Summary of the Evaluation Results
I. Outline of the ProjectCountry㧦The Philippines

Issue/Sector㧦Health/Health System
Division in charge㧦JICA Philippine Office
Period of Cooperation㧦March 2006~March 2011
Project title㧦The Project of Strengtheningof Local Health System in the Province of
BenguetCooperation scheme㧦TechnicalCooperation
Total cost㧦325 million yen as of September
2010
Partner Country’s Implementing
Organization㧦Department of Health(DOH), DOH-Center for Health
Development Cordillera Administrative
Region (DOH-CHD CAR), Province of
Benguet, Provincial Health Office of
Benguet, 13 Municipalities, 13 Rural Health
Units, Philippine Health Insurance
Corporation
Supporting Organization in Japan㧦None
Related Cooperation㧦None

1-1 Background of the Project
The Department of Health (DOH) of the Philippines has been implementing health sector reformwith the aim of improving the quality of health services under the decentralization system. The
current implementation of health reforms builds upon the lessons and experiences from the major
health reform initiatives undertaken in the last 30 years. The Health Sector Reform Agenda(HSRA), conceptualized in late 1990s, aimed to establish effective and efficient health system.
FOURmula ONE for Health (F1), initiated in 2005 as the implementation framework of HSRA,
has been an attempt to achieve critical reforms with speed, precision and effective coordination
directed at improving the quality, efficiency, effectiveness and equity of the Philippine healthsystem. F1, initially started in 16 selected provinces, has expanded to cover the whole nation by2009.
Under the decentralization of the health service delivery, health issues faced in the Province of
Benguet were no different from other parts of the country. Inadequate supporting system of quality
health services, chronic financial deficit, lack of drugs, ineffective referral system were some of
the issues commonly perceived. As such, the Province was included in F1 sites in 2008 and has
been implementing the health sector reform since then.

1

As far as the HSRA is concerned, while no major change of policy is expected in the new Government,
DOH is currently crafting “Universal Health Care (UHC)” in which Human Resources for Health and
Health Information will be added to the four pillars (Service Delivery, Governance, Governance,
Regulation and Financing) of F1

Within the national context, this project supported by JICA’s technical cooperation wasdeveloped, aiming to strengthen health systems of Local Government Units (LGUs)
comprehensively and make contribution to health policy through sharing of outcomes and lessons
learned with other donors involving in the health sector reform. In 2006, the Project was launched
for the implementation period of five (5) years targeting the province of Benguet.
1-2 Project Overview(1) Overall Goal: Health Status of the People in the Province is enhanced.
(2) Project Purpose: Local health system is strengthened to improve quality of health service in
the Province of Benguet.
(3) Outputs
1. Supporting system of providing quality health services by Rural Health Unit (RHU) is
established.
2. Health governance (management) of the Province is strengthened.
3. Financial system of healthcare of the Province is strengthened.
4. Overall drug supply system of the Province is strengthened.
5. Information and experiences of the Project are shared with DOH and other FOURmula
one provinces.
(4) Inputs
Japanese side㧦Long-term Expert: 0
Equipment: 17,770,954PhP
Short-term Expert: 8 persons (99.83MM) Local cost: 15,715,811PhP
Philippines Side㧦Counterpart: 49 members in total
Equipment: N/ALand and Facilities: Project office space, venues for training and meetings
Local Cost: cost sharing of administrative expenses, salary of technical staff,
matching funds for activities
Others: N/A
II. Evaluation Team
Members of
1. Leader, Harumi Kitabayashi, Visiting Senior Advisor, JICA
Evaluation
2. Planning, Yukari Horii, Staff, Health Division III, Human Development
Dept, JICA
Team
3. Evaluation Analysis, Akemi Serizawa, Social Development Specialist,
Global Link Management, Inc.
4. Evaluation Analysis, Dr. Nicolas Gordo, Medical Specialist IV and Head ofHealth Facility Development Cluster, Department of Health (DOH) Centerfor Health Development (CHD), Cordillera Administrative Region (CAR)
5. Evaluation Analysis, Rolando Benitez, Supervising Health Program Officer,
Bureau of International Health Cooperation (BIHC), Department of Health(DOH)
Period of
September 12 to 27, 2010
Type of Evaluation㧦Terminal
Evaluation

III. Results of Evaluation
1 Achievements
1-1 Outputs
Output 1: Supporting system of providing quality health services by Rural Health Unit (RHU) is
established.
It has already been achieved. The number of RHUs which comply with requirements of SS-II
certification and PhilHealth accreditations has increased through the training of health staff andprovision of equipment. Referral manuals were developed and are utilized, and referral cases arerecorded in all health facilities. Monitoring has been conducted quarterly since 2010, andmonitoring tools were pilot-tested and are ready to be reproduced shortly.
Output 2: Health governance (management) of the Province is strengthened.
It has also been achieved. The Provincial Investment Plan for Health, the Provincial Annual
Health Plan, Inter-local Health Zone (ILHZ) mid-term plans and ILHZ annual operation plans weredeveloped and are reviewed regularly. All four ILHZ are functioning: the board meetings are held
regularly to develop and review the plans,
Output 3: Financial system of health care of the Province is strengthened.
It has also been achieved in terms of the indicators. Income from user fees, amount for
Maintenance and Other Operating Expenses (MOOE) for health programs, amount of other sourcesin total health budget, number of PhilHealth enrollment and amount of capitation fund haveincreased. However, the quality of the financial data is limited and inconsistency and absence ofsome data hampered the correct analysis. Data on actual expenditure was not obtainable, either.
Output 4: .Overall drug supply system of the Province is strengthened.
It has also been achieved in terms of stock management at the health facilities as they keep thestock record and take record of number of days of out of stock on the indicator drugs.
Output 5: Information and experiences of the Project are shared with DOH and other FOURmulaOne provinces.
Experiences from the Project are shared with other provinces through the study tours and HealthPartners’ meetings in Manila.

1-2 Project purpose
Project Purpose: Local health system is strengthened to improve quality of healthservice in the Province of Benguet.
Indicators for the
Project Purpose
Number of RHUs with
SS-II certification and
PhilHealthAccreditations are
increased.

Annual Health Plan isdeveloped in Provinceand ILHZs based on
medium-term Plan for
Health.

Baseline
2005
SS-II
4
PhilHealth11(OPB)
PhilHealth
7(TB)
PhilHealth2(MCP)
Provincial mid-term HealthPlan :Already in place, withsimple situational analysis
Provincial Annual Health
Plan: Already in place, but
not based on ILHZ plans
ILHZ Mid-term Plan:
Already in place, but withno subsequent revision andvirtually dormant
ILHZ Annual Operation
Plan: Non existent

Total health budget isincreased.

P 167,539,543.43

Total number of days
8.9daysout of stock forindicator drugs is(average of 6 facilities)
decreased.
Source: End-line survey report July 2010

Achievement
2010
7

SS-II
PhilHealth
13(OPB)
PhilHealth
12(TB)
PhilHealth
4 (out of 5)(MCP)
Provincial mid-term Health Plan:
Revised as PIPH with detailed
situational analysis (2008)
Provincial Annual Health Plan:
Plan for the year 2010 was
developed based on PIPH and
ILHZ plans.
ILHZ Mid-term Plan: Revised withthorough situation analysis andincorporated in the PIPH
ILHZ Annual Operation Plans:
Since 2008, developed annually.
P 255,667,687.22 in 2009(53% increase)
4.4days(average of all 19 facilities)

The Project Purpose has been achieved in terms of the indicators. Other aspects that are notcaptured by the indicators are as follows:
1) Institutionalization of the project outcomes
The capability of health facilities to provide quality of services is confirmed by the SS-II
certification and PhilHealth accreditations that are renewed every year. Upgraded referral
systems and monitoring systems are already in place, while close follow-up should be
required.
The provincial and ILHZ plans are implemented and monitored regularly by the Provinceand ILHZs.
The indicator about “increase of health budget” does not say how it is utilized, and the
Project does not look at the expenditure and specific items of expenditure.

2) Improvement of service delivery
The health staff perceives that the service delivery has been improved. Clients keep coming
and the number of clients has increased, as they know they can receive good services as there
are capable staff, equipment and drugs available.
2 Summary of Evaluation(1) Relevance
Project design is relevant in view of consistency with national and local policies, Japan’s
cooperation policies and the needs of the target groups.
One of the purposes of the health sector reform policy of the Philippines is strengthening
local health systems in the process of decentralization. The four Outputs of the Project match
the four pillars of the FOURmula one strategy of the Health Sector Reform Agenda.
Having faced to the fragmentation of health services in the process of decentralization,
local governments and health facilities felt necessity for revitalized district health systems.
The Project is coherent with the Japan’s Country Assistance Program for the Philippines
and JICA’s Country Assistance Strategy, in which a focus is placed on strengthening of local
health systems.
(2) Effectiveness
The Project was effective because not only has each of the four Outputs played a vital roleon its own for strengthening local health systems, but also they have produced a mutually
reinforcing effect. For example, improvement of drug management at the facility level has
created better evidence for health finance planning, which also led to improved drug supply
and service delivery.
The change of the government in 2010 did not affect the government health policy, and theleadership transition in local government was also smooth. Under the strong leadership andcommitment of the Provincial Governor, the Local Chief Executives participated in the
project management and decision making effectively, which contributed to the success of the
Project.
(3) Efficiency
The Project has been implemented efficiently as most inputs and activities have been
appropriate and contributed to the achievement of the outputs, although some equipment
procured by the Project is not functioning or did not meet the needs. There has been turnoverof some staff members who received training in the Project, but it was minimal.
(4) Impact
It is not possible to measure to what extent the Overall Goal has been or would beachieved. The reliability of the data is in question. Hence it was recommended that theOverall Goal be changed to “improvement of service delivery” and appropriate indicators
identified.
A positive impact of the Project is strengthened relationship with government and private
hospitals/clinics in the municipalities through the process of improving the referral system.
A negative impact that some project members felt is that the project activities, especiallyadministrative work for the ILHZ put extra burden on their workload at the expense ofproviding services to the clients.
(5) Sustainability

Regarding the policy aspect, the health sector policy in the Philippines is likely to continue
giving a priority to strengthening of the local health systems.
Concerning the institutional aspect, the strong leadership of the Governor and thedemocratic process of decision-making are a positive sign of sustainability. The changes ofthe leaders in the future might pose challenges to the sustainability of project outcomes.
Ownership of and participation in the Project of the Philippine members have been derived
from the perceived need to work together in the ILHZs to discuss issues of common interest.
However, ILHZs have varied degree of perceived needs for collaboration due to different
conditions of the four ILHZs. Declining interest of some ILHZ constituents is a risk factor to
the sustainability of ILHZs. Most staff members are likely to stay in the province, whileturnover of a minimal scale has already been experienced and may continue.
In terms of finance, the budget to sustain the outcomes of the Project is likely to be secured
after the end of the project period as the Philippine side has been sharing the cost of the
project activities and the leaders would allot appropriate budget to the health sector as long as
they are interested in the health sector.
Regarding the technical aspect, the health staff would keep the same level of capacity thathas been upgraded through the training provided by the Project.
3㧚Factors that promoted realization of effects(1) Factors concerning to Planning
N/A(2) Factors concerning to the Implementation Process
1) The Governor has been committed to strengthening local health systems and has
provided support in various forms such as provision of matching fund to ILHZ Common
Health Trust Fund and sharing PhilHealth premium for sponsored members. The local
government executives and health staff have been convinced to participate actively in the
Project.
2) The decisions have been made in a democratic manner through active participation ofmembers in the EC, TWG and ILHZ board meetings.

3) CHD-CAR is always present at EC and TWG meetings and monitors the
progress of the Project closely. DOH representatives participate actively in the project
activities and provide technical support.
4㧚Factors that impeded realization of effects(1) Factors concerning to Planning
N/A(2) Factors concerning to the Implementation Process
ILHZs are loose associations of the Province and the municipalities, with their respective
health facilities. If there is no strong leadership or if the members do not believe in thenecessity for coordination, ILHZs might fall apart. They do not have staff specificallydesignated to handle the administrative matters. Some ILHZ members feel that ILHZ related
administrative work has become additional burden, such as compiling plans and reports for
the ILHZs and taking turns to host meetings.

5㧚Conclusion
The Project has been successful in terms of the improved indicators. The working
mechanism of the Provincial and Municipal stakeholders, though not captured by the projectindicators on PDM, is a most remarkable outcome of the Project.
6㧚Recommendations
1) Sustainability of ILHZs
Referral system formalized with stronger communication between the district hospitals andMHOs/RHUs has been the most remarkable outcome of the ILHZs. More patients are now
referred to district hospitals from RHUs which know that adequate services are available there.
The perceived merit of ILHZ compared to the administrative requirement is not the same among
the municipalities. It is necessary to review the functions of the ILHZ and focus on planning theselected cross-cutting or common issues of the locality rather than duplicating the mandates of therespective municipalities. Formulation of operational guidelines or implementing rules andregulations (IRR) in each ILHZ could streamline the administrative requirements and procedures.
PHO and DOH representatives should support the ILHZs to pursue the productive and quality
discussions, which may not be necessarily ensured by the formative definition of functionality
such as quarterly meeting.
2) Conversion of the Executive Committee and Technical Working Group in to a regularprogram as mechanism for provincial stakeholder coordination
It is expected that the functions of EC and TWG, not the formalities or the names, are sustained
as regular coordinative program of the Province so that the stakeholders could continue theprocess of health system strengthening as their routine mandate.
3) Commitment and Support of Local Chief Executives
Under the decentralized government system, the commitment to and ownership of the healthsystem reform by the Local Chief Executives (LCEs) and other political leaders is vital to thesustainability of the achievement of the Project.
It is strongly urged that that the LCEs, understanding the potential impact of their decisions on
health service deliveries, lead the health care reform at the local level assisted by the technicalstaff. The MHOs are encouraged to communicate to the leaders their analyses of improved drug
management utilizing acquired skills in stock management, IT, and presentation effectively.
4) Possibility of participation of municipalities in province-wide pooled procurement ofdrugs
It is expected that the LCEs also explore the possibility of province-wide pooled purchase ofdrugs in the future for more timely and economical procurement of drugs.
5) Documentation
Besides the acceptance of study tours and presentation at the seminars, the achievements andgood practices of the Province of Benguet should be shared with other provinces andmunicipalities more widely. Documents such as drug management manual and referral manual
could be effective tools for replication in other LGUs. Documentations of successful
arrangements and processes such as establishment of common health trust fund, resource poolingand sharing are also strongly encouraged. Electronic documentation uploaded in the web page
may be one of the low cost measures to widely disseminate the process and results of the Projectat various levels.

6) Strengthening of relevant financial information system
Improvement of financial information system is needed to monitor the progress of reform at the
local level. The new initiative of DOH that emphasizes strengthening the information system in a
relevant strategy to address these issues. The local health account to be initiated under the newhealth sector reform strategy should ensure more rational and transparent data collection andanalysis system.
7) Modification of the Overall Goal
In the current PDM, the Overall Goal is expressed as “the health status of the people in theProvince is enhanced” with the indicators described as “infant mortality rate, maternal mortality
rate, incidence rate of non-communicable diseases and incidence rate of communicable diseases
are decreased”. Although those indicators are relevant to the ultimate goal of the health system as
a whole, there are many external factors to influence the indicators other than the project
achievements.
For the sake of measurable impact to be confirmed, it is suggested to change the expression of
the Overall Goal in the PDM from the health status to service delivery (access and utilization) as
compared to the present.
The TWG and JICA experts are requested to identify the appropriate indicators and come up withthe baseline figures by February 2011.
7㧚Lessons Learned
1) An effective approach to health system strengthening: visible achievement for the healthservice providers and communities
Improvements in heath systems are not necessarily visible in short term, especially when
physical investment does not accompany, Thus there is a potential risk of “fatigue”, or dwindling
motivation among health workers. It is necessary that the participating health workers have thefeeling of progress and returns to their efforts. In case of the Project, the drug stock management
was often mentioned as a component which has produced an outcome (reduced day out of stock)that can be confirmed by the managers and service providers. Similar projects which aim atstrengthening of local health system should be designed to include a component that can bringabout some tangible benefit.
2) Investment in quality data collection and analysis
At the beginning of the Project considerable time and efforts were devoted to baseline survey bywhich the situation of all participating health facilities were assessed and validated. The result of
the survey was utilized as the basis for PIPH and ILHZ plans and the benchmarks for monitoring
the progress of the activities by the PHO, MHOs and other members. Training on information
management with computer contributed to enhancing the capacity of health staff in evidencebased planning and efficient drug management. Some facilities which presented no data on drug
supply or user fee income in 2006 are now monitoring the figures by themselves. Quality of
discussions at TWG meeting has been improved, for the members are more comfortable with thestatistical analyses. It could be concluded that the investment in the data collection accompanied
by managerial capacity building and IT skills paid off in many aspects of the local health systemdevelopment.