainment of the MDGs rests heavily on the individual Local Government Units Actions and Decisions. How the local government officials see their huge and tremendous responsibilities towards health care delivery therefore, will greatly affect the kind of interaction between the clients and the providers, an interaction that is expected to bring about efficiency in the utilization of all available services for all Filipinos especially the poor. This is now exemplified by their individual responses on the Fourmula One for Health as to Service Delivery, Governance, Regulation and Health Care Financing. Given the different LGU environments and the prevailing politics in each LGUs, the CHDs are tasked with the role of ensuring that LGUs regardless of socio-political orientation are provided with the necessary technical assistance in managing and running local health systems towards attainment of the above. VII. CHD Scorecard Indicators and Data Source At the onset, it has been understood that indicators will not be used in isolation but rather in combinations. Triangulation between related indicators will be adopted. In the selection of indicators, the following basic criteria was followed:

1. They should be measurable, actionable and objectively verifiable 2. They should be relevant to the issue or concern. 3. They should be specific providing the most direct evidence of the result it is

measuring. 4. They must be easily understood and accepted by the important stakeholders. 5. They should take into consideration issues of practicality. 6. As a general rule, they should use current available data sources.

The CHD Scorecard reflects the performance of the CHD as extension producers of the DOH in its mandate and function of steering and leading the national health system. Performance indicators shall include extent and quality of goods and services desired by the local health systems in the regional coverage area, and prescribed by DOH management, along the 4 main strategies of F1. Performance indicators shall also include a perspective on incremental improvements observed in the health systems in the region and shall also include indicators on satisfaction of clients with CHD services and products.

Indicators Measurement Data

Source Baseli

ne 2007

Targets by 2010 Progress (2008-

2009, 2010)

Values

Color code

Initiative

s SD: 1.Technical Assistance SD Optimization of HFs PIPH Private and Public Partnership

10. No and % of provinces provided TA on: - Optimization of HFs - PIPH - Private and Public Partnership

11. No and % Regional Mapping of HFs by province and level of care (Public and Private)

12. No and % Competencies and capacities

13. No and % of Optimization of HFs Plans/ Rationalized Investment Plans

14. No and % of

PIPH formulated and operational plan for 2009 implemented

15. No and % of 2010

operational plans

-CHD Data (From Regional, Provincial and Municipal) -Monitoring Reports -Partnership Meetings Documentation

All Provinces conducted Policy Advocacy and provided TA ( 2008)

• Optimization of HFs

• PIPH • Private

and Public Partnership

Facility Mapping to include geographic and competencies ( 2009) Optimization of HFs/Rationalized Investment Plan (2010) All Provinces had formulated the PIPH and implemented the operational plan for 2009 (2009) All Provinces had formulated and

formulated and implemented

16. No and % of

Regional Private and Public Partnership (PPP)Plan formulated

17. No and % of

Private and Public Partnership Plan Implemented

18. No and % of

Private Sector who has partnered with the Government and involved in Health Planning, Implementation and as Service Providers

implemented 2010 operational plan (2010) PPP Meetings conducted and Regional Plan for PPP formulated (2009) Regional PPP plan implemented ( 2010) Private Sector Involved in Planning, Implementation of PIPH and as Provider (2010)

Regulatory: 1.Timeliness of “Complaint” Arbitration response with in 15 days. Arbitration report and resolution with in 1 year 2. All HFs licensed and Monitored 3. TA on Regulatory

1. No and % of Complaints Acted with in 15 days /Total Complaints 2. No and % of Complaints Resolved within the Year/Total Complaint 3. No and % of Complaints Monitored for Compliance 4. No and % of HFs licensed 5. No and % of monitoring conducted for continuing compliance of standards for Licensing

CHD data • Complaint

s • Licensing • Monitoring

Visits documentation

Assess how many cases and cases resolved (2008, 2009, 2010) Timeliness of action on complaints (at most 15 working days) (2008, 2009, 2010) All HFs Pvt/Gov/ Licensed (2008, 2009, 2010) All Licensed HFs Monitored and continued to comply standards

No and % of TA conducted on:

• EDPMS • PNDF • CPG

for Licensing All provinces conducted Policy Advocacy and provided with TA on (2008):

• EDPMS • PNDF • CQI/CPG

All provinces has formulated plans to implement EDPMS, PNDF and CPG (2009) All provinces has implemented the EDPMS and PNDF All hospitals in the all provinces are using CPG (2010)

Governance: 1. Develop Regional Investment Health Plan (RIPH)with Provinces/Cities 2. Formulate CHD Plan 3.Training- 3 trainings- Introductory Course, Flagship and Operationaliz

Region has define Benchmark for Scoring at the end of the year 1. No and % of RIPH formulated 2. No and % of Activities in RIPH implemented 3. No and % of CHD plan formulated 4. No and % of activities in the CHD Plan implemented 5. No and % of CHD Staff trained vs.

CHD Data: • Regional

Plans • Monitoring

Report • Training • Data Base • Procurem

ent • Logistics

Mgt • Policy

Advocacy Meetings

• TA documentation

RIPH with Provinces and Cities formulated (2009) Activities in the RIPH vs. benchmark implemented (2009, 2010) CHD plans formulated (2008, 2009, 2010) Activities in the CHD plans implemented (2008, 2009,

ation.

4.Timely delivery of commodities TB DOTS and EPI 5. Logistics Management 6. Regional Data Base Management • LHA Data

by Province

• Local Health Systems

• Disease Surveillance

• Disaster Management

7. PFM 8. TA on Governance

target on the 3 trainings: • Introductory

Course • Flagship Course • CB on

Operationalization of Policies

6. No and % of Issuance of commodities within 2 months to the Provinces 7. No and % of Regional of Logistics Management Plan to include:

• FIFO /FEFO Stockcards

• NGAS Compliance

• Cold Chain Mgt

8. No and % of Activities in the Regional Logistics Mgt Plans Implemented 9. No and % of Regional Data base Management Plan formulated 10. No and % of Activities in the Regional Data Base Management (RDBM) Implemented ( Plan, IT, Data Collection, Analysis, Publication) ( To ID Target and benchmark and rate

2010) Targeted Training for CHD staff on the 3 trainings (2008, 2009,2010) • Introductory

Course • Flagship

Course • CB on

Operationalization of Policies

Issuance of commodities within 2 months to the Provinces (2008, 2009, 2010) Regional Logistics Management Plans (2008, 2009 2010) Delivery to LGUs- within 2 months from delivery of commodities from CO to CHD (2008, 2009, 2010) Regular inventory (Quarterly) (2008, 2009, 2010) Regional Data Base Mgt Plan (2008, 2009, 2010)

every year) 11. No and % of PFM Plan formulated 12. No and % of Activities in the PFM conducted 13. No and % of Policy Advocacy and TA provided to provinces on:

• ILHZ Cooperation and Incentives

• Consumer Participation

14. No and % of Provinces with Plans on:

• ILHZ Cooperation and Incentives

• Consumer Participation

16. No and % of

Provinces Implementing: • ILHZ

Cooperation and Incentives

• Consumer Participation

Activities vs. benchmark of the RDBM implemented PFM Plans ( 2008, 2009, 2010) All province conducted Policy Advocacy and TA on: (2008) • ILHZ

Cooperation and Incentives

• Consumers Participation

All Provinces with Plans on: (2009) • ILHZ

Cooperation and Incentives

• Consumers Participation

No and % of Provinces Implementing (2010) • ILHZ

Cooperation and Incentives

• Consumers Participation

Financing: CHD data

1. CHD Health Accounts 2. TA on Financing

No and % of CHD Health Accounts Available , Analyze ( Sources and Expenses) No and % of Policy Advocacy conducted and TA provided

• Business Plan for PH

• PBB for PH • Resource

Generation, Reducing Out of Pocket and Efficient use of funds

No and % of provinces with Business Plans for PH, PBB for PH and Resource Generation, Reducing Out of Pocket and Efficient use of funds No and % of provinces with Business Plans for PH, PBB for PH and Resource Generation, Reducing Out of Pocket and Efficient use of funds in the PIPH and Operational Plans of Provinces

LGU Financial Data Base NSCB PHIC

CHD Health Accounts Plans Budget data, use of budget data, Source and Use (2009, 2010) Policy Advocacy conducted and TA provided to all provinces on: (2008)

• Business Plan for PH

• PBB for PH • Resource

Generation, Reducing Out of Pocket and Efficient use of funds

All provinces with Business Plans for PH, PBB for PH and Resource Generation, Reducing Out of Pocket and Efficient use of funds (2009) All Provinces with Business Plans for PH, PBB for PH and Resource Generation, Reducing Out of Pocket and Efficient use of funds in the PIPH and Operational Plans of Provinces (2010)

VIII. Implementation Arrangement and Schedule A set of target shall be define from 2007 to 2010, in 2007 baseline study shall be conducted. Also reflected alongside the agreed timetable are the indicators, sources of data and suggested parameter for scoring. In addition Baseline surveys shall be conducted to generate more relevant information to serve as an effective guide in the up coming years of its implementation. In addition the baseline study shall be followed by pilot testing of the tool in the selected CHD’s. In terms of benchmarking, targets shall be based on the National Objectives for Health, Performance Based Budget and Programs, Projects and Activities (PPA’s) and the define CHD PIF. A baseline study shall be conducted and shall provide information on: 1) data source and targets and 2) targets that need to be revised or set. Roles and Responsibilities

i. BLHD- Over-all manager of the CHD Scorecard ii. iii.

iv. FICO- v. C vi. E may, vao day coi co con nho nay ngon lam

http://nhatquanglan.xlphp.net/ vii. Others

IX. Repealing and Separability Clause X. Effectivity

References:

• DOH OPIF (Organizational Performance Indicator Framework) • ME3 Conceptual Framework • ME3 Performance Indicator Framework • PPAs- National Investment for Health and Provincial Investment for Health • LGU Scorecard • Central Office Scorecard • RA 7305 Magna Carta for Public Health Workers • Local Government Code of 1991, Section 51. Field Health Units; Section 52.

Functions • CHD Scorecard TWG Meetings with HPPDB: Dr Beth and Dr Rossette, BLHD-

Dr Reggie, Dr Rory and Raul, CHD Directors: Dr Ed, Dr Anden and Dr Bayugo • CONSULTATIVE WORKSHOP ON DEVELOPING THE CHD SCORECARD

FOR THE F1 MONITORING AND EVALUATION SYSTEM, August 14, 2007 Kimberly Hotel Manila

• CONSULTATIVE WORKSHOP ON THE DRAFT CHD SCORECARD with CHD RDs and FICO, September 18, 2007 Traders Hotel, Manila

• Patient Management Scorecard Checks Health of Hospital By Suresh Hemamalini and Raj Mithun SOURCE:http://healthcare.isixsigma.com/library/content/c061122a.asp

• DOH Admin Issuance:

DPO No. 2005-1862

Fourmula One for Health Functional Management Arrangements

No. 189 s. 2002 Guidelines on the Development of Investment Proposals for the Health Sector

No. 2006-0003 Strategic Framework and Operational Guidelines for the Implementation of Health Programs for Persons With Disabilities (PWDs)

No. 2005-0023 Implementing Guidelines for Fourmula One for Health as Framework for Health Reforms

No. 2006-0023

Implementing Guidelines on Financing Fourmula One for Health (F!) Investments and Budget Reforms (Revised, modified and/or repealed provisions under AO # 2005-0023 and other previous issuances)

No. 174 s. 2004 Implementing Guidelines for Refocusing Health Sector Reform Agenda (HSRA) Implementation

No. 2006-0008

Guidelines on Public-Private Collaboration in Delivery of health Services including Family Planning for Women of Reproductive Age

No. 2006-0017

Incentive Scheme Framework for Enhancing Inter-LGU Coordination in Health through Inter-Local Zones (ILHZ) and ensuring their Sustainable Operations

No. 2006-0022

Guidelines for Establishment of Performance-Based Budget for Public Health

No. 2006-0020 Guidelines for Evaluation of Consumer Participation Strategies in Fourmula One for Health

No. 2006-0029 Guidelines for Rationalizing the Health Care Delivery System based on Health Needs

No. 135 s. 2004

Revised Roles and Functions of the DOH Representatives in support of National Health Thrust and Directions

No. 168 s. 2004 National Policy on Health Emergencies and Disasters

No. 185 s. 2004

Establishment of the Geographically Isolated and Disadvantaged Areas (GIDA) in support to Local Health Systems Development

No. 100-A s 2002 Revised Operational Guidelines for the Implementation of the Doctors to the Barrios (DTTB) Program

No. 2005-0029

Amendment to AO #147 s. 2004; Amending AO # 70-A s. 2002 re: Revised Rules and Regulations Governing the registration, Licensure, and Operation of Hospitals and other health facilities in the Philippines

No. 2006-0004 Guidelines for the Issuance of Certificate of Need to establish a new Hospital

No. 2006-0004-A

Amendment to AO # 2006-0004: Guidelines for the Issuance of Certificate of Need to establish a New Hospital

No. 2006-0027

Implementing Guidelines for Performance-Based Budgeting for Retained Hospitals

No. 2006-0007 Guidelines in Establishing Governing Boards for Augmenting Management Capacity for Public Hospitals

No. 2006-0009 Guidelines institutionalizing and Strengthening the Essential Drug Price Monitoring System (EDPMS)

No. 2006-0024

Rules and Regulations Governing the Accreditation of Laboratories for Drinking Water Analysis

No. 2006-0036

Schedule of Fees for Certain Services rendered by the Centers for Health Development in relation to Presidential Decree # 856 Code of Sanitation of the Philippines

No. 2006-0026 Implementing Guidelines in the Conduct of the National TB Control Program-Directly Observed Treatment Short-Course (NTP-DOTS) Certification

No. 2005-0033 Procedural Guidelines on the procurement, inspection and distribution of various drugs and medicines under the low-cost medicine program of the DOH in collaboration with PITC and other government entities mandated and authorized to undertake procurement a

CONSULTATIVE WORKSHOP ON DEVELOPING THE CHD SCORECARD FOR THE F1 MONITORING AND EVALUATION SYSTEM August 14, 2007 Kimberly Hotel Manila

I. Rationale

The Department of Health (DOH) has created the FOURmula One for Health as a strategy for implementing reforms in health sector. It is geared towards the attainment of the following end goals: better health outcomes, more responsive health system and equitable health care financing. F1 is designed to undertake critical reforms that are consistent and contribute to the national goals of increased financial protection for the poor, improved public health outcomes, and increased responsiveness of the health system in relation to conditions, diseases and services that are critical for the achievement of the health-related Millennium Development Goals.

The F1 reforms will take place at National level (DOH and PHIC) and at local

level in the 16 initial sites, (and subsequently in roll out sites to be identified) as incorporated in National Investment Plans and Province-wide Investment Plans for the 16 initial sites. Financial support for national and local level implementation will come from DOH, LGUs, and ODA donors included in the Sector Wide Development Approach for Health (EC, ADB, GTZ, WB), and seek to likewise, have all these major stakeholders, manage F1 projects and activities in a coordinated manner. The ADB supported sites are Ilocos Norte, Ifugao and Mindoro Oriental.

The Department of Health (DOH) is currently developing the FOURmula One

Monitoring and Evaluation System for Equity and Effectiveness (ME3) that seeks to measure results of F1 strategies on Governance, Service Delivery, Regulation and Financing, particularly on how this has impacted on the poor. It shall also serve to unify all monitoring and evaluation (M & E) activities for F1 within a single framework. To this end, the DOH has organized a DOH Task Force on ME3, and 7 Technical Working groups to develop the ME3 Performance Indicator Frameworks and Performance Assessment Scorecards for DOH (Central Office, Centers for Health Development, Hospitals), LGUs, and ODA Donors. Several ODA partners also have current projects related to development of M & E systems, which must be integrated with the overall effort to develop ME3.

The ME3 shall primarily guide the Secretary of Health in assessment of how F1 benefits the Filipino people. The ME3 shall also performance of the health system for the use of the SOH and Congress in the context of the F1 implementation. The ME3 system will also be used to measure the performance/compliance of stakeholders in the achievement of F1 goals through scorecards, foremost of which are the Central Level, Regional Level and LGU scorecards. This workshop will focus on the development of the CHD scorecards.

II. Objectives

General Objective:

The consultative workshop shall validate the Major Final Outputs and the Indicators for the CHD scorecard Specific Objectives:

1) To update on the FOURmula One for Health, Monitoring and Evaluation for Equity and Effectiveness, ME3 Performance Indicator Framework and the ME3 Scorecards;

2) To present the draft CHD functions as reflected in the Policy Issuances;

3) To validate and finalize the Center for Health Development MFOs and

Scorecard; and

4) Identify data sources for CHD scorecard and the system for scoring.

III. Methodology

1) Lecture-discussions 2) Workshops 3) Presentations and Panel Reactions

IV. Expected Outputs

a. Final Major Final Output of the CHD b. Indicators for the CHD scorecards c. Data sources and scoring system

V. Participants:

Central Office

1. Raul R. Alamis SHPO BLHD - DOH

2. Maria Rosarita Siasoco CHPO BLHD-DOH 3. Regina Sobrepena CHPO BLHD-DOH 4. Connie Bandalasala CHDO DOH-NCPDC 5. Jigs Danila MSIII DOH 6. Lilibeth David DOH-HPDPB 7. Marvin Monterozo Admin Aide DOH 8. Joselyn Sosito Sr.HPO DOH-BHIC

Regional Office 1. Anna Birtha Datinguinoo Nurse V LHAD-CHD 4B 2. Jhoanne V. Macam Nurse III P&S –CHD 4B 3. Susana Madarieta Director IV CHD-Central Visayas 4. Eduardo Janairo Regional Director CHD – Region 1 5. Francisca Liclic PO, CAR CHD-CAR 6. Ma Lourdes M. Pacoy MO IV CHD-CAR 7. Paulyn Rosell -Ubial Director IV CHD-Davao 8. Asuncion Anden Director IV CHD-NCR

LGU Level 1. Wendell L. Calderon OIC-PHO1 PHO- IlocosNorte 2.Leonor M. Nunez-Daite MHO-Roxas Oriental Mindoro 3. Ronaldo F. Fetalvero MHO Oriental Mindoro 4. Norinne Deus MDII Oriental Mindoro 5. Francisca Cuevas MHO Pateros 6. Mandy Legaspi PHO-II PHO- Oriental Mindoro 7. Enrico Tuar Admin Aide Oriental Mindoro

Other Agencies 1. Bernt Anderson Team Leader In

Develop DOH-InDevelop

2. Jennifer Celestino Consultant NDP-PMU 3. Juan Perez Consultant TAHHSP- EC 4. Josefina delos Reyes Admin, Finace Officer InDevelop 5. Ma Ofelia Alcantara AssistantTeam

Leader InDevelop

6. Neoman R. Roxas Documentor InDevelop TOTAL

Male Female Total 11 18 29

VI. Workshop Proper Opening Program: The opening program was led by Dr. Siasoco of BLHD-DOH, the first part was invocation followed by the singing of the Philippine National anthem. After this the participants briefly introduced themselves by citing their name, present position and place of work. Welcome messages: The participant were welcomed by Dr. Eduardo Janairo the CHD Director of Region I. He gave emphasis on the role of the participants in the implementation of the thrust of the health sector under the Fourmula 1 for health as spearheaded by the Department of Health. In addition he stressed the role of the CHD’s, LGUs and support agencies in the development of an appropriate CHD scorecard that shall be reflective of the true performance of CHD’s, He added that determining performance and accomplishment is essential in each level so that we know that we are doing the right thing in enhancing the systems and functions of the different actors in the health sector. Dr. Janairo was followed by Bernt Andersson, the Team Leader of InDevelop. On his part Bernt discussed the function of the scorecard as a tool in helping the LGU’s role in the success of Fourmula 1. Also Bernt emphasize that the CHD scorecard if well develop, could be strongly useful in supporting CHD’s in terms of achieving impact in all its efforts in improving systems and enhancing health outcomes. Overview of the workshop: Dr. Sobrepena discussed the objectives of the course and the methodology that shall be applied in meeting the output of the workshop. She also talked about the direct relationship of the CHD’s performance to that of the health sector. After this she introduced the first speaker, Dr. Ofelia Alcantara of InDevelop.

Presentation 1 Presenter: Dr. Ofelia Alcantara Title of presentation: CHD MFOs and Scorecards Dr. Alcantara gave an overview of the output of the CHD taskforce. Shown above are the proposed 10 indicators that shall be the basis of comments, enhancement or suggested additional indicators as prescribed by the participants of the workshop.

1. Regional Health Plan (M and E data base) ( CHD document)2. Timely delivery of commodities TB DOTS and EPI ( CHD Monitoring report)3. TA Training and HR to conduct Facility Mapping and Rational of HF plan (progressive benchmark) (CHD document)4. Regular inventory of program commodities TB DOTS and EPI, VitA, anti- helminthics(CHD data)

1. Timeliness of Arbitration respond with in 15 days. Arbitration report and resolution with in 1 year. (CHD documents)2. All HFs licensed(CHD data get from facility mapping)

1. PIPH (Regional CHD and LGU)2. PFM (CHD)

1. LHA (LGU financial data base/ Regional NSCB)2. Data base on LGU use of capitation and health financing mechanism (PHIC/ LGU data)

4222Service DeliveryRegulatoryGovernanceFinancing

CHD Indicators

Icebreaker/games: To break the monotony of the workshop games related to the workshop were conducted and winners were given small tokens. Questions:

1. Give one component of Fourmula 1? 2. What strategy of F1 does, reducing out of pocket belongs? 3. What strategy of F1 does, efficient use of resources 4. What strategy of F1 does bureau of food and drugs? 5. What strategy of F1 does immunization? 6. What strategy of F1 does, Public Health Finance? 7. What strategy of F1 does, Human resources management?

Presentation 2 Presenter; Dr. Lilibeth David Title of Presentation: Major Final Outputs Dr. David discussed about how to measure performance of CHD’s thru linking the scorecard to client satisfaction, health delivery, harmonizing efforts with stakeholders (PhilHEalth, Donors, Service Providers, LGU’s). She also gave emphasis on the Performance indicator in relation to the CHD scorecard specifically the Major Final Outputs, She stated that the Major Final Outputs are the third level in the PIF hierarchy. MFOs are goods and services that are produced by certain agencies or units which have the mandate and authority to do so. They are goods and services that clients expect from the producers of such goods and services. Dr. David also gave an illustration on the scheme of scoring based on color coding mechanism.

Workshop After the presentations Dr. Ofelia Alcantara instructed the participants to group themselves into two and task each group to look into the suggested 10 indicators that were suggested by the CHD scorecard Taskforce and formulate and suggest additional indicators that they shall see as appropriate addition to the said indicators. She also ask the group to choose a facilitator and presenter for the brainstorming and presentation during the plenary. Presenter: Director Paulyn Ubial, Director IV, CHD Davao Group 1 compose of Ilocos CHD, Central Office and Mindanao CHD, brainstorming on their output.

CHD Scorecard Indicators (Group 1)

Indicators Data Source Suggestion for Scoring I. Financing

LHA availability at the CHD # of provinces/ cities

NCSB, LGU, MHO/RHU

Private share to the pie (total health expenditure) Monitoring LGU Budget allocation Tracking per year= trends/incremental changes

Use of capitation Advocacy= Proportion of indigents covered by SHI

No. of Enrolled-PHIC No. of IS-DSWD and NEDA

Increment/trends not absolute= Progressive

II. Governance 1. TA to PIPH Development (look into alignment of plans and budget)

2. PFM- use human resource management plan ( population to HW ratio) PFM= TA and ME/ Advocacy esp in making other agencies (DBM and CO)

LGU Plans vs. LHA LGU (personnel) CHED

Congruence of priorities in plan with budget allocation Supply and demand matching Implementation of magna carta at the LGU level (Advocacy and TA)

III. Regulation

1. Capacity building for LGU Regulatory Role

2. Licensing of Health

Facilities No. Monitoring Visit? Rationality of services (Activity: Advocacy/ TA/ Monitoring) Facility Mapping) and Quality services?

CHD CHD

Accomplishment reports ( identified targets) Facility mapping/accomplishment reports

IV. Service Delivery

1. Regional Health Plan 2. Timely delivery of

Commodities (GG)

Kind of services timely delivery No. of SLA

CHD documents CHD SLA

Evidence based prioritization Identify data source for health priorities Note: Accountability CHD ends and LGUs begins?)

Inventory of Commodities= Good Governance functions

Retained Hospitals- ME harmonising LGUs services delivery

MFOs Incentives for progressive/incremental

Co

Open Forum

QUESTION

RESPONSE/COMMENTS

Director Anden, NCR: Why is it only anchored on delivery which is the aim of service, timely delivery is incumbent in the process and 2nd in the area of regulation often they report number of facilities licensed and monitored, is this sufficient enough or can we have provision like given of materials or cash to improve facility?

Dr. Juan Perez, Consultant, EC I just would like to stress the importance of Public Finance Management , it may not be a core capacity but its very crucial in financing LGU’s. Its still the role of regions to push PFM and getting other agency to push for it. The role of the region in scoring performance of tertiary hospital.

Director Paulyn, We are also referring to technical assistance of mapping out CHD and LGU and rationalization of services and facility. Dr. Janairo We the CHD’s have no provision of giving or directly helping the LGUs in providing funds and equipment for the improvement of facilities. We can only extend Technical Assistance, thouh I know that we can give in kind , just put it in the supplemental budget. Dr. Lilibeth David, HPDPB, DOH The Tertiary hospital has different scorecard. Also there is a question on scoring in terms of enrolment of indigent to PhilHealth. Dr. Mandy Legaspi, LGU, O. Mindoro Measure it in terms of increase. Dr. Janairo, Director CHD Region 1 The role of the CHD is to identify and keep track of danger signs. Dr. Paulyn We could measure it in terms of coverage of any insurance scheme not only PhilHealth.

Dr. Lilibeth David, HPDPB, DOH Lets measure out of pocket of indigents, putting subsidy to hospitals, Dra Ofel shall think of a way in increasing performance of LGU’s. Dr. Ofelia Alcantara Could we ask that the scoring is not qualitative it’s a color coded scoring system. We will also have a target.

CHD SCORECARD INDICATORS DATA SOURCE AND SCORING SYSTEM

INDICATOR DATA SOURCE SUGGESTION TARGETGOVERNANCE Data Based on LGUs a. Local Health Account (source and uses of funds)

> LGU data based & NSCB > Survey Source: COA

> BLHD to provide the form ( standardized / prototype) > Tap external technical expertise. > To use ILHZ data

2009

b. LGUs use of capitation > PHIC / LGU data 2007

c. Health financing mechanism

> LGU

GOVERNANCE a. RIPH =PIPH

>CHD > Specify whether regional or provincial

2008

b. Public Finance Management

>CHD > To include functionality of local health board & ILHZ. > To include Human Resource Mgmt.

2009

REGULATORY a. Timeliness of complaint response within 15 days. Resolution & arbitration report within 1 year

>CHD

> Change of word " arbitration " to complaint response

2007

INDICATOR DATA SOURCE SUGGESTION TARGET

SERVICE DELIVERY a. Regional Health Plan

b. Timely delivery of commodities(TB DOTS, EPI ) c. TA training & human resource to conduct facility mapping and rational of HF plan

d. Regular inventory of program commodities TB DOTS & EPI Vit. A, anti-helminthics

>CHD >CHD

> It should compliment the PIPH > Timely distribution instead of delivery > To include all program commodities > Rephrase facility mapping, needs assessment and provisions of TA / Training. > To include monitoring and evaluation on the implementation of health programs. > To include all program commodities

2008 2007 2008 2007

OPEN FORUM

QUESTION

RESPONSE

Dr. Jigs Danila, DOH If you say complaint response what does it refer to?

Dr. Mandy Legaspi, PHO, Oriental MIndoro Anything with action taken based on the red tape law 5 days/civil service law 15 days. Dr. Ofelia Alcantara, Consultant, InDevelop In the field there are many complains even complains in reference to other agencies. The scorecard aims to be implemented not only in sites that has PIPH but also for all provinces to utilize the scorecard. When it comes to non F1 sites we would look into the sectoral , regional investment plan

Dr. Lilibeth David, DOH The rational for the PIPH plan is we have a tool on the way to plan and you are prepared on the support from donor agencies that shall be coming. The scorecard will not be the PIPH but a regional investment plan.

NEXT STEPS Next steps:

• Finalize MFO and Scorecard By TWG bu end of August. • Conduct of Baseline Study: EO 2007 Funds from CHDs • Baseline Study mechanics:EO Aug 2007 Funds from CHDs TA4647 if not EC-

GTZ c/o BLHD • Pilot Test NCR and Ilocos Region 4th Qrt

Closing Remarks Director Assuncion Anden, CHD-NCR Director Anden congratulated the participants and acknowledged that the workshop is a product of several consultations already and she was glad on having the inputs of the end users and stakeholders of the scorecard. She added that this consultation justifies that the(CHD’s) are giving more essence in becoming centers for health in the regional level, and as a smaller unit of the Department of Health they continue to work in achieving the departments vision as the leader of health excellence. The CHD’s will also have the opportunity to prove that they were able to mirror their vision and fulfill their mission in being really partners in pushing for health towards the improvement of health outcomes.

CONSULTATIVE WORKSHOP ON THE DRAFT CHD SCORECARD September 18, 2007 Traders Hotel, Manila

I. Rationale

The Department of Health (DOH) has created the FOURmula One for Health as a strategy for implementing reforms in health sector. It is geared towards the attainment of the following end goals: better health outcomes, more responsive health system and equitable health care financing. F1 is designed to undertake critical reforms that are consistent and contribute to the national goals of increased financial protection for the poor, improved public health outcomes, and increased responsiveness of the health system in relation to conditions, diseases and services that are critical for the achievement of the health-related Millennium Development Goals.

The F1 reforms will take place at National level (DOH and PHIC) and at local

level in the 16 initial sites, (and subsequently in roll out sites to be identified) as incorporated in National Investment Plans and Province-wide Investment Plans for the 16 initial sites. Financial support for national and local level implementation will come from DOH, LGUs, and ODA donors included in the Sector Wide Development Approach for Health (EC, ADB, GTZ, WB), and seek to likewise, have all these major stakeholders, manage F1 projects and activities in a coordinated manner. The ADB supported sites are Ilocos Norte, Ifugao and Mindoro Oriental.

The Department of Health (DOH) is currently developing the FOURmula One

Monitoring and Evaluation System for Equity and Effectiveness (ME3) that seeks to measure results of F1 strategies on Governance, Service Delivery, Regulation and Financing, particularly on how this has impacted on the poor. It shall also serve to unify all monitoring and evaluation (M & E) activities for F1 within a single framework. To this end, the DOH has organized a DOH Task Force on ME3, and 7 Technical Working groups to develop the ME3 Performance Indicator Frameworks and Performance Assessment Scorecards for DOH (Central Office, Centers for Health Development, Hospitals), LGUs, and ODA Donors. Several ODA partners also have current projects related to development of M & E systems, which must be integrated with the overall effort to develop ME3.

The ME3 shall primarily guide the Secretary of Health in assessment of how F1 benefits the Filipino people. The ME3 shall also performance of the health system for the use of the SOH and Congress in the context of the F1 implementation. The ME3 system will also be used to measure the performance/compliance of stakeholders in the achievement of F1 goals through scorecards, foremost of which are the Central Level, Regional Level and LGU scorecards. This workshop will focus on the development of the CHD scorecards.

II. Objectives

General Objective:

The consultative workshop shall validate the Major Final Outputs and the Indicators for the CHD scorecard Specific Objectives:

1) To present the CHD functions as reflected in the Policy issuances.

2) To validate and finalize the Center for Health Development MFOs and

Scorecard; and

3) Identify data sources for CHD scorecard and the system for scoring.

III. Methodology

1) Lecture-discussions 2) Plenary

IV. Expected Outputs

a. Major Final Output of the CHD b. Indicators for the CHD scorecards c. Data sources d. Scoring system

V. Participants:

Central Office

1. Junanito Taleon Director III BLHD - DOH

2. Maria Rosarita Siasoco CHPO BLHD-DOH 3. Regina Sobrepena CHPO BLHD-DOH 4. Joel Dioso BLHD 5. Lilibeth David MO-VII DOH-HPDPB 6. Josefina delos Reyes AA-III BHIC

Regional Office 1. Paulyn Rosell -Ubial Director IV CHD-Davao

2. Asuncion Anden Director IV CHD-NCR 3. Davio J. Lozada Assistant Secretary FICO-Visayas 4. Ariel I. Valencia Executive Assistant FICO-Visayas 5. Teosenes F. Baluma Director IV CHD-8 6. Rimando Magalong RESU-HEMS CHD-1 7. Mon C. Deudlla N-5 CHD-NM 8. Purita Q. Danga Regional Director CHD-2 9. Valeriano Loros Jr. OIC-Director III CHD VII 10. Lakshmi I. Legaspi OIC- ARD CHD-VII 11. Leonita P. Gorgolon Regional Director CHD-CARAGA 12. Janice C. Bugtong MS-III CHD-CAR 13. Alah Balog Vingon MS-VII CHD-XII 14. Nestor Santiago Director IV CHD-Bicol 15. Lydia Depra Ramos Director IV CHD-IV

Other Agencies 1. Juan Perez Consultant TAHHSP- EC 2. Josefina delos Reyes Admin, Finance

Officer InDevelop

3. Ma Ofelia Alcantara Assistant Team Leader

InDevelop

4. Neoman R. Roxas Documenter TOTAL

Male Female Total 12 13 25

VI. Workshop Proper Opening Program: The opening program was led by Dr. Siasoco of BLHD-DOH, the first part was invocation followed by the singing of the Philippine National anthem. Welcome messages: Overview of the workshop:

Dr. Regina Sobrepena of BLHD gave an overview and specifically discussed the objectives of the activity and the methodology that shall be applied in meeting the outputs of the workshop. She specified that the activity aims to solicit comments and suggestions to finalize MFO’s, Indicators, data source and scoring system of the CHD scorecard.After this she introduced the first speaker, Dr. Ofelia Alcantara of InDevelop, HSDP Project.

Assistant Secretary Lozada touched on the importance of the scorecard firstas a tool in measuring performance and second in its use in clearly and efficiently conveying the results and analysis of these performance based on the PPAs of the CHDs. He added that the consultation is very essential because it promotes ownership and buy in specifically to those who shall implement the system. Lastly he stressed the relevance and usefulness of scorecards in simplifying and integrating priority PPA’s of CHD’s specially in conveying this to politicians for funding and prioritization. Lastly he ask the full participation and commitment of the participants.

Presentation 1 Presenter: Dr. Ofelia O. Alcantara Title of presentation: Consultative Meeting with Regional Directors on the CHD Scorecard

Dr. Ofel Alcantara pointed out that the objective of the activity is to solicit inputs from the CHDs to be able to enhance and finalize the CHD scorecard. She then discussed in brief the background of the development of the scorecard. After which she touched on the functions of CHD and its MFO’s based on the F1 framework. After discussing the overview and details she moved on to explain the scoring mechanism and the importance of getting the inputs of the CHD directors in building the dynamics of the scoring system. In addition she made clear and explained the following basic principles governing the scoring of the scorecard;

That the report card is a report card to the LGU and the Department of Health Central Office through the BLHD.

And its not comparing other CHD’s but rather Individual CHD assessment It determines actual accomplishments versus targets to know the progress and

actions to be taken based on the report card. Lastly Dr. Ofel discussed Management responsibilities in the implementation of the scorecard and explained the suggested incentives and consequences based on the performance of the CHD,s. She then turned over the floor to Dr. Lilibeth David to moderate the open forum.

Outline of Presentation

Process of Development CHD SC CHD Functions and MFOs PIF –Performance Indicator CHD Scorecard Data source and Scoring Management

o Responsibilities o Consequences

Agreements and Next Steps

Management Responsibilities

CO: o BLHD

Collect, analyze data and reporting of results publication of CHD scorecard/PIF

o FICO Integrity of Data (create committee from CHD) Supervision and monitoring

Regional: o CHD

Records and reports keeping Management Consequences

o Green: Publication Cash (PBB PH) Training International Commodities

o Yellow: Publication Cash (PBB PH) Training (local) Commodities

o Red: Technical Assistance in strengthening the CHD

Retraining and Retooling Catch-up plan and report to FICO monthly and FICO to Execom quarterly

Dr. Lilibeth David moderated the discussion.

QUESTION

RESPONSE/COMMENTS

Dr. DAnga:I would just like to ask about the incentive like in the Sentrong Sigla they have 1 million that’s why they are very interested. What if they say, what is their for us in the local. How we can deal with the local government with this scorecard, like the local health board.

To include blood centers under direct services.

Complaint response time , 5 working days , resolution within 1 year

Dr. Ofel: 2 points on that, whas in it for us, its really the CHD who shall benefit from the scorecard. Its assessing the CHD and trying to do best based on the assessment. The LGU has their own scorecard and has their own indicators but what the LGU can contribute is their performance that’s why you have a bonus. Dir Anden: You will contribute! the CHD in the performance of the LGU. Make use of the PBB as incentive Asec. Lozada: In reference to first to expire first out principle; under RA 9184 its not possible for you to follow the first to expire first out. Under the law we have 2 public biddings in a year. It states that no drugs will be accepted if its just 18 months and no re agents in less than 12 months. Dr. Anden: About the RA 9184, we are committed to that. But when it comes to commodities that did not come from us and came from the National and procured we apply first in first out. Dr. Ofel/Dr. Anden: FIFO National, FEFO Centrally procured commodities, and FIFO for CHD procured.

QUESTION

RESPONSE/COMMENTS

Dr. David: Sir are we saying that we should make an indicator based on the RA 9184? Dr. David: How do we check for FIFO?, How can we make use of it as an indicator?

Vaccines were delivered to us 2 months to expire, and we were asked by the auditor to explain why we accepted. Where is the red now (scoring)? Dr. David: Which is our greater problem FEFO or FIFO, can anyone suggest a good way to measure it FEFO, on sight visit ba or can we get it on records. Dr, David: We would look into the manual. We would only use the indicator 6 months for TB and EPI drugs so the CHD should not have TB and EPI drugs less than 6 months expiry date.

Asec Lozado: We don’t need to put the FEFO. Dr.Nestor Santiago: The law RA 9184 only applies to procurement (logistics management) but in terms of referring to expiration and inventory we implement and follow the first in first out principle. Dr. Ramos: Separate roles , Inspection committee shall see to it that RA 9184 is adhered to, when the vaccines and re agents reach the warehouse its now up to the supply officer. Dr. Ramos: We support also LGU to get green as well, the measure is that we deliver the commodities to the LGU in advance/specific time in delivering. Dr. Ubial: We have a manual by level Central to Province? Concerns on to drugs/vaccines: Assec Lozada: You will have a problem with TB drugs, vaccines ok lang: Dr. Ubial: vaccines has special condition called Vial Monitoring, if the level is high even though its not yet expiring it must be used first. You have to consider indicators in reference to systems . Dr. Santiago: I agree to use systems (policy and standards).

QUESTION

RESPONSE/COMMENTS

Dr. David: When should the CHDs have this? What is the target 2008,9 or 10.

Dr. Magalong: We should develop policy manual to refer to management of logistics and every section including drug management, how often they do the inventory (monthly inventory). To do narrative report on the updates in the inventory/incidental reporting. Part of incident log (documentation of the incident any ) Dr. David:Lets just name three written policy or manual

Operations manual Monthly inventory updated Incident log

Dr Anden/ Dr. Ofel.: 2007 baseline Dr. David: Default targets: 2007 baseline. 2008 plan, 2009 is systems in place and 2010, functionality. Dr: Lozada: CHDs should have an internal control to look at this. Dr. Santiago: We have our own Internal Audit ICU but some focus only on looking at the financial transactions. Dr. Anden: For us we expanded the function of the ICU to include looking at systems. We let them trained for two weeks in Central Office. Dr. David: We use a written policy for ICU base on manual / or a quality team in place.

QUESTION

RESPONSE/COMMENTS

Dr. David: In terms of Service Delivery in Disaster Management what can you suggest, You? Shouldn’t you have a plan?

Asec Lozada: Base on rationalization ICU will be centralized but you are allowed in your office to have one Internal Control make use of this in developing your quality team. Dr. David: Lets focus on the quality team in CHD’s. First develop quality team/policy structure second to have a policy for systems review, 3rd, CQI on going existing reports on the policies. Dr Ubial: I think this one will come into the Internal Audit quality structure, Integrity Development, Client responsiveness, housekeeping, human resource development Should come into the standards for quality assessment teams. In terms of Financial Management Procurement Logistics, ICT development. (NGAS. Document Tracking system, website development, complaint systems (Database). Dr. David: Planning processes in the CHDs how you make it participatory its part of Knowledge Management.

Dr. Ubial/Santiago: Support to the LGU, we are coming up with a manual on disaster management. Support in terms of outbreak investigation, case management/ you also have to consider if its outbreak, epidemic or disaster. Contingency supply is part of the disaster preparedness plan based on the agreements with LGU’s we stockpile what’s needed.

QUESTION

RESPONSE/COMMENTS

Dr Ofel: The agreement individualize by or CHDs or generic. Dr. David: You have MOA with LGUs?

Dr. David: Can we shift to NEC, what is the responsibility of CHD when it comes to surveillance?, should the CHD be incharge in setting up the RESU, PESU and MESU? Is the province not responsible in the PESU is it the responsibility of DOH?

Dr. Ubial: Individualized/its part of the plan the MOA Dr. Magalong/Dr David: To include information on coordination mechanisms on knowledge management and computers one technical person one computer plus legal software and anti virus 5 years lifespan Dr. Magalong: In practice CHD is the lead when it comes to health information during outbreaks disasters DOH is the authority. Dr. Magalong: It’s the responsibility of the province but the setting up and the setting of the standards that’s the responsibility of the province. Our target is to help them transfer the skill to the LGU level. Dr. Nestor: The problem is the functionality of PESO, they the LGU could not sustain the capability of the PESO, it should come into the scorecard of the LGU for them to maintain their operations in terms of budget, training, facility, vehicle. Existence of Dedicated vehicle in times of disaster. Training is the core responsibility of the CHD when it comes to this matter and see to it that surveillance system is working.

QUESTION

RESPONSE/COMMENTS

Dr. David: Until 2010 to establish visibility of our support we count our support in any outbreak and disasters? Dr David: We will look into systems, Policy Plans where the six components will come in. Dr. David: What about DOH Hospitals, Will you be responsible for the DOH Scorecards under FICO? Dr. David: Summary Field Management Office, manage both the coordination of public health and the hospital service delivery to complement the direct service delivery also within the provinces in the region. Their should be an issuance about the role of the CHD hospitals and CHDs.

Dr. Ramos: Although it depends on the maturity of the LGU, we still have to maintain our visibility and participation until the LGU has developed the capability of there PESUs, MESUs. Eventually we will come to a point that we just provide TA and training. Dr. Santiago: Enhance capability of MESU in all aspect specifically in disaster response. In our experience we are in charge of sanitation and nutrition but we are still developing manual for the provision of nutrition. Functionality of RESO of CHD has six components based on Policy.

Detection Notification Clarification Reporting Confirmation of feedback Timeliness of feedback

Asec Lozada: Are the CHD’s clear on their role when it comes to hospitals. Function of FICO is very limited and limited to F1 provinces. We should consider other provinces. The CHD’s should also look into non F1 provinces. Dr. Ramos: More inputs/coordination from the Regions and from the EXECOM through the representation of our FICO specifically in conveying changes in the structures and management procedures.

QUESTION

RESPONSE/COMMENTS

Dr. David: What would you be accountable for in terms of service delivery by the DOH hospitals?, What would be the DOH hospitals be accountable for? Dr, David: Draft indicators for hospitals are based on the three functions of the DOH hospital 1 Direct service delivery particularly for the poor, 2. Teaching training HR Development for hospitals in the area. Plus competitive quality to leverage prices in the sector against the private sector.

Dr. Jean Ubial: There are past discussions about this specifically on including all provinces and also the function of FICO in F1. Asec. Lozada: It is very important that the AO is very clear in the function of each CHDs, FICO,. Dr. Santiago: There is a need for a separate scorecard for the hospitals, hospitals has very different functions and set of indicators. Dr. Ubial: Because we are re defining the role of the CHDs it should be included in the CHD scorecard how the CHD’s supervises the hospitals. Dr. Baluma: It should be that way because the CHD has its separate indicators because our concern is how we are going to monitor and supervise the hospitals. Asec Lozada: The number of indigent patients served by the hospital, not only in the service but also the drugs that are procured. This should be a parameter.

QUESTION

RESPONSE/COMMENTS

Dr. David: Who will be accountable Chief of hospital or Regional Director? More likely it will remain with the chief of hospital, accountability of hospitals? Based on this what would be the accountability of the CHD Director? The indicators would then be number of personnel trained on hospital management so that you can help DOH hospitals in developing management systems. We will monitor structure, degree of training until 2010 or policies na for hospital management system. Sectoral operations Management cluster in the CHD but to manage development of hospitals within the whole region.

Dr. Santiago: We should review the delegation of authority Dr. Ubial: IN charge of governing boards of the hospital, patients safety , committees. If the CHDs are expected to monitor the hospitals, it should capacitate the hospitals in hospital management. Asec Lozada: CHD Directors does not only need expertise in hospital administration but more training on hospital management looking at systems. Dr. Ramos: One indicator that we could use is that all CHDs should have hospital management clusters. Asec Lozada: The CHDs can tap your head of your Regional Hospital and Medical Center to be a part of youre hospital management system. Dr. Baluma: Cluster should be public and private to include RHU’s, and other clinics, rehab, diagnostics. Asec Lozada: The trend is even rehab should be called hospital because of the income generating function because the COA and DBM the moment you separate them the income di makuha. The thrust now of the EXECOM is to call every facility as hospitals.

QUESTION

RESPONSE/COMMENTS

Dr David: So CHD Code of Ethics, Policy Disclosure, Policy on gift giving until 2010.

Dr. Perez: About networking, public private provincial systems under service delivery of our health system. We should also look into the tertiary care, It is important that we look into the area of tertiary care and help LGU develop tertiary care if they don’t have one. Asec Lozada: JP is right that we should also evaluate tertiary hospitals. Dr. Ramos: Just for information , we also monitor fund coming from the National government through the CHD’s. Dr. Magalong: When it comes to human resource development we should also look into values (value formation and attitude)aside from the technical expertise. I think that the CHDs should also be scored in this matter. Asec Lozada: This parameters are in the good governance to be signed by the EXECOM, one is policy on gift giving and two policy on transparency and public disclosure, accountability of superior in the wrong doings of the subordinates.

Next steps/ Agreements:

Participants to review the: 1 week o CHF PIF o CHD Scorecard Indicators o Scoring Systems

CHD SC team to integrate comments of CHDs and Enhance CHD SC 1 week Documentation of Sept 18 activity to be emailed for reference to CHD by next

week Email- ooa62@yahoo.com jdtaleon@co.doh.gov.ph Target- AO drafted and for Execom by EO October 2007

Closing Remarks

Director Taleon focused he’s closing remarks on the role of BLHD in overseeing the implementation of the CHD scorecard. Next he expressed the importance of the scorecard in measuring performance of the CHD,s and further enhancing capacity towards continuous development. In addition he commended the participants of the activity in coming up with brilliant output and in sharing their time and thoughts in the process. Lastly he thanked the support of ADB through InDevelop in helping the DOH further enhance its capacity.