Summary of the Evaluation Results
1. Outline of the ProjectCountry: The Philippines

Project title: Mother and Child Health Project

Issue/Sector: Health/Mother and Child Health

Cooperation scheme: Technical Cooperation

Division in charge: JICA Philippine Office

Cooperation expenditure: 372 million yen as of end of
August 2009

Period of Cooperation: March 2006〜March 2010

Partner Country's Implementing Organization:
Department of Health （DOH）, Local Government
Units, Provincial Health Offices of Ifugao and Biliran
Provinces
Japanese Cooperating Organization（s）: None.
Related Cooperation: Expert in Mother and Child
Health: 2003~05）

1-1 Background of the Project
The Republic of Philippines （hereinafter referred to as “the Philippines”） has reduced its Maternal Mortality
Ratio （MMR） and Infant Mortality Rates （IMR） over the last several decades. However, compared withneighboring ASEAN countries, like Vietnam and Indonesia, the Philippines' rate of improvement has beenslower. To achieve the Millennium Development Goals （MDGs）, of reducing MMR from 209 to 52.3 and
IMR from 57 to 19, the country is required to make further efforts. Under the decentralization policy in thePhilippines, the Department of Health （DOH） has implemented the Health Sector Reform. In 2005 DOH
enforced FOURmula one strategy with clear direction and procedures for strengthening comprehensive healthservices provision with strong harmonization with development partners.
It was in the above conditions that JICA launched the technical cooperation project named, "Maternal andChild Health Project （MCH project）" for a four year period beginning in March 2006. The Project aims at
improvement of maternal and child health and focuses on introducing an emergency obstetric care system andimproving general MCH services quality. The MCH project targets two project areas: AMADHS-Inter Local
Health Zone covering 3 municipalities （Alfonsolista, Mayoyao, Aguinaldo） in Ifugao province （CAR） and
Biliran province （Region VIII） covering 8 municipalities.
1-2 Outline of the Project
Overall Goal:
In the framework of the National Goal of Improving Women’s and Children’s Health, organizational capacity
at the central and provincial levels to implement effective MCH strategies is strengthened; and the quality andquantity of MCH services is enhanced.
Project Purpose:In the project target areas, the health and safety of mothers and neonates in the pre-natal, during delivery andpost partum periods is improved through improving the quality of care and increasing the utilization of service
provided.
Outputs:(1) Implementation mechanism and capacity of the central level to enhance Emergency Obstetric Care
（EmOC） in all levels is strengthened(2) The MCH services and EmOC are strengthened in the project target areas(3) Supportive mechanisms for mothers and babies in the communities are strengthened

(4) Management and supportive mechanisms are in place for Women’s Health Teams （WHTs） and Rural
Health Midwives（RHMs） to improve quality of service and their work environment in the project target
area(5) Lessons learned from the MCH project implementation contribute to dialogues at the national and theprovincial levels and in MCH policy discussions, and are reflected to the MCH policy formulation
1-3 Inputs （as of September 2009）
Japanese side:
Japanese Experts

Long-term 3 persons （121.2 MM） Equipments
Short-Term 5 persons （6.5 MM）

Training in Japan 18 persons （including 7 for grouptrainings）

24,133,821 peso

Local Costs
41,181,000 peso
（Costs above were as of Augsut 2009）
OthersN/APhilippine side:
Counterparts

22 positions （33 in total）

Equipments N/ALand/Facilities

Project Offices （3 offices）

Cost Sharing Travel Allowance, Meetings,
Telephone/Electricity, Upgrading of healthcare
facilities, etc.

Others N/A
2. Outline of the Terminal Evaluation
Evalu
ation
Team

1.
2.
3.

PeriodLeader, Harumi Kitabayashi, Visiting Senior Advisor, JICA
Cooperation Planning, Yuko Ishida, Associate Expert, Health Systems and Reproductive HealthGroup, Human Development Department, JICA
Evaluation Analysis, Makiko Komasawa, Specialist in International Health, Earth and Human
Corporation

October 5 ~ 27, 2009

Type of Evaluation: Terminal

3. Summary of Evaluation Results
3-1 Achievements
NB: The indicators of the Project in the Project Design Matrix ver.3 （PDM3） did not have target values.
Thus, we have assessed achievement levels based on the changes in values recorded in each of the indicators.
Degree of Achievements: Outputs
Output 1: Implementation mechanism and capacity of the central level to enhance EmOC in all levels is
strengthened
Output 1 has been achieved. A series of training materials on Basic Emergency Obstetric Care （BEmOC）
was developed （Indicator 1-1）. “Community-Managed Maternal and Newborn Care （CMMNC）” was also
developed and became ready to be used in order to improve the clinical skills of MCH service providers andintroduce the community based MCH care just before and after the project commencement. Development ofthese materials was initiated by DOH and collaboratively supported by development partners and thePhilippine Obstetrics and Gynecology Society. By using the developed materials, trainers for BEmOC andCMMNC trainings were trained nationwide （Indicator 1-2: 184 trainers were trained with collaboration ofother development partners, half of all expensis were contributed by the Project）. The project also supported"Dr. Fabella Memorial Hospital” to set-up a core national training institute. BEmOC training materials havebeen widely utilized and became the national standard.

Regarding the monitoring and supervision tools, the Project utilized existing tools, such as “Field HealthServices Information Statistics （FHSIS）” and “Target Clients List （TCL）,” instead of developing a new tool（Indicator 1-3）.
Output 2: The MCH services and EmOC are strengthened in the project target areas
Output 2 has been achieved. Skilled Birth Attendants （SBAs） at the district hospital and RHU levels in thetarget areas were trained for both BEmOC （Indicator 2-1: all target, 60 SBAs in total） and CMMNC（Indictor 2-2: 143 persons trained）. Then, 143 Rural Health Midwives （RHMs） of BHSs in target areas
were also trained to upgrade their midwifery skills in local settings （Indicator 2-3: 62 persons trained）. This
led to the strengthening of the MCH services and EmOC at municipal and barangay levels.
Increased accessibility of facility-based delivery in rural areas has been achieved, both RHUs and BHSs whichwere selected by the DOH, have been equipped with the obstetric equipment in accordance with the
PhilHealth Guideline for Maternity Care Package （MCP） accreditation. As a result, all designated facilities（8 RHUs in Biliran and 3 RHUs in Ifugao） obtained PhilHealth MCP accreditation （Indicator 2-4）. Then,
numbers of BEmOC facilities became 9 in Biliran province and 6 in AMADHS （Indicator 2-5）. Further,numbers of facility providing normal delivery centers became 15 in Biliran province and 6 in AMADHS.
Some municipalities adopted ordinances or resolutions which decided introduction of user fees, creation oftrust fund and how to make use of the fund. Improved skills, working environment, and incentives from LGUs
and the trust funds motivated the staffs and enabled them to offer better services on a 24 hour-basis. These
improvements made possible the transition of facility-based delivery and higher accessibility to better MCH
services. However, it was recognized that claims and reimbursements of MCP benefits had not been
accelerated and necessity of exploration of its reasons.
Based on the improvement of above, the most important indicator “Percentage of deliveries assisted by a
SBA” （Indicator 2-7） was drastically improved, from 44％ （2005） to 92％（2008） in Biliran and from54％（2005）to 71％（2008）in AMADHS. “Percentage of facility deliveries”（Indicator 2-8）also improved
from 25％ （2005） to 89％ （2008） in Biliran and from 19％ （2005） to 34％ （2008） in AMADHS.
Output 3: Supporting mechanism for mothers and babies by community members in the project target areas isenhanced
Output 3 encouraged community-based health activities and raised community people’s awareness towards
healthy motherhood and further supporting environment for pregnant women. Women’s Health Teams（WHTs） were formed from the existing barangay human resources in health field, including barangay healthworkers, barangay nutrition scholars, and hilots （traditional birth attendants）. In Biliran, 374 WHTs wereorganized and 1,122 persons joined from all 132 barangays. In AMDHS, 96 WHTs were organized with 321
members from all 63 barangays （Indicator 3-1）. Under the supervision of midwives of BHSs, WHT members
provided MCH information to pregnant women, encouraged pre/post natal care and facility delivery,
accompanied to a delivery place, tracking all progress of pregnancy and delivery in communities. In Biliran,“Parent class” was held by WHTs and midwives almost weekly and in AMADHS “Fathers class” was held 11
times for far （Indicator 3-2）.
WHT and male leaders together made birth planning for each pregnant woman and emergency support plans
for a whole community were prepared in each barangay （Indicator 3-3）.
In AMADHS, the WHT evolved into AYOD community health teams including male member and expanded
into province-wide. Since 2008, a new training program named “Active Male’s Movement against Violence
and for AYOD "（AMMA） was introduced in Ifugao province and AYOD male members were trained as peer
trainers and provided health education sessions for over 500 male community members.
Output 4: Management and supportive supervision mechanisms are in place for WHTs and rural healthmidwives（RHMs） to improve the quality of service and their work environment in the project target areas
Output 4 succeeded to improve the quality of services and to encourage community support of activities based

on the results of Output 2 and Output 3. At BHS weekly meetings between midwives and WHTs （or AYOD in
Ifugao） are conducted in which they share the pregnant women’s tracking results and discuss issues they arefacing （Indicator 4-1）. Municipal health offices （MHOs） hold a monthly meeting with all staff including
midwives assigned to BHSs and share the results of WHT reports （Indicator 4-1）. Over 90％ of WHT
members are satisfied with working as a member （Indicator 4-4）.
MHOs conducted regular meetings as well as irregular supportive supervision and monitored all midwives’
activities （Indicator 4-3）. The Provincial health office （PHO） monitored MHO and BHS through TCL andmade supportive supervision visits to rural health units （RHUs）. MHO also set-up maternal death review（MDR） procedures and implemented them soon after incidents were reported （Indicator 4-2）.
Output 5: Lessons learned from the MCH project implementation contribute to dialogues at the national andthe provincial levels MCH policy discussions and is reflected to the MCH policy formulation
Overall, it is acknowledged by DOH that the project made possible an effective translation of the "Maternal,
Neonatal and Child Health and Nutrition" （MNCHN） policy into practices. The Project shared its
experiences in successful establishment of WHTs and AYODs in all barangays with other provinces in Region
VIII and CAR, through the Centers for Health Development （CHDs）. Furthremore, the Project member
participated in the meeting between DOH and development partners in order to discuss the MCH policies andissues at central level （Indicator 5-1）.
Various textbooks and teaching materials that were developed were provided to the FOURmulra One for
Health convergence sites （provinces and municipalities） and USAID sites, outside the Project target areas
for replication of activities （Indicator 5-2） and utilized.
The Project conducted/participated in various meetings and conferences, 12 times in total up to October 2009
（Indicator 5-3）. It is worth mentioning that document titled “TEAMING UP for Safe Motherhood” wasproduced, which described step-by-step process of Project implementation including actions taken by thevarious stakeholders such as DOH-central, LGUs, PHOs, and the communities. This document was distributed
to all PHOs and MHOs of CAR and Region VIII at the occasion of a regional meeting organized by CHDs. It
was also shared with development partners active in health sector reform at the launching ceremonies held in
Ifugao and Biliran in 2008 （Indicator 5-3）.
Degree of Achievements: the Project Purpose
Project Purpose: In the project target areas, the health and safety of mothers and neonates in pre-natal,
during delivery and post partum period is improved through improving the quality of care and increasing theutilization of service provided.
One of the important indicators of the Project Purpose "percentage of deliveries assisted by the SBAs in target
areas" has rapidly increased from 44％ in 2005 to 92％ in 2008 in Biliran and 54％ in 2005 and 71％ in2008 in AMADHS. The other indicator, "percentage of facility-based deliveries", has dramatically increased in
Biliran from 25％ （2005） to 89％ （2008）, which exceeded the national goal, and moderately increased in
AMADHS, from 19％ （2005） to 34％ （2008）.
Regarding the indicator of receiving prenatal care, it should be pointed out that there are huge differences
between the number of the national FHSIS and the provincial FHSIS. Inconsistency was observed in terms offrequency of visits （3 or 4） in national statistic for Ifugao. Thus, the Evaluation Team concluded these data
are less likely reliable. However, if we assume the numbers in 2008 are reliable, they are considerably lower
than the national goal （2010） of 80％ set by Administrative Order （No.2008-0029）. Further effort isrequired to increase prenatal visits starting from the 1st trimester. It is not possible to judge that there are any
significant changes in maternal and infant mortality because the number of deaths is so small in target areas.
Achievement of the Overall Goal
Overall goal: In the framework of the National Goal of Improving Women’s and Children’s Health, the central
and provincial levels of organizational capacity to implement effective MCH strategies is strengthened and thequality and quantity of MCH services is enhanced.
It is difficult to foresee exact achievement of overall goal due to unavailability of appropriate data. However, it
can be said that the national goal of 80 percent of facility-based deliveries assisted by SBA will hardly beachieved and it requires intensified nationwide implementation of MNCHN strategy. The FHSIS data formaternal and neonatal mortalities indicates the situations are far from achieving MDGs goals and require
urgent and wide interventions.
3-2 Results as per the Five Evaluation Criteria（1） Relevance
According to the following view points, the project is judged to be high in relevance.
The Government of the Philippines committed to attaining its MDGs targeted to reduce the maternal andneonatal mortality and DOH adopted the Administrative Order （No. 79 s. 2000） known as Safe Motherhood
Policy. In 2008, DOH updated the previous administrative order and set MNCHN strategy. It emphasized its
community-based approach including enhancement of conveniently located health facilities as birthing places.
The project purpose and design is consistent with the Philippine policies and strategy.
The project concept and strategy are also consistent with Japan’s Country Assistance Program （2008）.
The Project target areas （AMADHS and Biliran ILHZ） were selected from 16 F1 convergent provinces as afirst stage of the Health Sector Reform implementation and by consideration of socio-economic and healthstatus. The selection of the Project sites is appropriate.
（2） Effectiveness
The Project was effective because it produced the targeted result which is represented as the increase of
facility-based deliveries.
First, the project developed and standardized training courses and instruction materials which gave clear
direction and technical backstop for service delivery and trained trainers for it. It is worth mentioning thatcollaboration with Dr. Jose Fabella Memorial Hospital and the Philippines Obstetrics and Gynecology Society
in the development and provision of qualified trainings contributed to the training module and these materials
became national standards.
Second, the project activities contributed to the enhancement of delivery services and quality of services atprimary care facilities. Provision of trainings in BEmOC, LSS and CMMNC contributed to improvement inknowledge and skills of SBAs at RHUs and midwives and BHSs. The project provided equipments for
BEmOC services. In addition, LGU made efforts to improve staff rotation and increase staff numbers and also
to introducing a user-fee system.
Third, the project realized the community mobilization and strengthened the community support system.
Establishment of WHT, strengthening linkage between the communities and primary care facilities, andcommunity leader supports for WHT and BHSs, as well as tracking of pregnant women.
Rigorous mobilization of communities at the barangay level through organization of the WHT strengthened
the cooperative relationship between communities and primary health care facilities （RHUs and BHSs）.
Orientation and monitoring by staff of RHUs together with active involvement of local chief executive officers
promoted rapid launching of WHTs. Members of WHT facilitated behavioural change of mothers andutilization of services through pregnancy tracking, birth plan, personal support and assistance to pregnant
women such as escorting them to health facilities.
（3） Efficiency
Under the FOURmula One （Health Sector Reform Agenda） and based on the discussion on the MCH
program with other development partners （UNFPA, UNICEF, WHO, EU, GTZ）, JICA designed anddeveloped the project. Even before the Project launching, JICA and other development partners assisted DOH
to develop the BEmOC training module in 2005 as a national training program. In addition, training tools wereprovided to the Fabella hospital in Manila as one of the national training centers. Having the established
BEmOC training program as the national standard enabled the Project to have an immediate and smooth start
to the activities right after the launching.
（4） Impact
There is a slow but steady increase in facility-based delivery attended by skilled birth attendants at the national
level. To achieve the national goal of 80 percent facility-based deliveries, intensified nationwide
implementation of MNCHN strategy is required. Available data could not tell that the overall goal can beachieved in 3-5 years after the project termination. At least the project provided good practices in improving
mother and family health status and influenced the national MCH program.
Various good practices such as WHT, AYOD community health teams, Family Health Diary, were taken up by
the CHDs （Region VIII and CAR） and were expanded to other areas outside target Project areas. These arepositive impacts.
No negative Impacts have been observed.

（5） Sustainability
1）
Political aspect
Political commitment at all levels towards achieving MDGs on maternal and infant deaths is likely to besustained irrespective of administration changes. Some concerns remain regarding continuing commitment andsupport to MNCHN programs by the LGUs if there is change in political leadership.
2）
Organizational Aspect
The Project was implemented by the existing local health system at region and province levels. Through theimplementation of the Project to provide quality MNCHN services, the coordination mechanism of
stakeholders became functional, and the capacity of the respective members engaged in the Project wasenhanced for coordination of the complex structure of DOH-CHD-PHO-public health service
providers-community as well as the LGUs.
At the moment of the Project terminal evaluation, this integrated mechanism is effectively working. The
mechanism will be sustainable with encouragement from the central DOH.
3）
Financial Aspect
As for the financial sustainability, the Public Health Development Program Fund （PHDPF） and “HealthFacilities Enhancement Program” budget of DOH are expected to add a major capital contribution to
implement the PIPH （2005~2010）, and significantly boost the expansion and upgrading of facilities andequipment. PhilHealth MCP reimbursement and user fees, if enforced appropriately, would contribute tosustaining operation and maintenance of facilities and motivating health workers and communities.
4）
Technical Aspect
Knowledge and skills required to provide MNCHN service package were well standardized in the training
modules （BEmOC, CMMNC and LSS）, and proven effective in the rural settings of the Philippines.
Technical sustainability will be high with systematic implementation of continuous re-training and supportive
supervision by PHOs/CHDs.
3-3 Promoting and Inhibiting Factors（1） Promoting Factors
Integrated coordination mechanism of complex stakeholders can be considered as one of the promoting factorsof the project’s success. There are two important players, namely health care providers and political leaders.
Coordination of these two players created synergetic effects and maximized outcomes. Regarding the LGU

side, the project activities have been promoted by various political commitments. Their most outstanding
commitment is adoption of political decisions including provincial executive orders and resolutions andmunicipal and barangay resolutions.
（2） Inhibiting Factors
There is a gap among municipalities in terms of increases of SBA-assisted deliveries and facility-based
deliveries. Municipalities with less improvement are facing a lack of health staff and frequent staff turn-over.
These conditions lessened the effectiveness of the project.
3-4 Conclusion
In general, the Project accomplished its objectives. It is acknowledged as an effective translation of MNCHN
policy into practice. Various good practices produced in the target areas were disseminated nationwide.
Considering that high sustainability can be expected, the Evaluation Team concluded the Project can be
successfully terminated as planned.
3-5 Recommendations
1）
Governance
To LGU Executives: Continuous political supports are urged to sustain the Project outcomes in LGUs. Even if
the executives are changed the supports should be taken over by new administration.
2）
Service delivery
To LGU Executives: To provide effective services and create closer relationship with community, it isrecommended LGUs make efforts to recruit midwives, preferably from the assigned community. Furthermore,assigning one midwife per BHS is desirable.
To PHOs and MHOs: Maintaining facilsity and equipment is essential for keeping better EmONC services. To
do so, maintenance systems should be established under the supervisions of PHOs from the technical andfinancial view points.
Increasing facility-based deliveries were successfully achieved, but more attention should be paid to enhancing
other MNCHN services, such as promotion of prenatal care, postnatal care, nutrition and family planning.
To DOH and CHDs: For strengthening the monitoring and evaluation function, existing tools, such as FHSIS
and TCL, should be improved and effectively utilized. The process of data collection and analysis at BHSs and
RHUs and compilation at PHOs should be supervised, and appropriate and timely feedback should be provided
when the weakness is found in order to formulate better evidence-based action plans.
To PHOs and CHDs: Regarding maternal death reviews, even though it was strengthened in the Project target
areas, there still remains some weakness in the following aspects: holding a timely review session,
documentation of medical records and the findings, and feedback of the results to community members.
The Evaluation Team recommends PHOs with the CHD technical assistance enforce the DOH procedure of
MDR thoroughly and utilize the analysis for continuous improvement of services to prevent further maternalmortality.
3）
FinanceTo CHDs: One of the important strategies the Project took was promoting MCP accreditation of facilities andhealth personnel under the PhilHealth scheme in order to accelerate access to better facility based-services,
including prenatal care, delivery and newborn care. However, at this evaluation moment women and even
health facility staffs were not well aware of the benefits, and the utilization rate was quite low in the target
sites. There might be fundamental problems behind such circumstances. Thus, it is recommended that CHDs
with DOH assistance should conduct a study to explore reasons for low usage of PhilHealth MCP （See Annex
13 for details）.
To PhilHealth: It is strongly recommended to PhilHealth offices i） to raise awareness of health workers andcommunities about PhilHealth membership and MCP benefits, ii） to facilitate MCP claims to be made byhealth facilities, iii） to fast-track reimbursement procedures for RHUs and BHSs.

To LGUs: To increase MCP utilization, sustained enrollment of indigent families in PhilHealth needs to beensured by LGUs.
To sustain and encourage the activities by community actors, especially WHT/AYOD members, some kinds ofcompensation for transportation expenses related to WHT activities should be taken into consideration.
3-6 Lessons Learned
Through the experiences of the Project, active involvement of LGUs in project implementation was proved
effective in mainstreaming the maternal and child health in local development agenda.
Rigorous interaction and mutual learning by health officers at all levels streamlined local health service
deliveries responding to community needs in a consistent manner with the national strategy.
Under the decentralized health systems of the Philippines, a project which aims at improvement of healthstatus of the rural population should be designed taking into consideration coordination of multi-layer andmulti-sector stakeholders.