Final evaluation report : child survival program (492-0406)

Program implementation was effective, well-coordinated, and highly accountable. All benchmarks were met, resulting in tangible policy reforms, including: (1) increased prioritization of child survival; (2) identification of underserved areas and effective, decentralized health planning from the bottom up; (3) implementation of a well-chosen core package of maternal/child health interventions, including Control of Acute Respiratory Infection (CARI), which was new to the Philippines, and family planning, which was revived after a period of stagnant implementation; (4) a comprehensive IEC strategy utilizing various media to increase consumer demand and promote improved health behaviors; and (5) strengthening of supervision through integrated, criteria-based supervisory systems and health information systems. Significant measurable gains in child survival service delivery occurred, particularly with respect to immunization, ORT, and CARI. These gains appear to have greatly decreased child mortality; the years 1988-94 evinced a consistent and credible pattern of decreased infant/child deaths from pneumonia, diarrhea, and immunizable diseases. The greatest impact appears to have been in decreased ARI deaths, most likely due to the combined effect of the new CARI initiative, improved measles immunization coverage, Vitamin A capsule distribution, and other nutritional interventions. The reduction in ARI deaths was in the 25%-50% range, resulting in over 10,000 infant/child deaths averted per year. The Department of Health leveraged other donor assistance and Government of Philippine (GOP) resources in implementing the program, and the recurrent costs of improved service delivery have been effectively absorbed by the GOP. Substantive work on health care financing, begun under the program, continues. During the program, a major event occurred with far-reaching effects on the entire health system -- the devolution of authority for health services from the DOH to Local Government Units (LGUs), which was fully implemented in 1993 after program disbursements and benchmarks were completed. Hence, program sustainability will depend on the success of the devolution process. Unfortunately, the response of the DOH as an institution has been less than adequate -- both conceptually and operationally. Moreover, technical/functional linkages between the DOH and devolved health personnel were inadvertently severed along with the loss of administrative line authority. Consequently, rather than a reconfigured health system, there is a shattered and fragmented one; rather than new relationships between the DOH and devolved health personnel, there is an absence of relationship. Technical supervision, monitoring, and support to the rural health units and barangay health stations have been substantially weakened, and hospital services are increasingly isolated from preventive and primary services. Lessons learned are as follows. (1) A performance-based disbursement mode, rather than project assistance, can be a highly effective means of achieving health sector goals in settings such as the Philippines, where there is broad donor-host government consensus on needed reforms, a sincere commitment to implementing these reforms, and a highly capable and trained implementing agency. (2) Implementation of a few well-chosen health policy reforms can contribute to reductions in mortality in as little as 5 years. (3) Decentralization of health services, particularly when carried beyond the administrative confines of a ministry or department of health, requires major conceptual, operational, and structural readjustments on the part of that institution. (4) Changes in lines of administrative control may destroy essential technical linkages unless a conscious effort is made to redefine them in a new context. (5) Service-delivery indicators need to be selected with care, and investments made at the outset to obtain accurate baseline measures and ensure that baseline and endline measurements are comparable and reliable.