Institutionalization of Reproductive Health Preservice 
Education in the Philippines: An Evaluation of 
Programmatic Efforts, 1987–1998
JHP-16
Prepared by
Melahi Pons, MA, MS
Barbara Rawlins, MPH
Susan J. Griffey Brechin, DrPH, BSN
February 2002
United States Agency for International Development
CREDITS
Editors: Kathleen Hines, Jane Zadlo Sudbrink
Copyright ” 2002 by JHPIEGO Corporation. All rights reserved.
JHPIEGO, an affiliate of Johns Hopkins University, is a nonprofit corporation working to improve the health of women 
and families throughout the world. 
ACKNOWLEDGMENTS
Special thanks go to the faculty, students and school principals/deans of the nursing and
midwifery schools for participating in this assessment. We would also like to thank Dean Cecilia 
Laurente, President of Association of Deans of Philippine Colleges of Nursing (ADPCN);
members of the ADPCN board; Dean Marco Santo Tomas, President of Association of
Philippine Schools of Midwifery (APSOM); and members of the APSOM board for facilitating the 
participation of the schools and sharing the results of their work under the Training in
Reproductive Health Project from 1987 to 1998 and more recent experiences. 
The authors’ gratitude goes to JHPIEGO consultants Elizabeth Valles and Remedios Fernandez 
for their comments on the questionnaires, for administering the questionnaires and for their
assistance with data collection preparations.
We would further like to acknowledge staff at the JHPIEGO/Baltimore office, including Kama
Garrison who contributed to the initial conceptualization of the Philippine preservice program
assessment, Terri Dean and Ricky Lu who provided important background information on the
program, and Ron Magarick who helped to identify programmatic areas of interest for the
assessment. We are also grateful for the assistance of Lydia Palaypay, Vice President for
Academic Affairs at Far Eastern University (FEU) in the Philippines and a member of the
JHPIEGO Board of Trustees (at the time of the preservice program, Ms. Palaypay was Dean of 
FEU and President of ADPCN), and Ruby Fernandez, former Project Director of the Philippines 
preservice program, who both provided a comprehensive background of the Philippine program 
and helped to frame the assessment. Finally, our thanks go to Jane Zadlo Sudbrink for editorial 
assistance and Jennifer Boyle and Vanessa Rodas for administrative assistance.
TRADEMARKS: All brand and product names are trademarks or registered trademarks of their respective
companies.
This publication was made possible through support provided by the Office of Population, Center for Population,
Health and Nutrition, Bureau for Global Programs, Field Support and Research, U.S. Agency for International
Development, under the terms of Award No. HRN-A-00-98-00041-00. The opinions expressed herein are those of the 
author(s) and do not necessarily reflect the views of the U.S. Agency for International Development.
Printed February 2002

JHPIEGO Technical Report i
TABLE OF CONTENTS
ABBREVIATIONS AND ACRONYMS ......................................................................................... ii
EXECUTIVE SUMMARY ........................................................................................................... iii
INTRODUCTION ........................................................................................................................1
Background.....................................................................................................................1
METHODOLOGY .......................................................................................................................3
Purpose and Objectives ..................................................................................................3
Procedure .......................................................................................................................3
Sample............................................................................................................................4
Operational Definitions and Indicators.............................................................................5
FINDINGS ..................................................................................................................................5
Availability of Trained Family Planning/Reproductive Health Faculty...............................5
Implementation of the Family Planning/Reproductive Health Curricular Components......9
Utilization of Clinical Training Sites................................................................................14
Contributions to Family Planning/Reproductive Health Service Delivery and Evidence of 
Scaling Up.....................................................................................................................17
DISCUSSION AND CONCLUSION ..........................................................................................21
Implications for the Future.............................................................................................22
Conclusion ....................................................................................................................23
REFERENCES .........................................................................................................................24
APPENDIX A: Capacity and Institutionalization Indicators
APPENDIX B: FP Curriculum Covers
JHPIEGO Technical Report ii
ABBREVIATIONS AND ACRONYMS
ADPCN Association of Deans of Philippine Colleges of Nursing
AHSE Associate in Health Science Education
AIDS Acquired immune deficiency syndrome
APSOM Association of Philippine Schools of Midwifery
ARH Adolescent reproductive health
CHED Commission on Higher Education and Development
CTS Clinical training skills
DECS Department of Education, Culture and Sports
DOH Department of Health
FP Family planning
GTI Genital tract infection
HIV Human immunodeficiency virus
IP Infection prevention
IUD Intrauterine device
ModCal™ Modified Computer-Assisted Learning
NGO Nongovernmental organization
Pap smear Papanicolaou smear
RH Reproductive health
STI Sexually transmitted infection
TRH Training in Reproductive Health
USAID United States Agency for International Development
JHPIEGO Technical Report iii
EXECUTIVE SUMMARY
From 1987 to 1998, JHPIEGO, through its Training in Reproductive Health (TRH) Project,
collaborated with the Association of Deans of Philippine Colleges of Nursing (ADPCN) and the 
Association of Philippine Schools of Midwifery (APSOM) to strengthen preservice nursing and
midwifery education in the Philippines. Between 1987 and 1994, JHPIEGO initiated activities to 
strengthen family planning/reproductive health (FP/RH) and enhance trainer/faculty
development in five nursing schools and five midwifery schools. By the end of the program in
1998, the number of participating schools increased to 27, and the activities included: 
® Facility needs assessments and refurbishment of FP clinics affiliated with the schools
® FP/RH clinical skills update courses for providers
® FP/RH clinical training skills (CTS) courses for faculty and providers at the clinics and
schools
® Production of curricular support materials
® Procurement of teaching aids and equipment
® Faculty training in infection prevention, Depo-Provera, reversible FP methods and RH
counseling
In February 2001, JHPIEGO conducted an evaluation in the Philippines to assess the impact of 
the preservice program since its closeout in 1998. The objectives were to determine the current 
capacity of the participating nursing and midwifery schools to implement the strengthened
FP/RH preservice program, and to assess the institutionalization of the interventions. The
sample consisted of 16 of the 27 program-affiliated schools: 8 nursing schools and 8 midwifery 
schools. Responses were obtained from 29 faculty members, 210 students, 16 school
principals/deans and 16 school clinic administrators.
The findings show that a core group of faculty trained by JHPIEGO in FP/RH was still working at 
both the nursing and midwifery schools. Institutionalization of the strengthened FP/RH
curriculum in the schools was demonstrated by teaching assignments that took into account
faculty training and teaching experience. About 80% of the FP/RH faculty was providing clinical 
instruction to students and clinical services to clients attending the school clinics. For the most 
part, only those who had received CTS training were assigned to teach the clinical component 
of the curriculum. 
In addition, at the start of the preservice program, Philippine nursing licensure policies did not
allow nurses and midwives to provide certain services such as IUD insertion. Toward the end of 
the TRH Project in the Philippines, the program staff worked extensively with the Department of 
Health’s (DOH) Family Planning Service to advocate for trained faculty to receive accreditation 
to provide FP/RH services, including IUD insertion, in the school clinics. In 1999, the DOH, after 
a review of the training process, recognized the 2-week service provider course and the 3-week 
FP/RH CTS course conducted by the TRH Project as meeting the national accreditation
requirements.
The findings also demonstrate that all schools continued to emphasize a clinical, skill-related 
component in their FP/RH curriculum. The faculty continued to use the instructor’s
guides/clinical program guides, teaching materials and teaching equipment for both the
classroom and clinical portions of the FP/RH courses. Clinical instructors still utilized
competency-based training teaching methods/aids (models and demonstrations were the most
JHPIEGO Technical Report iv
frequently used [96%]). Ninety-four percent of students reported access to anatomic models,
and 88% reported that they had sufficient time to practice with models. According to students, 
competencies for FP/RH skills procedures were assessed with checklists (100% of the
midwifery students and 93% of nursing students reported assessment in these areas). The
inclusion of FP/RH questions in the licensure examinations signified at the national level the
importance of FP/RH content in preservice education. APSOM’s and ADPCN’s recent efforts in 
preservice education policy formulation indicate the institutionalization of their leadership role in 
preservice education. 
The school clinics, developed as part of the preservice strengthening program, continued to
provide a comprehensive range of FP/RH services, but only offered limited opportunities for
students to practice FP/RH skills with clients (FP counseling, breast examination and condom
use demonstration were most frequently mentioned by three-quarters of the clinical faculty).
More than three-quarters of the students, however, said that clinics provided them with sufficient 
opportunities to conduct FP/RH procedures. Institutionalization of these school clinics was
demonstrated by the expansion of clinic services to include other RH and child health
services—prenatal care and well-baby care were the new services most often cited in 13 of the 
14 clinics. Institutionalization of the school clinics was also illustrated by all clinics becoming
service delivery points for the government’s Family Planning Program.
Findings from this evaluation also suggest an impact on FP/RH service delivery and evidence of 
scaling up. Ninety-three percent of students considered their education as “adequate” to “very
adequate” preparation for providing FP/RH services upon employment. Graduates from the
preservice program schools performed better on the national licensure examination compared
to graduates from other schools. One-half of the schools reported they had a system in place to 
track the employment status of graduates. Three nursing schools and two midwifery schools
used their clinical sites to conduct inservice training, an indication of the recognition of the need 
for the quality training available from these schools. Some schools were also recipients of donor 
assistance for RH programs, including HIV/AIDS.
The Philippine nursing and midwifery education system has the capacity to continue
implementation of its strengthened preservice education program. This capacity is evident in the 
availability of trained faculty, the continued implementation of FP/RH curricular components and 
the availability of adequate clinical training sites. Government and operational policies of
schools and public policies (e.g., accreditation) were found to have ensured the maintenance of 
the capacities developed, indicating institutionalization. Operational policies of schools,
however, were seen to affect the degree of institutionalization within the schools. Some findings 
were more positive for midwifery schools where they used the strategy of teaching FP/RH as a 
separate course rather than integrating it into existing courses as with the nursing schools. The 
recently introduced tiered system for healthcare provider courses will affect the preservice
program—FP/RH will now be integrated into other courses rather than being taught as a
separate course in both the nursing and midwifery schools.
Future areas in which JHPIEGO could provide technical assistance in the Philippines include:
strengthening of FP/RH inservice training programs; development of new areas of competency 
in preservice education; development of school accreditation systems; strengthening human
resource policy development; development of a network to provide regional leadership in
preservice education; and faculty development to strengthen preservice education.
JHPIEGO Technical Report 1
Institutionalization of Reproductive Health Preservice 
Education in the Philippines: An Evaluation of 
Programmatic Efforts, 1987–1998
INTRODUCTION
It is important to JHPIEGO to examine the results of country programs after its assistance has 
ended. In February 2001, JHPIEGO conducted an evaluation to assess the effectiveness of an 
11-year program (1987 to 1998) to strengthen preservice nursing and midwifery education in the 
Philippines. The objectives were to determine the extent to which program interventions had
remained in place in the 3 years since the end of the program, and to assess the
institutionalization of the interventions. 
Background
Through its Training in Reproductive Health (TRH) Project, JHPIEGO collaborated with the
Association of Deans of Philippine Colleges of Nursing (ADPCN) to strengthen nursing
education, and with the Association of Philippine Schools of Midwifery (APSOM) to strengthen
midwifery education. 
Based on weaknesses identified in the needs assessment,1
 the initial phase of the Philippine
program (from 1987 to 1994) focused on the following areas:
® Strengthening family planning/reproductive health (FP/RH) in preservice nursing education
® Strengthening FP/RH in preservice midwifery education
® Strengthening trainer/faculty development in preservice nursing and midwifery education
To develop a standardized, competency-based FP/RH curriculum, FP/RH concepts and clinical 
skills were defined through a consultative process involving experts and stakeholders in
preservice nursing and midwifery education. This process resulted in the development of
instructor’s guides, reference materials and lesson plans. For midwifery schools, APSOM
developed the Instructor’s Guide on Family Planning for Schools of Midwifery in the Philippines. 
The text incorporates a clinical program guide and it has 17 comprehensive lessons on FP. For 
nursing schools, ADPCN developed the Model Instructional Plans in Family Planning, which
comprises nine topics. It also includes a clinical teaching plan for four services that serves as a 
model teaching plan for other subject matter that the faculty may want to include in their
instruction. Both the APSOM and ADPCN instructor’s guides recommend teaching methods
such as lectures, role plays and group discussion. The guides also suggest use of teaching aids 
such as flipcharts, posters and anatomic models. To complement the instructor’s guides, the
TRH Project assisted in the development of reference materials for use by both faculty and
students. APSOM developed the Reference Manual on Family Planning for Schools of
Midwifery in the Philippines. ADPCN developed Towards Health Through Family Planning: A
Manual in Family Planning for Nursing Students in the Philippines Setting and the ADPCN 
Family Planning Anthology.
 
1
 The initial needs assessment revealed that competency-based training methods were not being used to teach
family planning/reproductive health (FP/RH) in the nursing and midwifery schools, anatomic models were not
available for students to practice FP/RH procedures and school-affiliated clinical training sites for FP/RH were
inadequate.
JHPIEGO Technical Report 2
The strengthening of nursing education included:
® Workshops for nursing faculty on FP methods
® Workshops for nursing faculty on teaching strategies
® Introduction of competency-based training approaches
® Preparation of a course syllabus on RH
® Training skills courses and RH updates for master trainers and nursing school faculty 
® Facility improvement of FP clinics affiliated with five collaborating nursing schools
® Skills enhancement of faculty service providers
® Monitoring of clinics to ensure implementation of standardized FP procedures
For midwifery schools, support included: 
® Conducting a training needs assessment of faculty in midwifery schools
® Workshops on training skills curriculum development
® Training skills courses and RH updates for master trainers and midwifery school faculty
® Facility needs assessments and refurbishment of FP clinics affiliated with five collaborating 
midwifery schools
In the second and final phase of the program (from 1994 to 1998), JHPIEGO, in collaboration 
with both ADPCN and APSOM, expanded the program to include eight more nursing schools
and nine more midwifery schools. The major activities in the 27 program-affiliated schools
included: 
® Facility needs assessments and refurbishment of FP clinics affiliated with the schools
® FP/RH clinical skills update courses for providers
® FP/RH clinical training skills (CTS) courses for faculty and providers at the FP clinics and
schools including CTS for genital tract infection (GTI)
® Production of curricular support materials
® Procurement of teaching aids and equipment
® Faculty training in infection prevention (IP), Depo-Provera, reversible FP methods and RH
counseling
In this phase, JHPIEGO initiated efforts to sustain gains made in both the nursing and midwifery 
preservice education strengthening programs. Program-affiliated schools developed action
plans and conducted training of faculty who taught FP at other schools in their region. To
improve the sustainability of school clinics, JHPIEGO funded workshops for the school deans to 
plan for increasing client load and for mobilizing funds. JHPIEGO pursued other new initiatives 
during this period, including an adolescent reproductive health (ARH) services project to: 1)
strengthen RH services at existing clinical training sites to include the provision of ARH
services, 2) enhance ARH training in nursing and midwifery schools, and 3) strengthen the
linkages between government and non-government counseling services provided at established 
RH clinical sites.
Another initiative pursued in the final phase was the pilot testing of JHPIEGO’s IUD Modified
Computer-Assisted Learning (ModCal™). Twenty-eight participants (including faculty members,
JHPIEGO Technical Report 3
service providers, nursing and midwifery students) from six program-affiliated schools
participated in the pilot test. The objectives were to assess the acceptability of this innovative
learning tool among the various participant groups and to determine institutional support for
sustaining computer-assisted learning. The results of the pilot test demonstrated the
effectiveness of ModCal as a practical learning tool in preservice education for providing 
efficient and effective knowledge and skill transfer (Fernandez et al 1999).
An evaluation conducted in September 1995 measured the attainment of program outputs such 
as improvements in curricular quality of training and quality of services. It concluded that the
program had helped preservice initiatives take important steps toward improving
institutionalization of FP/RH education (Vollmer, Dean and Valadez 1996).
METHODOLOGY
This assessment built upon a desk review, conducted in the fall of 2000, which examined past 
JHPIEGO studies conducted in the Philippines and other JHPIEGO Philippine program
documents. It is a mixed-method followup study that combined findings from the desk review
with data collected from field visits to a sample of nursing and midwifery schools. During the
field visits, self-administered questionnaires were given to students and faculty, and interviews
were conducted with school administrators and school clinical training site staff.
Purpose and Objectives
The purpose of the assessment was to document progress made in strengthening the nursing 
and midwifery FP/RH preservice program in the Philippines 3 years after the end of the
program. Progress was assessed in two ways: in the capacity of the nursing and midwifery
schools to implement the strengthened FP/RH preservice program and in the institutionalization 
of the interventions introduced by JHPIEGO. Specific objectives included an examination of:
® Availability of trained FP/RH faculty
® Implementation of the FP/RH curricular components
® Utilization of clinical training sites
® Contributions to FP/RH service delivery and evidence of scaling up
Procedure
The desk review provided the scope and details of JHPIEGO’s preservice program in the
Philippines. Using the information from the desk review, JHPIEGO developed an evaluation
framework and formulated indicators. To develop the study design, JHPIEGO consulted with
staff members who had worked on the Philippine program. Subsequently, data collection
instruments2
 were developed and designed, and are listed in Table 1. 
 
2
 Copies of the data collection instruments are on file in the JHPIEGO Research and Evaluation Office.
JHPIEGO Technical Report 4
Table 1. Data Collection Instruments
Instrument Topics
School information sheet Enrollment, graduates, licensure examination 
passing rate, school budget 
Classroom tutor questionnaire Teaching assignments, training(s) attended, use of 
the standardized FP/RH curriculum, teaching 
methods, reference materials, teaching materials, 
experience in using the FP/RH curriculum
Clinical instructor questionnaire In addition to the above, types of procedures 
students permitted to do with clients, required 
competencies, competency measures used, other 
use of clinical sites 
Student questionnaire Same as above (to validate faculty responses), 
employment plans
Interview guide for head of school Faculty training and teaching assignments, 
experience in using the FP/RH curriculum, 
information system on school graduates
School clinical training site assessment form Providers, clinic hours, FP/RH and other health 
services, equipment and supplies, number of clients, 
clinic records and reports
Two former Philippines-based JHPIEGO staff members provided technical assistance and
participated in the data collection. A JHPIEGO Research and Evaluation Office staff member
traveled to the Philippines and together with the two Philippine consultants administered the
study instruments from 21 February to 9 March 2001. To cover all 16 schools in the sample
during the limited data collection time period, the field study team made 2-day visits to most
schools as a 1-person data collection team and to a few schools as a 2-person team. At the end 
of the data collection period, the initial results of the assessment were presented to the United 
States Agency for International Development (USAID)/Manila Population, Health and Nutrition
Deputy Director. The results were also presented to APSOM and ADPCN representatives.
Ideas generated during these discussions have been incorporated into this report.
Sample
The sample consisted of 16 of the 27 preservice program-affiliated schools: eight nursing
schools and eight midwifery schools. These schools are the same ones that were included in
two earlier evaluation studies conducted by JHPIEGO on other aspects of the Philippine
program (Fernandez et al 1999; Vollmer, Dean and Valadez 1996). This sampling allows the 
findings of this present study to complement the findings of the earlier studies, and provides a
broader information base in the overall assessment of the Philippine program. 
Because of the limited time for data collection, the field study team distributed faculty
questionnaires using convenience sampling. All faculty members available during the 2-day 
period of the study team’s visit were given a questionnaire to complete. Twenty-nine faculty
members responded to the questionnaires (16 from the nursing schools and 13 from midwifery 
schools), which is 47% of the total number of faculty reported to be teaching FP/RH from the
start of JHPIEGO’s preservice program. The two types of faculty questionnaires, the classroom 
tutor questionnaire and the clinical instructor questionnaire, were distributed based on teaching 
responsibility. A faculty respondent who taught both the classroom and the clinical portions of
the course responded to both questionnaires. There were 22 faculty respondents for the
classroom tutor questionnaire (13 from the nursing schools and 9 from the midwifery schools)
and 23 faculty respondents for the clinical instructor questionnaire (12 from the nursing schools 
JHPIEGO Technical Report 5
and 11 from the midwifery schools). Sixteen classroom tutor respondents (9 nursing school
faculty members and 7 midwifery school faculty members) taught both the classroom and
clinical portions of the FP/RH curriculum and, therefore, filled out both questionnaires.
The field study team distributed student questionnaires to all students in the classrooms at the 
time the study team visited the school. The questionnaire was given to students who were
currently taking or had completed the FP/RH courses. Responses were obtained from 170
nursing students, estimated to be 75% of the total number of nursing students who were
currently taking or who had completed the FP/RH courses. Responses were obtained from 40
midwifery school students, estimated to be 95% of the total number of midwifery students who 
were currently taking or who had completed the FP/RH courses.
Responses were obtained from all the 16 school principals/deans and 16 school clinic
administrators.
Operational Definitions and Indicators
Capacity refers to the human resources, operating guidelines and infrastructure that enable 
training institutions to respond to the need for service providers in the health field and produce 
intended results. 
Institutionalization is defined for this assessment as the process by which an organization—that 
is, a school, government or both—utilizes and maintains the capacities developed through
policies, strategic plans, operating systems and procedures.
Indicators for capacity and institutionalization were defined and measured for each of the
following areas: availability of trained FP/RH faculty, implementation of the FP/RH curriculum
and utilization of school clinics. (See Appendix for a complete list of the indicators.)
FINDINGS
The schools varied in enrollment size. Nursing schools had a much higher student enrollment
than midwifery schools. The eight nursing schools had an estimated total enrollment of 1,700,
while the six midwifery schools reported a total enrollment of 88 students. Two of the eight
midwifery schools in the sample had temporarily closed enrollment for the 2000–2001 school 
year, one because of a lack of students and the other because of the recent sale and ensuing 
reorganization of the school.3
Information collected from the assessment is described and analyzed below according to the
assessment objectives listed under Purpose and Objectives. 
Availability of Trained Family Planning/Reproductive Health Faculty
Training faculty in effective FP/RH teaching strategies and clinical skills was a key component of 
the preservice strengthening program. The findings show that a core group of faculty trained in 
FP/RH was still functioning in both the nursing and midwifery schools. Institutionalization within 
the schools was demonstrated by teaching assignments that took into account faculty training 
 
3
 Anecdotal reports suggest that the recent lifting of the requirement that applicants to 4-year colleges take college 
entrance examinations has resulted in increased enrollment in 4-year colleges and decreased enrollment in midwifery 
schools, which are 2-year institutions.
JHPIEGO Technical Report 6
and teaching experience. It was also indicated by government accreditation of clinical faculty
that permitted them to provide FP/RH services in the school clinics.
All schools in the sample had at least one full-time trained faculty member (tutor or
clinical instructor) assigned to teach FP/RH. More than three-quarters of those teaching
FP/RH had received training through JHPIEGO’s TRH Project, and they had attended
most of the courses offered through the preservice program.
Thirty faculty members were reported to be currently teaching FP/RH in the 16 schools. The
eight nursing schools had 17 FP/RH instructors currently teaching or an average of 2.1 per
school, and the eight midwifery schools had 13 FP/RH instructors or an average of 1.6 per
school.
The TRH Project supported the implementation of eight types of courses aimed to strengthen
the FP/RH skills of the faculty. The duration and types of courses were as follows: 
® 2-week FP/RH teaching methods course
® 2-week service provider course
® 3-week FP/RH CTS course
® 5-day ARH course 
® 3-day IP course
® 2-week GTI course
® 5-day advanced RH counseling course
® 2-day natural FP course
More than three-quarters (76%) of the faculty respondents had attended a TRH Project training 
course. Among those who attended (n=22), almost two-thirds (64%) had attended at least 5 of 
the 8 courses conducted by the TRH Project. Table 2 shows the number of faculty who
attended TRH Project courses.
Table 2. Distribution of Faculty Respondents by Number of Courses Attended
Nursing
(n=15)
Midwifery
(n=14)
Both
(n=29) Number of TRH Project 
Courses Attended
n % n % n %
5 or more 7 47 7 50 14 48
3 or 4 4 27 2 14 6 21
1 or 2 1 7 1 7 2 7
0 3 20 4 29 7 24
Most of the FP/RH faculty had been trained to teach the clinical portion of the FP/RH
curriculum.
Of the total respondents, 55% provided both classroom and clinical instruction, 24% provided
clinical instruction only and 21% provided classroom instruction only. Overall, about 80% of the 
faculty was providing clinical instruction to students and clinical services to clients attending the 
JHPIEGO Technical Report 7
school clinics. Midwifery schools had a higher proportion of faculty providing clinical instruction 
than did nursing schools (Table 3).
Table 3. Distribution of Faculty Respondents by Teaching Responsibility
Nursing
(n=16)
Midwifery
(n=13)
Both
Teaching Responsibility (n=29)
n n n %
Classroom and clinical 9 7 16 55
Clinical only 3 4 7 24
Classroom only 4 2 6 21
Schools took into account faculty clinical training skills and years of experience in
decisions related to teaching assignments, an indicator that institutionalization of faculty 
clinical training skills had occurred within the schools.
The 3-week CTS course in FP/RH was considered the training course that faculty members had 
to attend to teach the clinical portion of the FP/RH curriculum effectively. In each school, at least 
one of the clinical instructors had attended the 3-week CTS course. Of the 23 clinical faculty
respondents, 20 (87%) had attended CTS training. On the other hand, none of the faculty
members assigned to teach only the classroom portion had attended the CTS training (Table 4). 
Thus, for the most part, only those who attended the CTS course were assigned to teach the
clinical portion of the curriculum. This finding shows that the school administrations considered 
faculty training when making teaching assignments, indicating that schools recognized the
importance of clinical training skills.
Table 4. Faculty Clinical Training Skills by Responsibility: Nursing and Midwifery Schools
Teaching Responsibility (n=29)
Clinical or Classroom 
and Clinical (n=23)
Classroom Only
(n=6)
CTS Training
n % n %
Attended a FP/RH CTS course 20 87 0 0
Never attended a FP/RH CTS course 3 13 6 100
In addition to having attended CTS training, the faculty members who were assigned to clinical 
instruction responsibilities were those who had more years of teaching experience. They had an 
average of seven years of teaching experience as compared to an average of five years
experience for those with classroom teaching responsibilities only. Overall, the average FP/RH 
faculty member had 6.5 years of teaching experience (Table 5).
JHPIEGO Technical Report 8
Table 5. Average Years of Faculty Teaching Experience by Teaching Responsibility
Average Years of Teaching Experience
Teaching Responsibility Nursing
(n=16)
Midwifery
(n=13)
Both
(n=29)
Clinical or classroom and clinical 6.9 7.0 6.9
Classroom only 5.0 5.0 5.0
Overall average 6.4 6.6 6.5
Institutionalization was exhibited by government accreditation of clinical instructors as
FP service providers in school clinics.
At the start of the preservice program, Philippine nursing licensure policies did not allow nurses 
and midwives to provide certain services such as IUD insertion. Toward the end of the TRH
Project in the Philippines, the program staff worked extensively with the Department of Health’s 
(DOH) Family Planning Service to advocate for trained faculty to receive accreditation to provide 
FP/RH services, including IUD insertion, in the school clinics. The DOH, after a review of the
training process, recognized the 2-week service provider course and the 3-week FP/RH CTS
course conducted by the TRH Project as meeting the national accreditation requirements. The 
DOH subsequently recommended accreditation by the Professional Regulation Commission.
Beginning in March 1999, clinical instructors who completed the required training obtained
accreditation, which stated, “she/he is legally authorized to render service in IUD insertion, pill 
dispensing and provide injectable methods under the authority of the Republic of the
Philippines.” The Professional Regulation Commission gave accreditation to all JHPIEGO￾trained faculty in both program-affiliated and non-program affiliated schools. The DOH also
granted participants of the above-mentioned courses an equivalent of 40 units of continuing
professional education credits (required for renewing a professional license). 
The practice of formal designation of clinical instructors was an indicator that there was 
institutionalization of the clinical portion of the curriculum. 
Only one nursing school clinical faculty member and one midwifery school clinical faculty
member reported that they did not have formal designation as clinical instructors. The rest of the 
faculty providing clinical instruction reported that they had received formal designation as clinical 
instructors from their school administrator. 
FP/RH training opportunities for faculty were reduced after the TRH Project preservice
program ended, but faculty took the initiative to stay updated in FP/RH through other
means. 
At the time of this evaluation, only about one-third of the faculty had attended any FP/RH
training in the three years since the end of the preservice program in 1998 (Table 6). Although 
there seemed to be limited opportunities for FP/RH training, the respondents reported a variety 
of ways to obtain updated FP/RH information. The most often cited sources of new information 
were journals and books, experts and the Internet.
JHPIEGO Technical Report 9
Table 6. Distribution of Faculty Attendance at Family Planning/Reproductive Health Training 
During the Past Three Years
Nursing
(n=16)
Midwifery
(n=13)
Both
(n=29) Attendance at FP/RH 
Training
n % n % n %
Yes 6 38 4 31 10 35
No 9 56 7 54 16 55
No answer 1 6 2 15 3 10
Implementation of the Family Planning/Reproductive Health Curricular Components
The TRH Project assisted APSOM and ADPCN in the development and implementation of a
standardized, competency-based FP/RH curriculum for nursing and midwifery schools. During
this evaluation, all schools were still using the instructional materials developed through the
preservice program. The faculty continued to implement the FP/RH curricular components with 
instructor’s guides, teaching materials and teaching aids (e.g., models, videos). The strategies
used to implement the FP/RH curriculum, however, differed between the nursing and midwifery 
schools. Nursing schools used an “integration” strategy in which FP/RH was taught as a
component of selected nursing courses. Midwifery schools used a strategy where FP/RH was
taught as one separate course. 
The importance of FP/RH curricular content was indicated at the national level by the inclusion 
of FP/RH questions in the nursing and midwifery licensure examinations. Institutionalization was 
indicated through the leadership of APSOM and ADPCN in preservice policy development.
Capacity existed in the implementation of the classroom portion of the standardized
FP/RH curriculum.
All nursing and midwifery schools reported using the FP/RH course outline, course syllabus and 
instructor lesson plans developed by ADPCN and APSOM, respectively, with assistance from
the TRH Project. Most (82%) of the classroom tutors reported using the instructor’s guide
“always.” Specifically, for midwifery schools, all classroom tutors reported using the instructor’s 
guide “always.” For nursing schools, two-thirds of classroom tutors used the instructor’s guide
“always,” and the remaining one-third reported using the instructor’s guide only “sometimes.”
This difference may be because the instructor’s guide for midwifery schools was developed to 
cover all topics, while the guide for nursing schools was developed only for selected FP topics.
Most (73%) of the classroom tutors reported ease in teaching “all or most topics” in the
instructor’s guide. Again, midwifery schools had a higher proportion of tutors reporting ease in 
teaching “all or most topics” (Table 7).
JHPIEGO Technical Report 10
Table 7. Distribution of Use of Instructor’s Guide and Ease in Teaching Family Planning/
Reproductive Health Topics
Nursing
(n=13)
Midwifery
(n=9)
Both
Indicator (n=22)
n % n % n %
Always use guide 9 69 9 100 18 82
Sometimes use guide 4 31 0 0 4 18
Ease in teaching all or 
most topics
8 62 8 89 16 73
Capacity existed in competency-based FP/RH clinical instruction. 
All schools had a clinical, skill-related component in the FP/RH curriculum. All clinical
instructors, with the exception of one clinical instructor in a midwifery school, reported using the 
clinical program guide and using measurable learning objectives for teaching the clinical portion 
of the FP/RH curriculum. When asked to enumerate competencies expected from students,
most of the clinical instructors (83%) were able to identify the competencies correctly (Table 8).
Table 8. Clinical Instructors’ Use of Clinical Program Guide, Use of Measurable Learning 
Objectives and Satisfactory Identification of Student Competencies
Nursing
(n=12)
Midwifery
(n=11)
Both
Indicator (n=23)
n % n % n %
Use of clinical program 
guide
12 100 10 91 22 96
Use of measurable 
learning objectives
12 100 10 91 22 96
Satisfactory identification of 
student competencies
10 83 9 82 19 83
Faculty continued to use the competency-based training teaching materials,
methods/aids and equipment provided by JHPIEGO for teaching both the classroom and 
clinical portions of the FP/RH courses.
All 16 schools reported using the teaching materials provided by the preservice program, which 
consisted of RH flipcharts and posters. All schools had at least one each of the following
teaching aids made available through the program: breast model, pelvic model, handheld
uterine model and condom model. Training equipment, including training videos and
videocassette recorders, overhead projectors and film projectors, were also still in use. All
schools had functional videocassette recorders, and all nursing schools reported having a
functional overhead projector available for teaching. Five midwifery schools had functional
overhead projectors, while the other three midwifery schools reported overhead projectors that 
were in a “condition that limits its use.” Coaching, role plays, anatomic models for simulations 
and demonstrations were often used in clinical instruction by the clinical instructors. Models and 
demonstrations were the most frequently used teaching methods/aids reported by clinical
instructors (96%). Role plays were the least used (Figure 1). The most common reason cited
for not using role plays was lack of time. 
JHPIEGO Technical Report 11
Figure 1. Distribution of Teaching Methods/Aids Used in Clinical 
Instruction: Nursing and Midwifery Schools (n=23)
0
10
20
30
40
50
60
70
80
90
100
Coaching Role Plays Models Demonstrations
Method
Percentage
Frequently Used
Sometimes Used
Not Used
Students reported that competencies for FP/RH skills were assessed. Checklists were
used in competency assessments. Students practiced FP/RH procedures with anatomic
models. These practices are indicators that competency-based FP/RH instruction has
been institutionalized in most schools.
The field study team determined that all midwifery and nursing schools, with the exception of
one nursing school for which the data were insufficient, assessed student competency for
FP/RH skills procedures at the end of the students’ clinical rotations. All students in the 
midwifery schools and 93% of students in the seven nursing schools for which there were data 
reported being assessed for competency in FP/RH skills (Table 9). Checklists were used for
these competency assessments. Most students (94%) reported access to anatomic models, and 
most students (88%) reported that they had sufficient time to practice with the models (Table 9). 
Although both cadres of students had good access to anatomic models, nursing students had 
more difficulty getting sufficient practice time with the models.4
 Among nursing students, 54%
reported that they were assessed as competent in performing a pelvic examination with a model 
compared with 100% of midwifery students. Sixty percent of nursing students reported they
were assessed as competent in IUD insertion with a model compared with 98% of midwifery
students.
 
4
 Note that the number of nursing students enrolled was much higher than the number of midwifery students. The
higher ratio of nursing students to number of models available may have restricted their access to models more so
than for the midwifery students.
JHPIEGO Technical Report 12
Table 9. Student Assessment on Use of Competency-Based Approaches
Nursing Studentsa
(n=140)
Midwifery Students
(n=40)
Both
Indicator (n=180)
n % n % n %
Assessed as competent in FP/RH 
skills at the end of clinical rotation
130 93 40 100 170 94
Use of checklist in FP/RH skills 
assessments
130 93 40 100 170 94
Access to anatomic models 130 93 39 98 169 94
Sufficient time to practice with 
anatomic models
119 85 40 100 159 88
a
 One nursing school was dropped because of non-response to the question that asked students whether 
they were assessed as competent in FP/RH skills at the end of clinical rotation (54% non-response rate).
The school libraries had a sufficient supply of FP/RH reference materials, and students
were required to use them, confirming that there was institutionalization of the FP/RH
curriculum.
Most students (81%) considered the FP/RH reference materials in the libraries sufficient. A
higher proportion of students from midwifery schools reported sufficiency in library materials as 
compared to nursing school students. Overall, two-thirds of the students reported that they were 
required to read the FP/RH reference materials. A much higher percentage of students from 
midwifery schools (98%) reported being required to read reference materials as compared to
those from nursing schools (59%). (See Table 10.) Reading requirements may have been
easier to carry through/enact in midwifery schools as compared to nursing schools because
FP/RH was taught as one course in midwifery schools.
Table 10. Students Reporting Sufficient Library Reference Materials and Requirement 
to Read Reference Materials
Nursing
(n=170)
Midwifery
(n=40)
Both
Indicator (n=210)
n % n % n %
Sufficient FP/RH reference 
materials in library
133 78 36 90 169 81
Requirement to read 
FP/RH reference materials
101 59 39 98 140 67
The importance of FP/RH content in preservice education was signified at the national
level by the inclusion of FP/RH questions in the national licensure examinations. 
Both the nursing and midwifery licensure examinations included FP/RH questions. The inclusion
of FP/RH questions in the licensure examinations shows that FP/RH knowledge is a critical
requirement for nurses and midwives to obtain a license. This inclusion then ensures that the
nursing and midwifery curricula contain FP/RH content and may provide an incentive to TRH
program schools to continue to use, and institutionalize, the strengthened FP/RH curricular
components.
In 1994, computerization was implemented for the nursing licensure examination, formally
called the Integrated Comprehensive Nurse Licensure Examination. In this system, examination 
JHPIEGO Technical Report 13
questions are selected through a computer-based, randomization process from a bank of test
questions. The Board of Nursing, the government body responsible for nursing licensure,
determines the questions included in the test question bank. The questions cover the concepts 
that are specified in the syllabi of courses such as fundamentals of nursing, medical-surgical 
nursing, maternal and child health nursing, psychiatric nursing, community health nursing and
professional adjustment nursing. In a 1994 board resolution, the Board of Nursing specified that 
FP and related concepts were to be included in the syllabi and correspondingly in board
examination questions under maternal and child health nursing. Other FP and related concepts 
were also included in the fundamentals of nursing and community health nursing sections.
Institutionalization of the leadership role of APSOM and ADPCN in preservice education
policy development was illustrated in recent association-led efforts in preservice policy 
formulation.
At the time of the evaluation, the president of APSOM served as the Chairman of the Technical 
Committee on Midwifery Education of the Commission on Higher Education and Development 
(CHED). During the last three years, APSOM and the Technical Committee on Midwifery
Education of the CHED led the development of updated policies and standards for midwifery
education and issued the CHED Memorandum Order in December 2000. The order outlines
new policies and standards related to school administration and faculty, curriculum, instructional 
standards, library facilities, clinical facilities and student selection. Complementing APSOM’s
leadership in preservice midwifery education policy development was its faculty development
programs and activities. In May 2001, APSOM held a 3-day national conference for its
members. One of the conference activities was an update on FP/RH. APSOM and ADPCN also 
contributed to the recognition on behalf of the Board of Nursing of the need to include FP/RH 
questions on the nursing licensure examination.
At the time of the evaluation, the Technical Committee for Reproductive Health of ADPCN, with 
assistance from the CHED, was developing updated policies and standards for nursing
education. A memorandum order on the new policies and standards, which will be similar to the 
one developed by APSOM for midwifery education, was expected to be issued by the CHED
before the end of 2001. Likewise, ADPCN conducted updates and refresher courses in FP for
the nursing faculty in May 2001.
Recent preservice education policies provide opportunities for APSOM and ADPCN to 
strengthen their roles in accreditation. At the same time, these policies pose a challenge 
to FP/RH instruction brought about by the integration of FP/RH into other courses.
Accreditation opportunities for APSOM are defined in the CHED Memorandum Order in the
areas of school operations, faculty certification and clinical sites accreditation. Although the
approval to open schools is a responsibility of the CHED, continued school operation requires
accreditation by the APSOM Accreditation Board. In addition, faculty members are required to
be certified to teach and the National Midwifery Education Certification Council of APSOM
issues this certification. Schools are required to have a faculty development program that
includes clinical skills enhancement for at least two weeks a year. The CHED Memorandum
Order stipulates appropriate, updated syllabi and instructional methods and strategies
implemented through a system of supervision and evaluation. The clinical portion of the course 
can be conducted using hospitals that have been accredited by the DOH or clinics that have
been accredited by the APSOM Accreditation Board.
The curriculum described in the recent CHED Memorandum Order is consistent with a recently 
adopted policy instituting a 2-year Associate in Health Science Education (AHSE) program. The 
JHPIEGO Technical Report 14
AHSE program is the initial tier in a multi-tiered education system leading to a baccalaureate
degree in the health profession. In this system, students enrolling for a degree in nursing or a
certificate in midwifery need to complete the AHSE program in their first two years. Students
then take additional courses to complete their degree or certificate in subsequent years. The
implication of the AHSE program on FP/RH instruction in midwifery schools is that FP/RH will no 
longer be taught as a separate course but will be integrated into other courses. The effect of this 
integration on the quality of FP/RH instruction in midwifery schools remains to be seen.
Utilization of Clinical Training Sites
The TRH Project set up school clinics for FP/RH services as venues for students to practice
FP/RH procedures; assistance included procurement of clinic equipment. The school clinics
have continued to provide FP/RH services to clients as well as opportunities for students to 
provide services. The expansion of clinical services to include other RH and child health
services enhanced institutionalization of school clinics. The expansion to non-FP/RH service
delivery may be considered scaling-up, making the school clinics more viable and contributing
to their institutionalization. Institutionalization of the school clinics was also demonstrated by all 
clinics becoming service delivery points for the government’s Family Planning Program. 
The school clinical sites were well equipped and provided a comprehensive range of
FP/RH services. 
There were two types of school clinics: (1) clinics attached to hospitals or hospital-based clinics 
and (2) freestanding or community-based clinics. The field study team collected data at 14
clinics, which were equally divided between hospital- and community-based clinics. More
nursing school clinics (5 of 8) were community-based, while more of the midwifery school clinics 
(4 of 6) were hospital-based (Table 11).
Most clinics (11 of 14) were open five days a week from Monday to Friday, and some clinics
were also open on Saturday. On average, clinics were open 36.7 hours per week or about
seven hours per workday (Table 11). More than half of the clinics (57%) were open 40 or more 
hours per week. Only one clinic reported closing for a 6-week period during the year in which 
providers went on vacation. School clinics had an average of about 5 FP/RH clients per week, a 
low caseload for these services.5
 This low caseload obviously has implications for student 
exposure to FP/RH procedures during their clinical rotations and the length of time it takes
students to achieve competency.
School clinics had an average of 2.8 providers on site during the day (Table 11). Hospital-based 
clinical staff usually included physicians undergoing a residency program.
 
5
 At least one school clinic made special efforts to recruit additional FP/RH clients during the period of students’
clinical rotations.
JHPIEGO Technical Report 15
Table 11. Characteristics of School Clinics
Indicator Nursing
(n=8)
Midwifery
(n=6)
Both
(n=14)
Hospital-based school clinics 3 4 7
Community-based school clinics 5 2 7
Average number of hours open per week 34.6 39.5 36.7
Average number of FP/RH clients per year 221 252 237
Average number of health providers 3.0 2.7 2.8
The clinics provided a broad range of FP services that included IUD insertion and removal, oral 
contraceptives, condoms, injectable contraceptives and natural FP services. All clinics reported 
that these services were “always available in the last 6 months.”
Clinic equipment provided by the program was still available and functional. All school clinics
had the following equipment: 
® Examination table with stirrups
® Adjustable gooseneck lamp
® IUD kits
® Blood pressure apparatus
® Stethoscope
® Weighing scale
® Microscope
® Steamer/sterilizer
® Plastic container for decontamination solution
® Plastic container for disposal of waste
® Sink with running water
The school clinical sites appeared to provide limited opportunities for students to
practice FP/RH skills with clients. Students provided some key FP/RH services
frequently, but not all key FP/RH services.
Clinical instructors were asked to comment on which FP/RH skills students were able to practice 
in the clinic and how often. About three-quarters of the clinical instructors reported that the
FP/RH procedures that students conducted most frequently were FP counseling, breast
examination and condom use demonstration. About three-quarters of midwifery clinical
instructors and one-half of nursing clinical instructors reported that students frequently
dispensed pills. Only one-third of the nursing clinical instructors and one-half of midwifery
clinical instructors, however, reported that students administered Depo-Provera frequently.6
 A
quarter of the nursing clinical instructors reported that nursing students did not provide ARH
counseling services at all. In general, it was reported that students did not perform pelvic
examinations frequently, although midwifery students appeared to do so more often than did
nursing students. One-third of clinical faculty respondents from both sets of schools said
students never conducted a pelvic examination. Both nursing and midwifery students did GTI
 
6
 Caseload may have been low for this and certain other FP services.
JHPIEGO Technical Report 16
testing and counseling the least frequently, with half of the clinical faculty respondents reporting 
that students never performed this procedure during clinical rotation7
 (Table 12).
Table 12. Procedures Conducted by Students in Clinics as Reported by Clinical Instructors
Procedures Conducted by Students
Frequently (%) Sometimes (%) Not Conducted (%) Procedure
Nurse
(n=12)
Midwife
(n=11)
Nurse
(n=12)
Midwife
(n=11)
Nurse
(n=12)
Midwife
(n=11)
FP counseling 67 73 25 27 8 0
Breast examination 83 73 17 18 0 9
Condom use demonstration 75 73 17 27 8 0
Depo-Provera injection 33 54 50 9 17 36
Pill dispensing 58 73 25 18 17 9
Pelvic examination 33 45 33 18 33 36
GTI testing and counseling 25 18 25 27 50 54
ARH counseling 25 45 50 36 25 18
Most nursing and midwifery students felt that school clinics provided them with
sufficient opportunities to conduct FP/RH procedures and FP/RH counseling with clients. 
More than three-quarters of students said clinics provided them with sufficient opportunities to
conduct FP/RH procedures. A higher proportion, about four-fifths, reported clinics provided the 
opportunity to conduct FP/RH counseling. A higher proportion of midwifery students said clinics 
provided sufficient opportunities to conduct FP/RH procedures and counseling as compared to 
nursing students (Table 13). 
Table 13. Students Reporting Sufficient Opportunities to Perform Family Planning/
Reproductive Health Procedures and Counseling in Clinics
Nursing
(n=170)
Midwifery
(n=40)
Both
Indicator (n=210)
n % n % n %
Sufficient opportunities for 
FP/RH procedures
128 75 37 93 165 79
Sufficient opportunities for 
FP/RH counseling
133 78 40 100 173 82
School clinics have maintained quality standards for FP/RH service delivery.
School clinics were still adhering to the quality standards established at the time of the program. 
The clinics were observed to be using appropriate IP practices and ensuring the privacy of
clients. Most (93%) were found to be recording all FP methods dispensed on clients’ medical
records (Table 14).
 
7
 It is possible that student exposure to GTI service provision was minimal because of low caseload as well as
because students might not have been permitted to do testing.
JHPIEGO Technical Report 17
Table 14. Quality Practices of School Clinics
Nursing
(n=8)
Midwifery
(n=6)
Both
Indicator (n=14)
n % n % n %
Equipment and gloves soaked 
properly
8 100 6 100 14 100
Use of separate room or curtains in 
counseling areas
7 88 6 100 13 93
Client records filled out with FP 
method dispensed
8 100 5 83 13 93
School clinics provided other RH and child health services in addition to FP services.
These services enhanced institutionalization of school clinics. 
As previously mentioned, as part of the preservice strengthening program the TRH Project set 
up the school clinics for FP/RH services as venues for students to practice FP/RH procedures. 
The expansion to include non-FP/RH services may help to make the school clinics more viable, 
and contribute to institutionalization of the clinics.
Almost all clinics (13 of 14) provided services other than FP, with prenatal care and well-baby 
care being the most frequently mentioned. Five clinics (2 nursing and 3 midwifery) provided
normal delivery care. Other FP/RH-related services that were often reported included
counseling for infertility cases and testing for pregnancy. 
The volume of non-FP services tended to be high, as shown in the two clinics where year 2000 
data were available. A hospital-based midwifery school clinic reported 280 FP visits (or services 
provided) per year, but also reported 4,500 prenatal care, 550 Papanicolaou (Pap) smear and 
300 postabortion care cases. The other clinic, a community-based midwifery school clinic,
reported 3,500 clients, approximately one-third (1,100) of which were FP clients.
School clinics were service delivery points of the government’s Family Planning
Program, and thus were regularly provided with FP supplies. This finding attests to the 
institutionalization of FP services in school clinics. 
The DOH formally recognized the school clinics as service delivery points for FP, and as such, 
they became service delivery points of the DOH’s Family Planning Program. Accordingly, they
received regular contraceptive supplies from the DOH including pills, IUDs, Depo-Provera and
condoms. In addition, because they were service delivery points, these clinics were included in 
the DOH contraceptive logistics management system as receiving units, and obtained quarterly 
deliveries of these FP supplies. This recognition contributed to the institutionalization of the
clinics.
Contributions to Family Planning/Reproductive Health Service Delivery and Evidence of
Scaling Up
Information obtained from this evaluation suggests that graduates of the strengthened
preservice program were adequately prepared to provide FP/RH services. 
Some schools recognized the need to know how well FP/RH preservice education responded to 
the needs for FP/RH service delivery and initiated studies that tracked the employment status of 
graduates. At the same time, certain schools utilized their strengthened capacities in preservice 
JHPIEGO Technical Report 18
education for inservice training. In addition, some used these capacities to expand to non-FP 
applications.
Students of the strengthened preservice education program considered themselves
adequately prepared to provide FP/RH services when they enter the workforce. 
Students reported they had adequate preparation to provide FP/RH services when they enter
the workforce; most (93%) of the students considered their education as “adequate” to “very
adequate.” A higher proportion of midwifery students reported “very adequate preparation”
(58%) as compared to nursing students (27%). In addition, none of the midwifery school
respondents assessed their training as “inadequate,” whereas 13 nursing students (most of
these students were from one school) considered their preparation inadequate (Table 15). 
There was no opportunity to ask the students why such a response was given. 
Table 15. Adequacy of Training According to Students
Nursing
(n=170)
Midwifery
(n=40)
Both
Student Assessment (n=210)
n % n % n %
Very adequate preparation 45 27 23 58 68 32
Adequate preparation 112 66 17 43 129 61
Inadequate preparation 13 8 0 0 13 6
Graduates of the strengthened preservice education program schools performed better
on the national licensure examination than graduates from other schools. 
The average national passing rate and the average passing rate of a sample of four
strengthened preservice education program nursing schools visited by the study team are
compared for the years 1998, 1999 and 2000 in Figure 2 below. The average passing rates of 
the graduates from the strengthened preservice program nursing schools have been
consistently higher over time than the national average of the nursing schools, suggesting
improved preparation for service provision. 
Figure 2. Nursing Licensure Examination Passing Rates: Philippines
0
10
20
30
40
50
60
70
80
90
100
1998 1999 2000
Year
Percentage
Nursing: National Rate
Nursing: Rate for 4 Program Schools
JHPIEGO Technical Report 19
The nursing school graduate passing rates shown here for the strengthened preservice program 
schools were based on four schools where data were complete. Passing rates for these four
schools were calculated by comparing the total number of graduates with the number of
graduates who passed the examination. Passing rates at the national level were based on the 
number of graduates who took the examination. Table 16 below presents the numbers of
graduates associated with the passing rates.
Table 16. Nursing Licensure Examination: Numbers of Graduates Who Passed the Examination
1998 1999 2000
Rates Total 
Number
Passing 
Number
Total 
Number
Passing 
Number
Total 
Number
Passing 
Number
National Rates* 17,101 9,541 13,152 6,559 9,271 4,602
Program School 
Rates**
239 182 214 185 128 79
*Base number is the number of students who took the examination that year.
**Base number is the number of students who graduated that year.
As can be seen in Figure 2 and Table 16, the preservice program school passing rates were
repeatedly higher than the national passing rates. In 1998, 182 nursing school graduates (76%) 
passed the examination out of a total of 239 who ever graduated. In 1999, 185 nursing school 
graduates (86%) passed out of a total of 214 who ever graduated, and in 2000, 79 nursing
school graduates (62%) passed out of 128 who ever graduated. 
Students preferred to seek employment in the public rather than private sector after
graduation, suggesting that the public sector may have benefited more than the private
sector from the preservice strengthening program. 
Nursing and midwifery students ranked government hospitals as the most desirable place for
employment after graduation. The majority of students ranked government health centers as the 
next most preferred place for employment. Private health facilities, including FP
nongovernmental organizations (NGOs), were the least desirable places for future employment. 
Nursing students generally preferred hospital employment, while midwifery students showed a
greater preference for health center employment (Table 17). The preference for government
employment is attributed to the higher salaries in the public sector.
Table 17. Student Preferences for Place of Employment After Graduation
Percentage of Students by Rank 
Rank 1 Rank 5 Employer
Nursing 
Students
(n=170)
Midwifery 
Students
(n=40)
Nursing 
Students
(n=170)
Midwifery 
Students
(n=40)
Private hospital 24 8 24 41
Private maternity clinic 6 5 40 24
Government hospital 67 44 4 6
Government health center 17 34 15 3
FP NGO 11 11 33 23
JHPIEGO Technical Report 20
Five schools were conducting inservice training programs, an indication of the local
recognition and need for the quality training available from these schools. 
Three nursing schools and two midwifery schools reported that they had used their clinical sites 
to conduct FP/RH inservice training for DOH or local government service providers. One of the 
midwifery schools reported that it had trained between 60 to 70 participants during the past
three years, and the other reported to have trained 100 participants. The schools provided these 
inservice trainings in response to requests made by the local governments. 
The above is an important finding because it demonstrates the independent initiative taken by 
these five schools to pursue inservice training opportunities after the preservice program ended. 
It attests to the strong leadership of the school principals and faculty as well as their interest in 
building partnerships with local government entities. This finding also illustrates the initiative
taken by local government entities to identify sources of training. Overall, it indicates that there 
is recognition and need for the quality training provided by these schools.
Anecdotally, the head of a midwifery school that was conducting inservice FP/RH training noted 
that graduates from schools offering the strengthened preservice curriculum required less FP
inservice training than providers who had not been educated with the strengthened curriculum. 
Specifically, the graduates from schools with the strengthened preservice curriculum completed 
the didactic portion of the inservice FP training, which is designed for eight days, in five days,
and the practicum portion, designed for six days, in three days. 
Building on capacities developed in the preservice strengthening program, four schools 
were implementing donor-assisted RH programs.
One nursing school reported implementing an ARH program in collaboration with the local
division of the Department of Education, Culture and Sports (DECS). In this program, faculty
provided training for school nurses to provide ARH counseling and services to high school
students. Another nursing school received funding from the Japan International Cooperation
Agency to develop and implement a sexually transmitted infection (STI)/HIV/AIDS behavioral 
practices surveillance project. The same school obtained USAID assistance for the
development and implementation of a STI/HIV/AIDS community outreach prevention and
treatment program. Another nursing school used its clinical site to conduct training for providers 
from a NGO on HIV/AIDS client care and support and on Pap smear procedures. A midwifery 
school obtained funding from the Joint United Nations Programme on HIV/AIDS to develop and 
implement a program that would build on the capabilities of youth groups to promote HIV/AIDS 
prevention.
Half of the schools had a system in place to provide information on employment status
of graduates. A few schools were conducting formal studies to track employment of
graduates. 
One-half of the schools reported that they had a system to track employment status of
graduates (Table 18). The information was reported to be maintained by the alumni affairs units 
of the schools. Two schools (one each for nursing and midwifery, both state-funded institutions) 
were conducting school-funded research studies that track employment of graduates. These
studies also looked into the factors that affect employment status. 
Table 18. Information on Graduate Employment Status at the Schools
JHPIEGO Technical Report 21
Nursing
(n=8)
Midwifery
(n=8)
Both
Graduate Employment Status (n=16)
n % n % n %
With information 3 37 5 63 8 50
Without information 5 63 3 37 8 50
Total 8 100 8 100 16 100
DISCUSSION AND CONCLUSION
As part of this evaluation, the field study team visited sixteen out of the 27 schools included in 
the strengthened preservice program. Findings revealed that the program’s investment has
been maintained three years after external funding ceased. In some cases, there had even
been a spillover effect into new areas—including expansion of services at school clinics to
include other RH clinical services. Five schools were using their clinical sites to conduct
inservice training for both government and nongovernmental health providers, and four schools 
were recipients of donor assistance for RH programs. The latter four schools utilized their
capacities in FP/RH preservice education to develop and implement programs in other areas of 
RH such as ARH and STI/HIV/AIDS prevention. The school clinical sites and related community 
outreach activities served as the implementing mechanisms for these programs. Half of the
schools also had a system in place to track employment status of graduates.
A key finding is that the Philippine nursing and midwifery education system has the capacity to 
continue implementation of its strengthened preservice education program. This capacity is
evident in the availability of trained faculty, the continued implementation of FP/RH curricular
components developed jointly by JHPIEGO, APSOM and ADPCN and the availability of
adequate clinical training sites. The schools’ clinical training sites have now become part of the 
government’s Family Planning Program, ensuring that supplies will be readily available. In 
addition, equipment and materials provided through the program to the schools for teaching in 
the classroom and in school clinics were still in place. Anatomic models were available for
student practice, the school libraries had a sufficient supply of FP/RH reference materials that
were still in use by students and the school clinical sites were well equipped to provide FP/RH 
services. Most students reported that faculty assessed their competencies in FP/RH skills at the 
end of their clinical rotations and used checklists, which demonstrates that the competency￾based approach to training in FP/RH has been institutionalized in the schools.
Government and operational policies of schools were found to have ensured the maintenance of 
the capacities developed, indicating institutionalization of the preservice interventions. 
Operational policies of schools also affected the degree of institutionalization of the
interventions within the schools. Institutionalization of the FP/RH curricular components was
observed to be slightly greater in midwifery schools where they used the strategy of teaching
FP/RH as a separate course compared to nursing schools where FP/RH material was
integrated into existing courses. The development of a more detailed and comprehensive
instructor’s guide and reference materials for midwifery schools was also considered as
contributing to the greater institutionalization observed in these schools. 
Overall, institutionalization of preservice program interventions was found to be high at both the 
nursing and midwifery schools visited. Smaller proportions of nursing school students, however, 
reported having sufficient opportunities to practice FP/RH procedures and counseling in the
clinics compared with midwifery school students. Nursing students were also less likely than
JHPIEGO Technical Report 22
midwifery students to report they had sufficient time to practice with anatomic models, sufficient 
FP/RH reference materials in the library or requirements to read FP/RH reference materials for 
their courses. 
The nursing school faculty was less likely than the midwifery school faculty to report always
using the FP/RH instructor’s guide and to be at ease teaching all or most topics included in the 
guide. Even though some of the results for the nursing schools appeared to be less positive
than those for the midwifery schools, faculty at both schools were using the curricular materials 
and competency-based approach most of the time.
Importantly, students of the strengthened preservice education program schools, both nursing
and midwifery, reported that they felt well prepared to provide FP/RH services when they enter 
the workforce. The high percentage of nursing graduates from program schools who passed the 
national licensure examination in comparison with national passing rates lends support to this
finding. 
As important as evidence of school-level institutionalization of the preservice program
interventions was the development of new public policies, in the form of accreditation of clinical 
instructors as service providers and inclusion of FP/RH questions in licensure examinations.
These policies illustrate the increased recognition of the importance of the FP/RH content
included in the preservice strengthening program. Recent policies introducing changes in the
nursing and midwifery curriculum, including a “tiered” system for health provider courses, may, 
however, pose a challenge to the gains made in the preservice strengthening program,
especially in midwifery schools. In the tiered system, FP/RH will be taught in both the nursing
and midwifery schools as course components in a number of courses and not as a separate
course, as is currently done in midwifery schools. The new policies, on the other hand, do
provide opportunities for both APSOM and ADPCN to strengthen FP/RH preservice education
further (e.g., taking on an expanded role in school accreditation). 
Implications for the Future
To preserve the gains made and to build on the scaling up of the preservice strengthening
program in the Philippines, JHPIEGO could provide technical assistance in the following areas: 
® Development of FP/RH inservice training programs that utilize the capacities in FP/RH
preservice programs
The FP/RH faculty in the preservice institutions could serve as inservice trainers, a practice 
already taking place in some schools. The school clinics could be utilized as clinical sites to 
implement a quality of care program for providers from government organizations and
NGOs.
® Development of new areas of competencies in preservice education
The capacities that exist in the FP/RH curriculum can serve as building blocks toward
strengthening the curriculum in other areas such as postabortion care, HIV/AIDS and
maternal and neonatal care. At least one school is already demonstrating development in
this area. 
® Development of school accreditation systems including clinical training sites accreditation
JHPIEGO Technical Report 23
The new policies in preservice education provide an expanded role for APSOM and ADPCN 
in school accreditation. Guidelines, systems and procedures will have to be developed to
support this expanded role. 
® Strengthening human resource policy development
This area includes the need for a national policy and a strategic plan to ensure a steady
supply of health human resources, including the development of a policy research agenda. 
This area may involve the development of information systems that quantify manpower and 
training needs and document and track graduates and participants. It may also involve the 
review of the incentive system for health manpower. Efforts in human resource policy
development will require working with government institutions such as the DOH and DECS.
® Development of a network to provide regional leadership in preservice education
The Philippines may be in a good position to take on a leadership role in the development of 
a regional network to share best practices in preservice education by developing a
repository of training technology documentation and by facilitating regional sharing of
experiences.
® Faculty development to strengthen preservice education further, such as:
· Development of a system of continuing education in FP/RH for faculty
· Development of a system of monitoring and supervision of trained faculty
· Development of a system for training new inflow of faculty
Conclusion
This evaluation found that, three years after the TRH preservice education program ended in
the Philippines, the nursing and midwifery schools have the capacity to continue implementation 
of their strengthened preservice education programs. This capacity is evident in the availability 
of trained faculty, the continued implementation of FP/RH curricular components and the
availability of adequate clinical training sites. Government and operational policies of schools
and public policies (e.g., accreditation) were found to have ensured the maintenance of the
capacities developed, indicating institutionalization. 
JHPIEGO Technical Report 24
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Fernandez RL et al. 1999. Pilot Testing ModCal™ for Inservice and Preservice Family Planning 
Training in the Philippines. JHPIEGO Corporation: Baltimore, Maryland.
Fort AL. 1999. Capacity Building in Training, A Framework and Tool for Measuring Progress. 
PRIME Technical Report 16. INTRAH: Chapel Hill, North Carolina.
Gaffikin L and P Blumenthal. 1993. Evaluation of Phase I: Strengthening Voluntary Sterilization 
Services in the Philippines. JHPIEGO Technical Report FCA-03. JHPIEGO Corporation:
Baltimore, Maryland.
JHPIEGO Corporation. 1992. Reproductive Health Training Sector: JHPIEGO Programming
Strategy 1992–1996, The Philippines. JHPIEGO Corporation: Baltimore, Maryland.
JHPIEGO Corporation Asia/Europe/Near East Office. 1992. Reproductive Health Training
Assessment, The Republic of the Philippines. JHPIEGO Corporation: Baltimore, Maryland.
Philippines Department of Health (DOH) and United States Agency for International
Development (USAID)/Manila. 1994. Integrated Family Planning Maternal Health Program (492-
0480). Philippines DOH/USAID/Manila: Manila, Philippines.
Smith TM and SJG Brechin. 1999. Developing a National Family Planning/Reproductive Health 
Clinical Training System in Kenya. JHPIEGO Technical Report JHP-02. JHPIEGO Corporation: 
Baltimore, Maryland.
Technical Working Group. 1996. National Reproductive Health/Family Planning Training
Program for the Philippines. Philippines DOH: Manila, Philippines.
Vollmer N, TF Dean and J Valadez. 1996. Evaluation of Preservice Midwifery and Nursing
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Corporation: Baltimore, Maryland.
JHPIEGO Technical Report A-1
APPENDIX A
Capacity and Institutionalization Indicators
Capacity Indicators
Availability of Trained FP/RH Faculty
® Proportion of schools having at least one full-time faculty member assigned to teach FP/RH
® Proportion of FP/RH faculty trained in TRH Project courses
® Proportion of FP/RH faculty who attended at least 5 of the 8 TRH Project courses 
® Proportion of faculty assigned to teach the clinical portion of the FP/RH curriculum 
® Proportion of schools in which FP/RH clinical instructors received formal FP/RH training
Implementation of the FP/RH Curriculum
® Proportion of schools still using instructional materials developed by the program
® Proportion of schools in which standardized course outline is used for the FP/RH course
® Proportion of schools in which a syllabus has been followed for the FP/RH course
® Proportion of schools in which instructor lesson plans have been used for the FP/RH course
® Proportion of faculty using the classroom and clinical instructor’s guides developed by the
program
® Proportion of faculty reporting ease in teaching all or most topics in the instructor’s guide
® Proportion of schools in which curriculum includes clinical skills component
® Proportion of clinical instructors using clinical program guide in teaching clinical portion of
course
® Proportion of clinical instructors using measurable objectives in teaching clinical portion of
course
® Proportion of clinical instructors able to identify appropriately competencies students need to 
develop in clinical rotation
® Proportion of clinical instructors using anatomic models and demonstrations
® Proportion of schools in which at least one condom model is available for use
® Proportion of schools in which at least one pelvic model is available for use
® Proportion of schools in which at least one uterine model is available for use
® Proportion of schools in which at least one breast model is available for use
® Proportion of schools in which a videocassette recorder is available for teaching
Utilization of School Clinics
® Proportion of schools with school clinic in operation
® Proportion of school clinics open at least 40 hours per week
® Proportion of school clinics with available and functional clinic equipment 
® Proportion of students reporting frequent practice of FP/RH procedures during clinical
rotation
® Proportion of students assessing clinics as providing sufficient opportunities to conduct 
JHPIEGO Technical Report A-2
FP/RH procedures and counseling services with clients
® Proportion of school clinics in which equipment and gloves are properly soaked in chlorine
after use
® Proportion of school clinics in which client privacy is ensured for counseling and examination
® Proportion of school clinics in which medical records indicate method dispensed to clients
Institutionalization Indicators
Availability of Trained FP/RH Faculty
® Proportion of faculty who received TRH Project CTS training and are assigned to teach the 
clinical portion of the course
® Average number of years of teaching for clinical instructors as compared to classroom
instructors
® Government accreditation of clinical instructors as service providers of FP/RH services
Implementation of the FP/RH Curriculum
® Proportion of schools in which student competency is assessed and documented
® Proportion of students ever assessed as competent in conducting pelvic examinations
® Proportion of students ever assessed as competent in IUD insertion
® Proportion of students reporting that checklists were used to assess competency
® Proportion of students reporting access to anatomic models
® Proportion of students reporting sufficient time to practice with anatomic models
® Proportion of students reporting sufficient FP/RH library reference materials
® Proportion of students required to read FP/RH reference materials
® Proportion of clinical instructors with formal designation
® Inclusion of FP/RH questions in licensure examinations
® Leadership role of APSOM and ADPCN in preservice education policy development 
Utilization of School Clinics
® Proportion of school clinics that provide services in addition to FP/RH services
® Proportion of school clinics that are service delivery points of the government’s Family
Planning Program
JHPIEGO Technical Report B-1
APPENDIX B
FP Curriculum Covers 
JHPIEGO Technical Report B-2