INTEGRATED MATERNAL, NEONATAL, CHILD HEALTH AND NUTRITION/FAMILY PLANNING REGIONAL PROJECT IN LUZON (LuzonHealth)

VOLUME I STORIES FROM THE FIELD

OCTOBER 2017 Cover photos and all photos accompanying stories provided by LuzonHealth staff. RTI International. (2017). Volume1: Stories from the field. Washington, DC: USAID and DOH Disclaimer: This publication was made possible by the generous support of the American People through the United States Agency for International Development (USAID). The contents of this publication are the sole responsibility of RTI International and do not necessarily reflect the views of USAID or the United States Government.

RTI International is a registered trademark and a trade name of Research Triangle Institute. The RTI logo is a registered trademark of Research Triangle Institute. Contents Acknowledgments ii Foreword iii List of Acronyms iv More Efficient, Focused, and Personal Usapan Improves Family Planning Uptake among Communities 1 Integrating Family Planning, Antenatal Care, and Immunization Delivers Results 3 Enhanced Community Health Service Record Helps Direct Families to Needed Health Services 5 Provincial Government and Partners Work to Provide Families with Timely and Appropriate Health Care 8 A Provincial Hospital Gears Up to Provide Family Planning Services for the First Time 10 Enhancing the Role of Hospitals in Increasing Family Planning Use 12 Increasing Access to Comprehensive Family Planning Services in a Public Hospital 15 Reaching Out to Underserved Communities 17 Itinerant Team Brings Family Planning Services Closer to Women 19 Emerging Success in Tri-City Adolescent Health Program 21 Peer Educators Promote Adolescent Health 23 Local Governance: Key to Sustaining Health Gains 25 A New Approach to Assess the Skills of Health Service Providers 27 Effective Tracking System Ensures Availability of Family Planning Commodities 29 Local Government Institutionalizes Data Quality Check for Better Decision-making 31 Integrated Maternal, Neonatal, Child Health and Nutrition/Family Planning Regional Project In Luzon (LuzonHealth) 32

i Acknowledgments

The Integrated Maternal, Neonatal, Child Health and Nutrition/Family Planning Regional Project in Luzon, or LuzonHealth, extends its gratitude to all those who made this compilation of stories from the field possible: To our regional and local partners for giving life to our interventions and whose stories of transformation are featured herein; To project beneficiaries who willingly shared how specific initiatives helped improve their access to maternal and child health and family planning services; and To all RTI staff who were involved in documenting, editing, and packaging these stories. Finally, special thanks go to USAID and the Department of Health without whose support these stories may not have been told.

ii Foreword

With USAID assistance and in collaboration with partners at the national, regional, and local levels, LuzonHealth works to improve the health of families in 14 provinces and seven cities in Luzon by expanding their access to high-quality, integrated family planning and maternal, neonatal, child health and nutrition services. The project achieves these aims by developing and introducing tools, systems, and capacity building approaches to help local governments increase family planning use and improve maternal and newborn care, with the ultimate goal of improving health outcomes. As LuzonHealth nears its completion, we are pleased to share the results of our initiatives through a series of stories that demonstrate how major interventions and innovations worked in particular project sites. Through these stories, we hope to enjoin program implementers and decision-makers, particularly those at the local level, to try out these simple yet proven approaches and interventions. This compilation is the first of two volumes that will chronicle the experiences of partners and beneficiaries whose lives the project has touched in one way or another. It is our hope that similar stories of small and large successes in replicating these interventions will be told not only in Luzon but also in other parts of the country and even beyond.

Chief of Party LuzonHealth Project

iii List of Acronyms

4Ps Pantawid Pamilyang Pilipino DOHRO Department of Health PHN Public Health Nurse Program Regional Office PHO Provincial Health Office AHDP Adolescent Health and DQC data quality check Development Program PPFP postpartum family EBF exclusive breastfeeding planning AJA Adolescent Job Aid EO Executive Order PPIUD postpartum intrauterine ANC antenatal care device EPI Expanded Program on BatMC Batangas Medical Center Immunization PPM private practice midwife BDH Baliuag District Hospital FHSIS Field Health Service PPO Population Program Information System Officer BEmONC basic emergency obstetrics and newborn care FP family planning PTE post-training evaluation BHS barangay health station FPCBT1 Family Planning QCHD Quezon City Health Competency-Based Department BHW barangay health worker Training Basic Course QMC Quezon Medical Center BMC Bulacan Medical Center FP/MNCHN family planning/maternal, REP Reaching Every Purok BNHS Batangas National High School neonatal, child health and nutrition RHM Rural Health Midwife BPDH Bondoc Peninsula District Hospital GDH Gumaca District Hospital RHU Rural Health Unit BTL bilateral tubal ligation HC health center RMMMH Rogaciano M. Mercado Memorial Hospital BTL-MLLA bilateral tubal ligation by HSP health service provider minilaparotomy under local HUP Health Use Plan RPRH responsible parenthood anesthesia and reproductive health IUD intrauterine device CA cooperating agency SDN service delivery network LGU local government unit CHD City Health Department SMDH San Miguel District LMC Laguna Medical Center Hospital CHO City Health Office M&E monitoring and evaluation SMRS Supply Management and CHSR community health service Recording System record MCH maternal and child health SIGH Southern Isabela General CHT community health team MHO Municipal Health Officer Hospital CPR contraceptive prevalence rate MMR maternal mortality ratio TA technical assistance DepEd Department of Education NDP Nurse Deployment TB tuberculosis Program DJFMH Dr. Jose Fabella Memorial TKH Teen Health Kiosk Hospital NFP natural family planning TOT Training of Trainers DMMDH Doña Marta Memorial District NHTS National Household Hospital Targeting System TPC Teen Parents’ Clinic DMPA depot medoxyprogesterone OB/GYN obstetrician/gynecologist USAID US Agency for acetate International OSCE Objective Structured Development DOH Department of Health Competency Evaluation iv More Efficient, Focused, and Personal Usapan Improves Family Planning Uptake among Communities

Usapan, a US Agency for International Development- developed social and behavior change communication strategy, aims to address the socio-cultural and informational barriers that discourage women from using a family planning (FP) method. A Filipino word that translates literally into ‘conversation’, Usapan is essentially that—a conversation or discussion on reproductive health and FP that is followed by one-on-one counselling and service provision for participants deciding to use an FP method. With branding that connects with Filipinos who have a cultural penchant for small talks, more people are encouraged to attend and participate these sessions.

However, despite high attendance, Usapan participants’ uptake of FP was disproportionately low. According to some feedback from attendees and facilitators, the sessions were too long, and too much information was discussed. As a result, the participants became confused and tired and were unable “I appreciate how Usapan was made shorter and more direct to make a decision. In response, LuzonHealth tweaked the to the point. In comparison with other health information Usapan’s design to make it more efficient, more focused, and activities, Usapan’s key messages clearly address specific needs more personal. of women. Its activities are very interactive, making it easier for participants to understand and realize the importance of More Efficient spacing and limiting,” LuzonHealth reduced the length of an Usapan session from says a public health nurse who has been facilitating the 150 to 30 minutes. Shortening each session without sacrificing enhanced Usapan sessions in Angat, Bulacan. the quality of the discussion or omitting any key information on FP was key in overcoming the abovementioned challenges. As a result, facilitators can now devote more time to one- What LuzonHealth did was redesign and streamline the on-one counseling, which enables them to answer questions, Usapan’s contents by putting more emphasis on essential, assuage fears, and facilitate decision-making. easily understandable, and emotionally appealing information. More Personal To further improve the Usapan session, a maximum of three Aside from discussing the different FP methods, facilitators facilitators can now jointly conduct the session by dividing the now ask participants to reflect on their personal workload amongst themselves. circumstances. Then, they are asked to make smart decisions and take actions to improve their situation. More Focused Participants are now selectively targeted based on their expressed unmet need for either spacing or limiting. The Photo top. (center, holding Usapan materials) maximum number of participants was also reduced to 15 facilitates an Usapan session in the Rural Health Unit of Angat from 30. Municipality.

STORIES FROM THE FIELD 1 In addition, a person who practices FP is often invited to out the enhanced Usapan, a process that involved training speak about her experience and the benefits of FP. Having 121 health service providers in the abovementioned changes. such testimonies helps convince participants to practice FP As a result, all local government units in the province have at themselves. least one trained Usapan facilitator who regularly conducts the sessions. With all these changes, participants can now identify the particular method that is most responsive to their fertility As of September 2017, 649 Usapan sessions have been intentions. conducted in the province. Of these, 144 were integrated with the immunization service in health centers. In this Furthermore, the referral of participants who have chosen strategy, mothers queuing for their children’s immunization long-acting methods, such as intrauterine device and sub- are invited to attend an Usapan session. dermal implant, and permanent methods, such as ligation, was made easier through another LuzonHealth intervention called These sessions were attended by almost 2,000 women, the service delivery network. This intervention strengthens of these, nearly 1,800 decided to use a method. This is the linkages among health facilities, such as Barangay Health equivalent to a 93 percent conversion, the highest among the Stations, Rural Health Units, and hospitals. Thus, participants project’s 21 project sites. have access to a full range of FP methods. Moreover, the prevalence of contraceptive use in the Bulacan Walks the Talk province increased from 26 percent in 2015 to 29 percent in 2016. Although brought about by the interplay of different Bulacan Province is one of the project sites where the interventions, Usapan has greatly contributed to this increase. enhanced Usapan has been rolled out and has shown some impressive results. With assistance from the project and the In fact, the province is now looking into making Usapan one Department of Health Region III Office, the Province rolled of its key strategies in meeting the national target of having zero unmet need for FP by 2018. To achieve this goal, the Photo top. A midwife holds an Usapan in the Barangay Health province is scaling up the conduct of Usapan sessions and Station in Binuangan, an island barangay in Obando Municipality. increasing the number of trained facilitators

2 VOLUME I Integrating Family Planning, Antenatal Care, and Immunization Delivers Results

Underutilization of family planning/maternal, neonatal, child health and nutrition (FP/MNCHN) services persists in most Project sites. In Caloocan City, for instance, the contraceptive prevalence rate (CPR) was, on average, of 12.8 percent during 2010–2013, and antenatal care (ANC) coverage was only 64.6 percent in January–September 2013.

Improving FP/MNCHN service utilization, especially among priority population groups, required adopting proven and tested demand generation strategies. One such strategy introduced by LuzonHealth in its Project sites is the provision of FP and ANC messages to mothers when they bring their children to the health facility for immunization. This strategy, which is the integration of FP/ANC with the Expanded Program on Immunization (EPI), takes advantage of the opportunity during immunization days to inform both mothers with unmet need for modern FP methods and pregnant mothers about the ANC services provided in the health facility.

Groundwork Capitalizing on the many women who visit the facility “During my son’s immunization follow-up, I was briefly on EPI days, the Caloocan City Health Office (CHO), in interviewed, provided information on FP and counselled. On collaboration with the Department of Health-National that same day, I decided to be a DMPA acceptor. Looking Capital Regional Office and the US Agency for International back after more than a year now, I know that I made the right Development’s LuzonHealth Project, adopted the approach choice because if not, I may have gotten pregnant again and in 7 out of 47 health centers (2 each in Barangays Bagong that means I have three children to take care of at age 22.” Silang and Camarin and 1 each in Barangays 69, South says 22 years old, and a resident of Bagong Caloocan, and Grace Park West) where annual EPI coverage Silang, North Caloocan, shown here with her son as the midwife administers is at least 70 percent. Two health centers (Phases 1 and 10) her chosen FP method: depot medroxyprogesterone acetate (DMPA). in Bagong Silang were selected because the barangay, which is the largest in the Philippines, is also the most populous, with 243,890 residents accounting for 16.4 percent of the total FP-Maternal and Child Health logbook, which is a recording, population of Caloocan City. Immunization in Phase 10 is held reporting, and monitoring tool, particularly when FP is being on Mondays, Wednesdays, and Fridays, with approximately integrated in the services that they provide. This tool also 30–70 children immunized per day or 360–840 per month. helps program managers and nurse supervisors to monitor progress and provide supportive supervision when needed. In September 2013, five nurses, five midwives, and 25 barangay health workers (BHWs) or parent leaders from Since 2013, this strategy has shown encouraging results. the identified health centers were trained in the FP/ANC- Implementing it on the usual immunization day allowed EPI integration strategy. The health service providers (HSPs) greater interaction between HSPs and mothers, making and BHWs were taught to use a one-page questionnaire to the delivery of FP referral messages more natural and gather basic information from mothers and provide short FP spontaneous. Furthermore, mothers became more open to referral messages, as necessary. They also learned to use the and conscious of the importance of birth spacing/limiting.

STORIES FROM THE FIELD 3 the records of FP acceptors generated using the FP/ANC-EPI strategy to improve recording and monitoring.

Since the strategy was introduced in the Phase 10 Health Center in September 2013, a total of 983 mothers provided with FP messages during an EPI day were found to have utilized FP services and were listed as new acceptors. This figure represents only mothers using FP services within the first two months of the initial interview because additional time and effort are required for BHWs to track and monitor mothers returning to the facility for counseling after three months and beyond.

Based on Phase 10 Health Center’s reports, the contribution of the strategy to the total number of new acceptors for the entire barangay has increased through the years: 3.3 percent in 2013 (72 out of 2,203), 7.4 percent in 2014 (126 out of 1,705), and 13 percent in 2015 (250 out of 1,970). From January 2016 to September 2017, the Phase 10 Health Center generated 29 percent (535 out of 1,842) of Barangay Bagong Silang’s total The sharing of experiences and updates among the HSPs number of new acceptors using this strategy. from the seven facilities during their monthly meetings paved the way for the development of innovations leading to Early Lessons improved outcomes. At the onset of 2014, mothers provided The accomplishments of the Phase 10 Health Center in with FP messages who showed interest and readiness to Barangay Bagong Silang show that increasing the opportunities accept FP services were immediately referred to a midwife for personal contact with women to discuss FP also increases for counselling and provided with the FP method of their the likelihood of FP uptake. choice, thus avoiding missed opportunities. Mothers who A higher proportion of the total number of new acceptors in remained undecided were followed up and encouraged to the pilot barangays would have been attributed to the FP/ANC- return to the facility for counseling. EPI integration strategy if a recording system existed to track mothers initially provided with FP messages who eventually Phase 10 Experience returned for counselling after three or more months and In the second half of 2014, some adjustments were made decided to use an FP method. when most BHWs and parent leaders implementing the strategy were asked to vacate their posts prior to the As of December 2016, the seven facilities implementing the nationwide barangay elections. In Phase 10, for example, strategy reported a total of 1,460 new FP acceptors, and 30 before the immunization starts, the midwife segregates percent of this total was contributed by the Phase 10 Health mothers who are not yet practicing FP from pregnant women Center. and FP users. This approach proved to be difficult in the Given these accomplishments, the CHO has recognized the beginning because of time constraints, a lack of staff, and potential of this approach in reducing the unmet need for the demands of other programs. At times, efforts yielded modern FP. The CHO has also acknowledged the necessity very low and even zero results, but the numbers gradually of assessing overall outcomes and developing measures to increased. In 2015, one of the former BHWs of the Phase address setbacks encountered to further improve performance, 10 Health Center volunteered to help without receiving particularly in areas where targets and expectations have not any allowance. The Phase 10 Health Center also segregated been met. These realizations will motivate the CHO to move forward with its plan to scale up and replicate the strategy in Photos. A BHW (top photo) lists the names of mothers with other barangays. In the long run, this expansion is expected to unmet FP needs, while a midwife (bottom) counsels a mother on FP during an EPI day in the Phase 10 Health Center, Barangay improve service utilization, leading to the achievement of the Bagong Silang, North Caloocan. city’s FP/MCH goals and targets.

4 VOLUME I Enhanced Community Health Service Record Helps Direct Families to Needed Health Services

In 2011, the Department of Health (DOH) initiated the To address these concerns, LuzonHealth enhanced the organization and mobilization of Community Health Teams Community Health Service Record (CHSR) developed by a (CHTs) to guarantee that the poorest Filipino households in predecessor project (i.e., HealthGov). The CHSR is a simplified the community, identified through the National Household data collection, recording, and updating tool for community Targeting System (NHTS), are regularly visited by health volunteers who are tasked with collecting routine information providers as part of the government’s efforts to achieve on family planning (FP), maternal and child health (MCH), and Kalusugan Pangkalahatan or Universal Health Care. tuberculosis (TB) among poor households. The tool facilitates the systematic collection and updating of information for During the early stages of CHT mobilization, the DOH more than 20 households within a 12-month period. Its main trained community volunteers in the use of the Health Use objective is to ensure that all those who have unmet need Plan (HUP)/CHT monitoring logbook as a recording tool to for FP, MCH, and TB services receive the appropriate services assist the CHTs in tracking the health services provided to coupled with constant follow-up visits. The tool is also used NHTS families. However, an assessment of CHT operations for reporting results to midwives to facilitate the identification revealed some issues regarding the use of the HUP. For of household members, preparation of the supply side, and instance, the tool has too many loose forms, making its use costly and unsustainable. Key steps, such as filling out HUPs and consistently following up on families to ensure adherence to Photo top. A representative from DOHRO V (left) validates the the HUPs, are not being completely achieved. Health messages entries in the CHSR, while a community volunteer (right) from are not adequately delivered, and data updating is not done in Brgy Bonot, Legazpi City explains the CHSR recording process some areas. undertaken.

STORIES FROM THE FIELD 5 proper recording of services provided. The monthly visits and • The CHSR allowed easier follow-up/tracking of service updating of information also allow for the reporting of results delivery, health indicators, and defaulters on Expanded to the DOH Regional Offices (DOHROs) that are then Program on Immunization (EPI), FP, and TB because data consolidated by the DOH Central Office. are kept in one columnar notebook.

In March 2014, DOHRO V and the Albay Provincial Health • The CHSR facilitated tracking the CHTs’ contributions in Office (PHO), with assistance from the US Agency for terms of referrals on EPI, FP, and TB. International Development’s LuzonHealth Project, organized • The CHSR facilitated linking poor families with health a three-day training course on CHSR for trainers and facilities through regular house-to-house visits and helped community volunteers. The first day focused on the training address inequities in access to health services, particularly of trainers (TOT) that capacitated 35 nurses under the among underserved families in hard-to-reach areas, such Nurse Deployment Program (NDP) from the six provinces as those living at the foot of Mount Mayon and in island of Region V, 16 Development Management Officers of barangays. DOHRO V, and 10 Program Coordinators of the Albay PHO. • Continuing support of the DOHRO was secured to The second day was devoted to the TOT roll out for two sustain CHSR implementation through the annual representatives each from the City Health Offices (CHOs) procurement of columnar notebooks and columnar and Rural Health Units (RHUs) composed of Municipal headings and the provision of CHT mobilization funds. and City Health Officers (M/CHOs) and Nurse Program • Financial support for training, logistics, and mobilization was Coordinators from the 15 municipalities and three cities provided by the local government units (LGUs) at all levels or a total of 36 health service providers. On the third day, (municipal, city, and barangay), particularly in the Cities of 93 community volunteers, including six midwives from Legazpi, Ligao, and Tabaco. the CHOs/RHUs, were trained. The training convinced the province that province-wide adoption of the CHSR • CHTs have shown dedication even in the absence of will help systematize the recording and reporting of the regular mobilization funds. health needs and status of the NHTS families. Thus, from • The CHSR facilitated conducting regular monthly meetings September to December 2014, the CHSR training was rolled involving the midwife, NDP Nurse, and community out by DOHRO V. In total, 4,059 community volunteers volunteer, resulting in quality reporting, validated target were capacitated and provided the CHSR tool or columnar client list entries where FP clients needing further notebook, including columnar headings. attention are easily identified for follow-up, and the immediate resolution of gaps and concerns. In November 2015, a year after the full-scale adoption of the CHSR in Albay, a CHSR implementation review was In 2016, when the DOH ceased to implement the Kalusugan conducted with representatives (Public Health Nurse, NDP Pangkalahatan (the CHT system), the CHSR continued to be Nurse, Rural Health Midwife, and community volunteer) from used in the municipalities of Albay by BHWs. These BHWs the 15 municipalities and three cities. Among the important were originally the community volunteers tapped and trained benefits of the CHSR highlighted during the review were the to become CHT partners. In Daraga, in 2016, the number following: of current FP users increased to 10,990, and of these, 1,978 were referred by BHWs using this CHSR. As a result, the • The CHSR made the community volunteers more referral contribution of BHWs using the CHSR increased confident in performing their duties because reporting has from 12 percent in 2015 to 18 percent in 2016. been simplified; record keeping and data collection and analysis are more systematic; and accomplishments can be Some good practices in CHSR implementation have also gleaned at a glance. been noted. For instance, Tabaco City implemented the • The CHSR assisted the community volunteers to Tulay Alalay, wherein one-on-one coaching or mentoring is determine the priority health needs of NHTS families, provided by NDP Nurses to their respective community especially among women and children, resulting in better volunteers to improve the delivery of health messages. utilization of FP and maternal, neonatal and child health Legazpi City initiated the city-wide adoption of the CHSR and nutrition (MNCHN) services. and started training the Barangay Health Workers (BHWs) in the use of the CHSR to cover non-NHTS families. Ligao City has intensified the supervision of its CHTs and assigned CHT

6 VOLUME I Analyzing Trends of Key FP/MNCHN Accomplishments Relative to CHT/CHSR Contributions in Daraga

Indicator Dec Jan Feb Mar April May June July Aug Sept 2014 2015 2015 2015 2015 2015 2015 2015 2015 2015 FP-CU (No./Percent) 9495 9671 1961 10229 10276 10495 10503 10591 10665 10738 Estimate precent of the 176/ 266/ 734/ 781/ 1000/ 1008/ 1096/ 1170/ 1243/ Accomplishments REFERRED by CHT 9671 9761 10229 10276 10495 10503 10591 10665 10738 Partners implementing CHSR Percent Contribution of CHSR to the 2% 3% 7% 8% 10% 10% 10% 11% 12% Accomplishments: Very Significant (VS) = 30% or more SSSSS Significant (S) = 10 to 29% A significant increase in current FP users in Daraga, Albay was attributed to the CHSR, as reported during the implementation review. leaders in every barangay. It also developed a monitoring tool aligned with the DOHRO reporting format, thus facilitating The recommendations and next steps identified included the timely submission of required reports. CHSR monitoring the following: and supervision were enhanced to improve program • Reorientation of CHTs in completing the DOH- oversight. CHSR Reporting Form No. 4 to ensure that a standard format is used for easier validation and Promising results have already been noted in the consolidation of accomplishments, thus facilitating the implementation of the CHSR for a short period of time. tracking of CHTs’/CHSR’s contributions to overall Given the positive outcomes and feedback, Albay is trends in the key indicators; determined to sustain its implementation. In this regard, areas needing improvement were identified to guarantee that the • Strengthening of the supervisory skills of NDP CHSR serves its purpose by ensuring that it remains a source Nurses and Rural Health Midwives to ensure that of accurate and reliable data. proper mentoring and guidance are provided in the preparation and submission of monthly reports; The implementation of the CHSR in Albay is still far from • Training of BHWs in CHSR and city/municipal-wide perfect. Nevertheless, these proactive measures, once in place, implementation of CHSR to cover non-NHTS families; are expected to yield greater benefits and have long-lasting impacts on improving CHT operations toward ensuring that • Provision of continuing supportive supervision to all Filipino families have access to and are utilizing basic health CHTs, particularly to those who were recently care services. To quote a 28-year-old onboarded (e.g., assistance in understanding technical mother of five from Purok 6, Sto. Cristo, Tabaco City: terms and delivering key health messages); “Every member of my family can feel the focused, timely • Amendment of the CHSR headings to include other health conditions to align the CHSR with the LGU and effective provision of quality health services by the scorecard and thus secure the LGUs’ commitment to government. During times when we fail to make it to the provide stable financial support to CHT members, health center, the CHT partner and the midwife either in addition to the mobilization funds provided by come to fetch us or bring the services to our home, e.g., the province and DOHRO, to avoid out-of-pocket immunization for our children and supplies for our chosen FP expenses; and method.” • Provision of a printed CHSR to eliminate the need for the CHTs to manually cut and paste the headings and, thus, avoid confusion and ensure proper recording.

STORIES FROM THE FIELD 7 Provincial Government and Partners Work to Provide Families with Timely and Appropriate Health Care

For most women, childbirth is perhaps the most wondrous and beautiful experience through which new life is brought into the world. However, it is also a risky and dangerous undertaking. Aside from the medical complications that may arise during pregnancy and delivery, the risks are increased by this country’s fragmented health system, which deprives women, particularly the poor, of the prenatal and postpartum care they need.

The dichotomy between public and private health services, the dissociation between general and specialist health service providers, and differences between national and local health available service delivery capacities of health care facilities and care policies and across geopolitical boundaries have led to providers. the fragmentation of health services. The second phase was the drafting of the network’s four In Batangas Province, reforms and improvements are taking operative documents. The first document is the Referral root with the August 2016 establishment of the Service Guidelines, which defines the roles and responsibilities of each Delivery Network (SDN), an initiative to improve and SDN member or facility to the clients entering the network strengthen service delivery and ensure continuity of services and articulates that each client is the accountability of the for families across geographical and jurisdictional boundaries. entire network. The second is the Service Providers’ Agreement, It seeks to address the three delays that could lead to deaths which outlines the commitments of the SDN members. The among pregnant women and girls: delays in deciding to seek third document is the Monitoring and Evaluation Guidelines, appropriate care, delays in reaching the appropriate facility, and which creates a monitoring and evaluation (M&E) system delays in receiving adequate health care. to determine how the referral system is working on the ground. In Batangas, there are three M&E tools: the referral Primarily directed at improving family planning and maternal, slip, the referral logbooks, and the data capture tools. The last neonatal and child health and nutrition (FP/MNCHN) document (i.e., Categorization of Referrals), which is unique to services, this network creates a referral system among all LuzonHealth-assisted SDNs, helps facilitate the matching of member health facilities in the province to ensure that clients patients’/clients’ conditions with appropriate health facilities receive appropriate and timely care at the appropriate and service providers. facility. For instance, a Rural Health Unit (RHU), which has a limited capacity, should refer high-risk patients, such as teens The last phase, which is currently ongoing, is monitoring the or hypertensive pregnant women, to district hospitals or functionality of the referral system using the abovementioned provincial hospitals where they can receive specialist care. project-developed tools, particularly in tracking the number and categories of outgoing/incoming and accepted/declined The US Agency for International Development’s LuzonHealth referrals. Through this activity, a purposive assessment in terms Project assisted the Provincial Government in setting up the of service delivery capacities based on recorded outgoing network in three phases. The first phase was securing buy-in referrals, identification of the facilities receiving most of the from the potential stakeholders in the province and enlisting the cooperation of the technical staff in conducting a rapid Photo top. The heads of member facilities of the Batangas assessment of the existing referral system, defining the need SDN during the signing of the Service Providers’ Agreement in and purpose of the network, and mapping and assessing the August 2016.

8 VOLUME I referrals, and assessment of service delivery capacities in Despite these achievements, some areas for improvement terms of the volume of referrals received by each member were identified during the initial monitoring and facility visits facility are possible. conducted. These include ensuring complete utilization of the M&E tools by all member facilities, resolving a few cases During its first 10 months of operationalization, the of uncoordinated referrals, and coordinating the referrals Batangas SDN has shown some impressive results. Of the from non-member facilities and neighboring provinces, 2,267 outgoing referrals, 2,255 (99.5 percent) were accepted. such as Laguna and Oriental Mindoro, among other issues. Of these, 49 percent were emergency cases needing sub- The LuzonHealth Project continues to support Batangas specialist care, and 32 percent were urgent and needed Province as it strives to further improve and enhance its specialist care. In total, 193 FP referrals were recorded: 86 for FP/MNCHN SDN. postpartum intrauterine device, 84 for bilateral tubal ligation, and 23 for depot medroxyprogesterone acetate.

Aside from these metrics, anecdotal evidence also points to the successful implementation of the network. “Before the SDN became functional, we were already referring patients for specialist care to the other equipped hospitals but it was difficult because our referrals were not prioritized so I had to spend time convincing and sometimes even imploring other hospitals to accept our referrals. Kanya-kanya thinking was prevailing. With the SDN, referring high-risk patients to the district or other bigger hospitals has become easier, simpler and faster because each patient is the accountability of the whole network,” said , a nurse at the Taysan RHU.

STORIES FROM THE FIELD 9 A Provincial Hospital Gears Up to Provide Family Planning Services for the First Time

services and the creation of an FP Core team headed by an FP Point Person, , who is an obstetric nurse. It also made available all FP methods, including fertility awareness (natural methods), the lactational amenorrhea method, postpartum and interval intrauterine devices (IUDs), bilateral tubal ligation, condoms, pills, and injectable.

With project assistance, a series of training courses was conducted to ensure that the hospital had the human resource complement needed to successfully offer the abovementioned services. l and four other health service providers (HSPs) were trained in interval and postpartum IUD (PPIUD) insertion and removal, while two obstetricians were given a refresher course on Bilateral Tubal Ligation by Minilaparotomy under Local Anesthesia (BTL-MLLA). One of US Agency for International Development (USAID)- LuzonHealth’s main thrusts is the revitalization of family , who oversees the efficient and effective provision planning (FP) services in hospitals, which have, in recent of FP services in the hospital, was also trained in monitoring, years, weakened because of the devolution of health services. recording, and reporting FP performance using tools such Recognizing that hospitals are important contact points as as the FP hospital registry. To avoid any commodity stock- many postpartum women decide to use an FP method while out, the hospital also adopted the Supply Management and recovering from delivery, the project has provided technical Recording System, a logistics management tool developed assistance to strengthen FP services in three hospitals in by a predecessor USAID project. An FP clinic where clients Laguna Province. are counseled and certain FP procedures are conducted was set up. This clinic is now equipped with a delivery table, The Laguna Medical Center (LMC), a provincial hospital a mayo table, a gooseneck lamp, an office table, side tables, a receiving referrals from lower-level health facilities in the weighing scale, filing cabinets, a blood pressure apparatus, and province, is one of these hospitals (the other two are the FP instruments. San Pablo District Hospital and Dr. Jose Rizal Memorial Hospital). In partnership with the Provincial Health Office To reach all potential clients within the hospital, an in-reach and Department of Health Regional Office IV-A, the project strategy has been adopted. Under this scheme, an assigned assisted the LMC management in formulating its policies on staff conducts regular FP classes and distributes brochures organization, operation, recording and reporting, in-reach and flyers to potential FP clients in the obstetrics, outpatient, activity, and financing. and recovery wards. FP has also been included in the list of available hospital services posted in the hospital entrance As an initial step, the hospital management issued a Hospital lobby. Directional signage leading to the FP clinic has been put Memorandum providing for the strengthening of its FP up in conspicuous locations around the hospital.

Furthermore, HSPs were oriented on the process for utilizing Photo top. A LuzonHealth trainer (extreme right) observes an PhilHealth reimbursements to improve the financial status of obstetrician of the LMC perform the BTL-MLLA procedure during a post-training evaluation. the hospital.

10 VOLUME I “With the Project’s help, we became more effective in counseling our clients as evidenced by the increase in the number of acceptors,” says .

From January to September 2017, 4,763 clients were provided with FP information through the in -reach strategy. Of these, 1,098 (23 percent) were counseled, 774 of whom became FP acceptors: 310 had caesarian section BTL, 172 underwent BTL-MLLA, 283 opted for IUD insertion, 2 chose pills, and 7 chose to receive an injectable. This number far exceeds the 10 FP acceptors recorded by the hospital in 2015. With a monthly average of 8 to 12 claims for PhilHealth reimbursement in 2016, the hospital was able to receive PHP 400 thousand for BTL cases. With the refresher training in BTL-MLLA and PPIUD, it is anticipated that PhilHealth reimbursements will increase.

Photo above. The counseling nook at the FP clinic of LMC.

STORIES FROM THE FIELD 11 Enhancing the Role of Hospitals in Increasing Family Planning Use

“I won’t need to worry anymore about having another ‘accidental’ pregnancy.’ I have always wanted to avail of BTL procedure but I was worried that it might be expensive. It’s a good thing that it’s free in this hospital,” said Helping Hospitals Avoid Missed Opportunities The introduction of BTL-MLLA in RMMMH was made possible by the US Agency for International Development (USAID)/LuzonHealth Project’s FP in Hospital technical assistance (TA) program.

Several studies have shown that women who have just given birth are more likely to avail themselves of an FP method to either delay or avoid future pregnancies. Hence, the availability of FP services in hospitals is critical in satisfying this need or desire to practice FP.

Although FP services are still available in some public hospitals, they are not mainstreamed, and only limited FP methods are offered. This results in missed opportunities as women, especially those who want to utilize long-acting family lives in a government relocation reversible and permanent methods, are either only able to site for Metro Manila’s informal settlers in Pandi Municipality. access temporary methods or, worse, unable to use any After relocating there in 2014, she was encouraged by a method at all. barangay health worker to practice an a family planning (FP) method. She wanted to be ligated, but she could not afford Aligned with the current administration’s health agenda, the out-of-pocket cost of BTL by spinal anesthesia, which which lists strengthening FP services in hospitals as a priority, was the only ligation procedure offered in public hospitals at the project provides assistance to 52 hospitals that were that time. Having no other choice, she opted for an injectable targeted using a baseline assessment of their FP capacities and contraceptive. willingness to improve their FP services. The project also used geographic location as a criterion to ensure equal access to Every three months, she goes to the Rogaciano M. Mercado all localities and maximize impact. Memorial Hospital (RMMMH) to have her shot. During her last visit, she was counseled by the hospital’s FP coordinator In Bulacan, the project has been helping RMMMH, Bulacan who informed her that BTL-MLLA, a procedure covered by Medical Center (BMC), Baliuag District Hospital (BDH), PhilHealth, is already available in the hospital. and San Miguel District Hospital (SMDH) improve their FP services. They serve as referral hospitals in the province’s Photo top. a 34-year-old mother of six, four congressional districts and are active members of the receiving a shot of injectable contraception as a temporary FP method while she waits for her scheduled Bilateral Tubal province’s FP/Maternal, Neonatal and Child Health and Ligation by Mini-Laparotomy under Local Anesthesia procedure Nutrition Service Delivery Network. (BTL-MMLA), a permanent FP method that was only made available in July 2016 at the Rogaciano M. Mercado Memorial Hospital (RMMMH) in Santa Maria Municipality, Bulacan Province.

12 VOLUME I Weaving Demand, Supply, and Policy Approaches Together The FP in Hospital TA integrates the project’s three-pronged approach to increasing the demand for and improving the supply of FP services and strengthening health policies. Increasing demand entails training hospital health service providers (HSPs) in the in-reach strategy whereby they conduct regular FP classes and distribute brochures and flyers to ensure that all potential FP clients in the obstetrics, outpatient, and recovery wards are informed about the different FP methods and services they can avail themselves of in the hospital. Meanwhile, improving supply involves training selected HSPs in different FP skills, such as counseling, IUD insertion/removal, and BTL-MLLA.

To institutionalize these initiatives, the project is also assisting hospital management in drafting policies that provide implemented to reduce the number of missed opportunities for budget allocation for FP services and the creation in the hospital. of an FP core team to oversee efficient and effective FP service provision in the hospital. They were also assisted As a result of these interventions, 607 women were recorded in completing documentary requirements for PhilHealth to have been provided with FP information from January to accreditation so that both HSPs and patients can benefit from September 2017, 563 (93 percent) of whom underwent one- this program. on-one FP counseling. Of these, 171 (30 percent) became FP users. In the same period, the share of long-acting reversible Each hospital is also encouraged to set up an FP clinic: a and permanent methods (i.e., postpartum IUD and BTL- dedicated room or space where counseling and service MLLA) stood at 87 percent, 10 percentage points higher than provision are conducted in privacy. Additionally, HSPs that recorded in the first half of 2016. This increase indicates are trained in recording, monitoring, and reporting FP that more women are shifting to permanent methods. performance using project-developed tools such as the FP hospital registry and in establishing an FP logistics The SMDH Experience management system called the Supply Management and Serving as a referral hospital for three municipalities, the Recording System (SMRS). SMDH in San Miguel Municipality records an average of 52 deliveries per month. Before the project started The RMMMH Experience its interventions in 2013, FP services were likewise not The RMMMH is a Level 1 district hospital receiving referrals mainstreamed. Although some HSPs were already trained not only from Sta. Maria Municipality, where it is located, in some FP competencies, no one had been trained in but also from five other municipalities and two cities in BTL-MLLA. Additionally, no standard recording and logistics Bulacan. It serves 40 percent of the province’s population management systems were in place. and has an average of 250 deliveries per month. Before the project started its intervention in 2013, FP services were not The project trained an obstetrician in BTL-MLLA to enable mainstreamed because none of the hospital staff was trained the hospital to offer this method. Selected SMDH personnel in basic FP competencies or procedures. Additionally, no were also trained in the SMRS to prevent commodity stock- standard FP recording system existed. outs. To enable the hospital to properly account for its FP accomplishments, selected staff were trained in FP recording The project trained two midwives in FP counseling, and an and reporting using project-developed tools. obstetrician was trained in BTL-MLLA. Chief of Hospital , who also chairs the FP committee, issued an Order providing for the creation of an Photo top. FP Coordinator of the SMDH, FP core team. In addition, an in-reach strategy has also been counsels a prospective FP client.

STORIES FROM THE FIELD 13 To date, only interval IUD services are available in the hospital, although plans are underway for training an obstetrician in BTL-MLLA. From January to September 2017, 1,490 women were provided with FP information through the in-reach strategy, 894 (60 percent) of whom underwent one-on-one FP counseling. Of these, 388 (43 percent) became FP users. Additionally, 153 IUD cases have been reimbursed by PhilHealth.

Laying the Foundation at BMC The BMC in Malolos City is a provincial hospital that serves as the end-referral facility for the entire province. In a month, it records 580 deliveries. Although FP services were already offered in the hospital before the project started, only one trained HSP was rendering FP counseling and services to all The management also issued a hospital order creating an FP clients in the hospital. Furthermore, no standard FP recording core team headed by an FP point person. It also geared up system was in place to track FP clients served, and no logistics for PhilHealth accreditation to qualify for reimbursements for management system was established to track the status of FP maternity services provided. commodities.

With these interventions, 595 women were recorded to Since 2013, the project has been helping the hospital lay the have been provided with FP information from January to foundation for the FP in Hospitals initiative. The TA provided September 2017, 387 (65 percent) of whom underwent one- included orienting the hospital management on how to on-one FP counseling. Of these, 124 (32 percent) became FP strengthen FP services, training four HSPs in FP counseling, users. In the same period, 49 IUD cases were reimbursed by and putting in place a recording and reporting system. PhilHealth. However, mainstreaming FP services has been slow and The BDH Experience difficult. Nonetheless, the project expects that FP will be The BDH in Baliuag Municipality serves as a referral prioritized with the signing by the President of Executive hospital for six municipalities in the province. It records Order No. 12 on achieving zero unmet need for modern FP a monthly average of 118 deliveries. When the project by 2018. Plans to improve in-reach demand generation and started its interventions, no standard recording and logistics train more HSPs in BTL-MLLA are in the pipeline. management systems were in place. From Zero to Three Heroes The project oriented the hospital management in With these interventions, the project helped reverse the strengthening its FP services. An HSP was trained in Family situation in Bulacan. From having no trained HSPs in BTL- Planning Competency-Based Training Level I, while selected MLLA, there are now three HSPs who are health heroes staff were trained in in-reach demand generation and FP in their own right to women like who want to recording and reporting using project-developed tools. limit childbearing through BTL-MLLA. Although admittedly Assistance in complying with the documentary requirements much work is still needed, it is worth noting that an increasing for PhilHealth accreditation was also provided. number of postpartum women in Bulacan are being reached by FP information and can access their chosen method. Photo top. BDH personnel, together with a LuzonHealth field staff, review the hospital’s FP records.

14 VOLUME I Increasing Access to Comprehensive Family Planning Services in a Public Hospital

Southern Isabela General Hospital (SIGH), a Department of Health (DOH)-retained hospital located in Santiago City, serves as a referral facility for nearby local government health facilities for various health services, including maternal and child health (MCH) and family planning (FP). It caters not only to residents of Santiago City but also to those living in 12 neighboring towns: 10 in Isabela and 1 each in the Quirino and Nueva Vizcaya Provinces. Given its strategic location, the LuzonHealth Project, in coordination with the DOH Regional Office II, has provided technical assistance to the hospital to enable it to offer a broad range of FP methods, create FP itinerant teams capable of responding to the needs of poor communities, and develop into a referral and training center for long-term and permanent FP methods, specifically, bilateral a 25-year-old BTL acceptor from the Municipality of San tubal ligation by minilaparotomy under local anesthesia Mateo says, (BTL-MLLA) and no-scalpel vasectomy. “My husband and I have decided a long time ago for me In this regard, five doctors from SIGH were trained in BTL- to undergo BTL. However, BTL services are not available MLLA in November 2014, and four were trained in progestin- at the RHU and the last time that an itinerant team visited only sub-dermal implant (three in November 2014 and one San Mateo was still in 2005. We were therefore very glad in March 2015). One nurse and one midwife underwent the when we learned that the SIGH now offers BTL services and Family Planning Competency-Based Training Basic Course immediately went to our RHU for screening and referral.” (November 2014) and interval intrauterine device (IUD) training (October 2014), respectively. The doctors trained in BTL-MLLA were certified in February 2015 after undergoing as a referral center in the service delivery network for FP a post-training evaluation. services, particularly for long-acting reversible contraceptives/ permanent methods, must be further strengthened. On May 14, 2015, the SIGH officially launched its FP services in line with the DOH’s efforts to make comprehensive FP Apart from being a referral center for FP services, the SIGH services available in public hospitals in support of Universal has also developed into a training hospital for BTL-MLLA and Health Care. The SIGH is the first DOH-retained hospital in PPIUD insertion. These courses are open to service not only the region to make available comprehensive FP services, from providers from the Province of Isabela but also those from which an estimated 78,384 women of reproductive age and other provinces in Region II and nearby regions. 8,309 women with unmet need for FP to limit childbirths are Soon, SIGH will organize an itinerant FP team to provide FP expected to benefit. services to those in remote areas of the province where the As of April 2017, SIGH has provided FP services to 1,181 unmet need for FP is high. women as follows: BTL (584), interval IUD (21), postpartum IUD (PPIUD) (547), and injectable (29). Photo top. A doctor participant performs the BTL-MLLA To be able to respond to the unmet need for FP, especially procedure on a client under the close supervision of a LuzonHealth trainer during the practicum phase of the BTL- for limiting births, for women like the role of SIGH MLLA training.

STORIES FROM THE FIELD 15 SIGH has established the following policies and guidelines to ensure an efficient referral system for BTL-MLLA services:

1. The referring unit shall ensure that the FP Form 1 and 7. After the procedure, the other half of the referral form Informed Consent Form are both properly completed shall be returned to the referring unit and indicate the and signed by the client in duplicate. One copy shall be procedure done and instructions for the clients, among retained by the referring unit and the other, submitted other information. to the FP Coordinator of SIGH. 8. Post-operative complications shall be documented by 2. The referring unit shall ensure that clients referred are the referring unit and reported immediately to SIGH. eligible for the procedure. 9. Services shall be free of charge. For PhilHealth members, 3. BTL shall be performed within 7 days after delivery for take-home medicines may be provided by SIGH but postpartum cases and at least 42 days onwards after only upon submission of the Member Data Record and delivery for interval cases, for as long as pregnancy is PhilHealth ID. For non-PhilHealth members, a Certificate ruled out. of Indigency issued by the Barangay Captain where the 4. The referring unit shall ensure that clients are client resides shall be submitted. Take-home medicines accompanied by adult health care providers and/or shall be provided by the referring unit. For clients relatives. without PhilHealth papers or Certificate of Indigency, payment shall be required based on the guidelines set by 5. The referring unit shall advise clients to bring a bottle of SIGH. water and cup noodles. 10. Transportation of the clients from their residence to 6. BTL services shall be provided every Thursday for not SIGH and back shall be the counterpart of the sending more than five clients. The SIGH FP Coordinator shall local government unit. screen and schedule the clients. Postpartum cases may be scheduled as necessary.

16 VOLUME I Reaching Out to Underserved Communities

The utilization of family planning/maternal, neonatal and child health and nutrition (FP/MNCHN) services in the City of Malabon has improved, as reflected by the increasing proportion of reproductive-age women using an FP method (32.6 percent as of March 2016 compared to 20.3 percent in January 2015). Additionally, the rates of facility-based deliveries, skilled birth attendance, and exclusive breastfeeding (EBF) practice now stand at 65.3 percent, 68.9 percent, and 63.3 percent, respectively.

However, Malabon City is not one to sit on its laurels. These accomplishments have only served to further motivate its health workers to find more effective ways of reaching clients with unmet need, especially those in underserved and poor communities where there are many program defaulters or drop-outs.

In February 2016, Malabon City expanded the types of health services delivered to the communities using the Reaching Every Purok (REP) strategy. Prior to February 2016, the REP strategy had been adopted only to increase the coverage of Soon after, a consultative meeting with health center the Expanded Program on Immunization. physicians and nurses was held to discuss the details of the First implemented in Purok Gabriel, the poorest purok in initiative. This was followed by an orientation for 50 Barangay Barangay Hulong Duhat, the expanded REP, which included Health Workers (BHWs) and Community Health Teams FP/MNCHN services, generated 10 new FP acceptors— (CHTs) on household master listing, information giving, and injectables (4), intrauterine device (IUD) (2), and bilateral the identification of target clients with unmet need for FP and tubal ligation (BTL) (4)—bringing the total number of current MNCHN using the CHT profiling form. users in Purok Gabriel to 26. Actual household profiling was conducted on March 14–25, With the relative success of the initial run, during the March 2016 and covered 1,777 households in 21 difficult-to- 2016 performance assessment meeting of the City Health reach puroks/areas. Those identified with unmet need were Office (CHO) with health center midwives, it was decided included in the midwives’ master list and invited to attend the that the REP strategy would be adopted by the other planned REP event. The health team enlisted the commitment 20 barangays to further expand the reach of FP/MNCHN of barangay officials, purok leaders, and parent leaders of the programs, with assistance from the LuzonHealth Project. Pantawid Pamilyang Pilipino Program (4Ps) to ensure the participation of target clients. Purok and barangay officials a 32-year-old mother of two (aged five provided tables, chairs, and tents for the venue. Additionally, and two), was one of the women profiled and included in the the 4Ps leaders assisted the BHWs in mobilizing and/or target client list. fetching clients on the day of the REP event. “The profiling process helped me decide to using an The first city-wide implementation of the expanded REP injectable. I think the process is now more convenient strategy coincided with the celebration of International because counseling and services are provided right here in our street,” said Photo top. A BHW provides information on FP to mothers during a REP Pactivity conducted in Block 8, Barangay Longos

STORIES FROM THE FIELD 17 of the 336 clients with unmet need for FP, 180 (54 percent) were informed/counseled, and of these, 80 percent were provided with the method of their choice: condoms (48; 27 percent), pills (66; 37 percent), injectable (19; 10 percent), and NFP (12; 7 percent). Thirty-five clients were referred for either IUD insertion (15) or BTL (20). The immunization gains overshot the target by 15 percentage points. Health center physicians instructed their BHWs to follow-up on clients referred for BTL and IUD insertion during the two REP events and to submit their reports by August 2016

For both REP activities, actual data for immunization, pre- and post-natal consultations, and EBF counseling exceeded the targets because families and individuals who were either Women’s Month on March 29, 2016. The theme was not profiled or hesitant to participate during the household “Kapakanan ni Juana, Isama,” and 21 poor puroks in master listing decided to participate in the activity and availed 21 barangays were covered. A team composed of a health themselves of the services they needed. Passersby from center physician, nurse, midwife, and BHWs/CHTs assigned neighboring puroks who witnessed the ongoing activity or to the barangay conducted medical consultations, lectures, who saw the REP banner posted at least a week earlier also counseling, immunization, and deworming, among other utilized services. Current users, particularly those buying pills services. Mothers were gathered for health classes and from drugstores, were provided a one-cycle supply and, along counseling on FP, MNCHN, STI/HIV/AIDS, and tuberculosis. with new acceptors, were recorded and listed for follow-up. It is worth noting that those in the master lists who failed to come were either fetched from their homes or followed-up/ Given the encouraging results of its initial implementation visited and provided the needed services. in 2016, REP is currently being undertaken every month in the 21 barangays of Malabon. Furthermore, the enhanced Data from 20 of the 21 puroks covered show that out Usapan is now integrated into the strategy; thus, clients who of the identified 334 clients with unmet need for FP, 287 are eligible for MNCHN and FP services who were identified (86 percent) were informed/counseled, and of these, during the household profiling but have not yet availed approximately 80 percent were provided with the method themselves of such services anywhere have been invited to of their choice: condoms (52; 18 percent), pills (129; 45 come to the venue of the scheduled REP to attend a more percent), injectable (33; 11 percent), and natural FP (NFP) focused discussion on MNCHN and FP based on their (15; 5 percent). Clients opting for IUD (19; 7 percent) and present conditions and reasons for attending the event. BTL (39; 14 percent) were referred to health facilities. Of the 284 children needing immunization, 266 (93 percent) were The CHO, through its 21 health centers, is taking proactive served. These figures do not include the accomplishments measures to avoid gaps in implementation. In June 2016, of Barangay Longos, the most populous barangay in the City, the health centers submitted to their respective Barangay because the summary report containing the breakdown of Councils a proposal for the provision of support for services provided that day was lost. conducting regular household profiling and follow-up visits through logistics support, BHW honorarium standardization, On May 31, 2016, during the observance of Safe and the deployment of additional BHWs. Effective January Motherhood Month, the second REP activity was organized 2018, all barangays will allocate a budget for REP. and covered another 21 priority puroks (i.e., difficult-to-reach areas, those where transportation costs are quite high, and Todate, all 155 BHWs have been trained and supported to those with a high incidence of poverty). A total of 1,637 perform house-to-house master listing for the entire city to households were covered during the profiling conducted on identify priority areas for subsequent REP activities. With the May 16–27, 2016. Reports from all 21 puroks showed that expanded implementation of the REP strategy, the profiling of National Household Targeting System (NHTS) families is also Photo top. A health service provider counsels a pregnant mother expected to improve. So far, only 11,500 of the 40,000 NHTS during a REP activity conducted in Purok Gozun, Barangay families have been profiled since 2008. Tonsuya

18 VOLUME I Itinerant Team Brings Family Planning Services Closer to Women

“I already have peace of mind after undergoing BTL, especially when I think about my children’s future because getting pregnant again at this age is very risky. I have been taking contraceptive pills for the past four years, and within those years, I conceived twice and I am now taking care of two children aged 3 and 2. If I didn’t get ligated, it is possible that I will get pregnant again anytime with either my life or my child’s life in danger because at my age, anything can happen. I am also thankful that my relationship with my husband improved a lot,” says , a 41-year-old mother of five from the Municipality of Unisan, Quezon.

In Quezon Province, demand for long-acting permanent family planning (FP) methods has been growing, particularly by the Dr. Jose Fabella Memorial Hospital (DJFMH). The for bilateral tubal ligation (BTL) based on the FP Form 1 PHO and LuzonHealth organized a two-day, free BTL service records available in most Rural Health Units (RHUs) and provision activity to conduct a PTE of the skills of the four out-patient departments of provincial, district, and municipal OB/GYNs. Two of them were found to be proficient and hospitals. However, the public hospitals have been unable to were certified as BTL service providers after the PTE. provide BTL services for more than a decade. For instance, although Quezon Medical Center (QMC) has four BTL- To pursue the creation of a functional BTL itinerant team, trained obstetrician/gynecologists (OB/GYNs), none of the PHO collaborated with four district hospitals—Doña them have engaged in actual service provision because they Marta Memorial District Hospital (DMMDH) in Atimonan, failed to undergo the post-training evaluation (PTE) and are, Bondoc Peninsula District Hospital (BPDH) in Catanauan, thus, not yet certified as service providers for BTL. As of Magsaysay District Hospital in Lopez, and Gumaca District September 2013, the Field Health Service Information System Hospital (GDH) in Gumaca—to identify potential members (FHSIS) recorded 7,366 BTL acceptors, but these were of the team. A subsequent training and PTE in BTL-MLLA was mostly contributed by private hospitals performing spinal or conducted between March and April 2014 for four OB/GYNs epidural BTL and the Marie Stopes itinerant team servicing from these hospitals, two of whom were eventually certified. selected local government units. These two are now part of the three-person itinerant team actively performing BTL in their respective hospitals and During the Inter-Cooperating Agency (CA) provincial in other areas where there is demand for BTL services. coordination meeting in August 2013, the Provincial Health Completing the three-person team is a resident OB/GYN Officer (PHO) expressed his desire for the province to have from QMC who was trained and certified in December 2014. an itinerant team that can provide BTL services, especially in geographically isolated and disadvantaged areas. With Prior to the aforementioned BTL-MLLA training and PTE assistance from LuzonHealth, preparations for the creation of for the itinerant team, a facility assessment was conducted an itinerant team commenced immediately with a series of to determine the readiness of the hospitals to provide the consultative workshops and planning sessions. service. Selected health staff also underwent the Family In October 2013, LuzonHealth conducted a refresher course Photo top. BTL acceptors rest in the QMC recovery room in the on BTL by Minilaparotomy under Local Anesthesia (BTL- presence of their husband or relatives, while two hospital staff MLLA) for the four OB/GYNs of QMC previously trained prepare other clients for the procedure.

STORIES FROM THE FIELD 19 With the news that BTL is already available, increasing numbers of women have expressed willingness to undergo the procedure. The itinerant team’s outreach activities and RHUs’ information dissemination efforts translated into increased demand among women in nearby municipalities.

From December 2013 to August 2017, the itinerant team was Planning Competency-Based Training Basic Course to enable able to provide BTL services to 366 women from 11 hospitals: them to provide effective FP counselling and assistance pre- QMC (46), DMMDH (96), Claro M. Recto Memorial District and post-operation. Hospital (38), GDH (19), Maria Eleazar Memorial District Hospital (6), BPDH (74), Candelaria Municipal Hospital (42), Part of LuzonHealth’s technical assistance to the PHO in Mauban District Hospital (18), Magsaysay Memorial District creating an itinerant team is facilitating the establishment Hospital (10), Unisan Medicare Community Hospital (9), and of linkages between and among the PHO and its partners. Guinayangan Medicare Community Hospital (8). The number As a result, when the itinerant team started its outreach would have been higher if sufficient stocks of Demerol had activities, two bottles of Demerol, which could serve 60 been available on the market. Demerol is an opioid narcotic clients, were provided by DJFMH. Additionally, Department of pain medication used as anesthesia in BTL procedures. Provincial Health Regional Office IV-A provided surgical supplies, such FHSIS data show the number of BTL acceptors has increased as intravenous fluids and needles, and RHU staff acted as from 7,366 in September 2013 to 9,986 in December 2016. Operating Room assistants. Measures to ensure the provision of regular BTL services have Prior to the conduct of outreach activities, the following been initiated by members of the itinerant team. For instance, parameters or guidelines were set by the itinerant team: the itinerant team leader from DMMDH has designated Tuesday 1. The referring RHU/facility shall be responsible for client as “BTL Day” and has either assisted clients in PhilHealth generation and shall ensure proper coordination with the enrollment or facilitated clients’ access to the provincial itinerant team in scheduling BTL services. government’s financial assistance program. 2. The referring RHU/facility shall ensure that clients have Two of the four other hospitals serving as BTL hubs (i.e., undergone proper counselling to make them understand DMMDH and Magsaysay Memorial District Hospital) have and accept the BTL-MLLA procedure, and the FP Form 1 also set a specific day for BTL services to avoid missed and Informed Consent Form should be signed. opportunities. Greater awareness about the benefits of 3. The referring RHU/facility shall assist non-PhilHealth clients PhilHealth reimbursements and the provincial government’s in either securing PhilHealth membership or accessing funding support are also providing impetus for the itinerant the province’s medical assistance program, which is team. Currently, a comprehensive presentation on the revenues readily available upon endorsement by either the PHO or or incentives that can be generated from PhilHealth is being Provincial Social Welfare and Development Office. developed and disseminated to encourage other services 4. Health staff of referring facilities shall assist the itinerant providers to be trained in BTL-MLLA. These strategies will team during pre- and post-operation procedures. hopefully expand the itinerant team and secure the cooperation of other district and community hospitals, such as the Candelaria 5. The referring RHU/facility shall conduct comprehensive Municipal Hospital, to lessen congestion at QMC. screening of clients to ensure that they are qualified to undergo BTL-MLLA to avoid instances of clients being To institutionalize and sustain the gains of the BTL initiative, refused to undergo the procedure. the itinerant team and PHO are now in the process of 1) 6. BTL schedules in district hospitals shall be posted on the strengthening the service delivery network to improve referrals bulletin boards of RHUs for information dissemination. between and among the Barangay Health Stations, RHUs, and hospitals (public and private), including PhilHealth-accredited 7. BTL for postpartum cases shall be performed within seven private facilities/lying-in clinics; 2) developing measures to ensure days after delivery, whereas for interval cases, BTL shall be the availability of logistics and supplies; and 3) lobbying with performed six weeks after delivery. the Provincial Government for the provision of a mobile BTL- MLLA clinic to bring BTL services to women, especially those in Photo top. leads the BTL itinerant team in an outreach mission in Tagkawayan, Quezon. geographically isolated and disadvantaged areas.

20 VOLUME I Emerging Success in Tri-City Adolescent Health Program

At 17 years old, Paula (name changed to protect her privacy) is five months pregnant with her first child. After dropping out of high school because of poverty, she started working as a waitress in a restaurant where she met the father of her unborn child. She admits that she is not prepared for childbearing and worries about her child’s future. Her story is a familiar one as teen pregnancy is becoming more prevalent. A United Nations report noted that teen pregnancy in this country is on the rise, despite the decline in the rest of the Asia Pacific region.

Batangas Province where Paula resides typifies this trend as teen pregnancies have remained prevalent. Data from the Provincial Health Office show that there were 5,716 recorded cases of teen pregnancies in 2014, which dropped slightly to 5,434 cases in 2015. This looming problem poses “The TPC is better because there is less queuing and I can a threat to the province’s development because, according have multiple consultations within the day. The nurses and to the results of the 2014 Young Adult Fertility and Sexuality doctors are accommodating and friendly. They counsel and Survey, teens who get pregnant commonly have lower help me prepare for motherhood,” educational outcomes. This, in turn, impacts their future says Paula, 17, who is shown having her prenatal consultation employment earnings and their children’s success. To help the with nurse BatMC’s TPC. province reverse this trend, the US Agency for International Development’s (USAID’s) LuzonHealth Project has developed public high schools had been selected as THK sites in other the Tri-City Model for implementing the Adolescent Health provinces assisted by LuzonHealth. To date, the tri-city and Development Program (AHDP). network includes seven school-based and three health facility- based THKs. The Tri-City Model Launched in June 2016, the tri-city AHDP model was Three TPCs have also been established. These accommodate precipitated by the fact that most teenage pregnancy cases patient referrals from THKs and walk-in clients who are occur in the province’s three key urban areas: Batangas, Lipa, offered a number of services, including complete antenatal and Tanauan. This model was designed not only to educate care, immunization, labor and delivery, family planning, and inform adolescents on teenage pregnancy prevention emergency obstetric care, dental care, nutrition, and psycho- but also to provide care to pregnant teens at-risk of pre-natal social counseling for the entire duration of their pregnancy. and postpartum complications. A seamless service delivery network was put in place to link schools, Rural Health Units Batangas City (RHUs), and a Teen Parents Clinic (TPC) in each City. Batangas City, which saw an increase in teenage pregnancy cases from 796 in 2014 to 826 in 2015, has four THKs housed Each city established Teen Health Kiosks (THKs) that serve in the Gusaling Pangkalusugan, Batangas State University, as information hubs and counseling nooks in schools and Lyceum of the Philippines-Batangas, and Batangas National RHUs. These connect students and community youth who High School (BNHS). Since these kiosks became operational, have health-related concerns and problems with the TPC. a total of 1,413 young individuals have participated in peer THKs have also been set up in private partner schools and education sessions. universities, which is a notable modification because only

STORIES FROM THE FIELD 21 Four cases of teen pregnancies from BNHS were referred to Tanauan City the RHU-based THK for antenatal care and were eventually Teenage pregnancy in Tanauan City increased slightly from referred to the TPC at the Batangas Medical Center (BatMC). 426 cases in 2014 to 429 in 2015. There are three THKs in As of October 2017, the clinic has admitted 865 cases of the city located at Tanauan City Health Center II, City College teen pregnancies, including Paula. Over half of these cases of Tanauan, and Bernardo Lirio National High School. These (281) were from Batangas City, while the rest were from THKs have reached 938 young individuals with relevant neighboring localities. information through peer education sessions. Additionally, Through these interventions, LuzonHealth contributes to they have referred four cases of teen pregnancy to the city’s USAID’s Cities Development Initiative, which has chosen TPC at Laurel Memorial District Hospital, which has served Batangas City as one of its convergence sites. As part of this 293 pregnant adolescents. effort, cross-cutting development assistance on education, energy, environment, health systems, and economic Early Success Signs investments has been implemented in the city to unlock On the aggregate, the Tri-City Model has made possible its growth potential and, ultimately, promote inclusive and the provision of information on adolescent sexual and sustainable development. reproductive health to a total of 2,567 young individuals and of appropriate services to 1,379 pregnant teens in Lipa City the province. These numbers prove that the model works. In Lipa City, cases of teenage pregnancies rose from 798 However, the ultimate goal is to make a significant dent in the in 2014 to 839 in 2015. To date, three THKs have been number of teenage pregnancies, which may take some time established in the Lipa East District Health Center, Lipa Grace to achieve. Academy, and Lipa City National High School. These have For obstetrician/gynecologist organized a number of peer education sessions in which 216 at the BatMC, although initial figures are very encouraging, young individuals participated. assessing the program’s impact now is premature as a more Lipa City’s TPC is located at the Lipa City District Hospital. systematic evaluation is needed. She says that the number of Since it opened in September 2016, 221 teens have been clients they have served, with a 70 percent follow-up rate, in served in the clinic. Three of these were referrals from the just six months is an encouraging indicator that the program school-based THKs. works. However, she believes that helping these teenagers get back on their feet so that they can finish school, eventually THUMBS UP. Officials from USAID Philippines, led by land a decent job, and become responsible mothers is a , and the Batangas Provincial Government, headed by better long-term qualitative measure of the success of the , launch the Tri-City AHDP Model in Batangas in June 2016. program.

22 VOLUME I Peer Educators Promote Adolescent Health

According to the National Statistics Office, in 2010, the nearly 20 million adolescents aged 10–19 comprised 21.5 percent of the country’s population. One in every 10 young women aged 15–19 is already a mother, doubling the likelihood of maternal death compared to those over 20 years of age, as reported by the Department of Health (DOH) and World Health Organization in 2002, and increasing their risk of dropping out of school and facing limited economic opportunities. In Cavite Province, the 2013 LuzonHealth Baseline Survey on Service Delivery Capacity showed that 2,027 women aged 15–17 had their first birth in 2012. In 2014, this number swelled to 8,232, and in 2015, it reached 12,710.

Having the highest recorded number of teen pregnancies in the region, the Regional Department of Health chose Cavite as the priority province for strengthening the adolescent leaders and peer educators; developing standards for setting health and development program (AHDP). Cavite’s AHDP up THKs; and establishing a recording and reporting system. has three main objectives: 1) the prevention and delay of It also facilitated multi-sectoral collaboration among the local rapid repeat pregnancy through postpartum family planning government units (LGUs), Department of Education (DepEd), (FP) counseling and services among teen mothers; 2) the and other public and private entities for the establishment of establishment of a service delivery network (SDN) through an adolescent-friendly SDN. which early referral to and provision of maternal care and FP information, counseling, and services among pregnant In November 2014, Cavite launched 11 school-based THKs adolescents are ensured; and c) the prevention of early in an event that highlighted the strong collaboration among initiation to sex/early pregnancy among non-postpartum, the Provincial Government, DOH, DepEd, Commission non-pregnant adolescents. on Population, National Youth Commission, and USAID- LuzonHealth. These THKs, where students can discuss with The US Agency for International Development (USAID), their peers issues related to adolescent health and teen through the LuzonHealth Project, has assisted the Provincial pregnancy prevention, are accessible to nearly 55,000 public Health Office (PHO) in developing a three-pronged strategy high school students. with the following elements: 1) school-based Teen Health Kiosks (THKs), which serve as the initial service points for a teacher and THK Adviser at the Trece adolescent-friendly maternal, child health, and FP information Martires City National High School, says, and services; 2) Rural Health Unit (RHU)-based THKs, which “Through the THK, we can prevent our youth from making serve as health referral facilities for cases referred by school- wrong decisions because here, we are able to help mold their based THKs and, in the case of out-of-school adolescents, the character and influence their behavior in and out of school.” community; and 3) Teen Parents’ Clinics to which pregnant teens needing comprehensive services in a hospital setting To date, the province has 140 trained peer educators, 40 will be referred. trained THK advisers, 27 Adolescent Job Aid (AJA)-trained guidance counselors and teachers, and 168 AJA-trained In addition, the project, in close collaboration with the PHO, assisted in identifying the most accessible and strategic Photo top. A trained peer educator from Tanza National High locations for the THKs; providing equipment support; training School presents key messages on teen pregnancy prevention to health providers, teachers, guidance counselors, parent- students visiting the THK.

STORIES FROM THE FIELD 23 health service providers. Year-round peer education sessions participatory processes in policy and plan development, and adolescent fora have been conducted in the 11 school- implementation, and monitoring and evaluation; and based THKs where age-appropriate and gender-sensitive 4) an improved health service delivery system through a information, education, and communication materials functioning SDN and the adoption of a holistic and integrated are distributed. A Teen Parents’ Clinic was established approach to reducing teenage pregnancy and maternal death. at the Treceño Medical Pavilion located at the General Cavite’s AHDP has already been recognized by both Emilio Aguinaldo Memorial Hospital Complex to provide DepEd-Region IV-A and DepEd-Cavite Province. The comprehensive medical/obstetric care, psycho-social province was given the Best Practice Award in Adolescent counseling, and health education. Health Development by DOH-Region IV-A during its The sustained implementation of these initiatives is expected Kalusugang Pangkalahatan Recognition Awards held in 2015. to result in: 1) a reduction in the teenage pregnancy rate; A 15-member Lakbay Aral team from the Municipality of 2) a reduction in the maternal death ratio among teen Llanera in Nueva Ecija, headed by the municipal mayor, also mothers; 3) improved governance in addressing the emerging visited Cavite to gather useful insights on what it takes to put problems of adolescents through the development of in place an effective program for adolescents and youth at the LGU-led, evidence-based, adolescent/youth-inclusive, and local level.

24 VOLUME I Local Governance: Key to Sustaining Health Gains

is one of the 48 municipalities/cities comprising Pangasinan Province. It is a coastal municipality with a population of 34,000 distributed in 19 barangays. The Municipality of Sual exemplifies how effective leadership and ownership of project assistance can lead to significant improvements in maternal and child health outcomes.

Leading Health Improvements in Sual The start of LuzonHealth’s technical assistance to the Municipality in 2013 was well timed because the municipality had just hired a new Municipal Heath Officer (MHO), Additionally, Municipal Mayor e had just completed his participation in the US Agency for International Development’s Municipal Leadership The municipality also invested in procuring equipment for and Governance Program, a leadership training program Wireless Access for Health, a project-supported electronic supported by the Zuellig Family Foundation for mayors and health data management system. In addition, the municipality’s MHOs. This opportune timing meant a fresh start for health birthing facility was assisted in obtaining PhilHealth programs and renewed zeal and commitment to solve health accreditation and securing a license to operate. This process problems in the municipality. entailed training and three RHMs in BEmONC In 2014, Sual’s contraceptive prevalence rate (CPR) was and passing a municipal ordinance to use PhilHealth capitation only 32 percent, and the child immunization rate was only for the Maternity Care Package and Newborn Screening in 80 percent. Only four of the seven rural health midwives the RHU. (RHMs) were trained in the Family Planning Competency- Based Training Basic Course and in Basic Emergency Obstetric Significant Improvements in Health and Newborn Care (BEmONC). The birthing facility was not Outcomes licensed to operate and was not accredited by PhilHealth. “When we were just starting to introduce these changes Furthermore, no systematic recording system was in place; and improvements, we encountered several difficulties. thus, preparing, storing, and retrieving health information was Fortunately, LuzonHealth has always extended its help every tedious and laborious. step of the way,” With project assistance, the municipality integrated family said z, who also shared that the CPR of Sual has planning (FP) demand-generation activities with the antenatal almost doubled from 32 percent in 2014 to 61 percent and immunization check-ups in barangay health stations in 2016. Additionally, the proportion of pregnant women (BHSs) and the Rural Health Unit (RHU). It also intensified who completed antenatal care (ANC) increased from 18.4 the Suyod Barangay strategy aimed to profile all households percent in 2014 to 32.9 percent in 2016. in a village and identify individuals with unmet FP need and More importantly, there have been no recorded maternal children who need immunization. Usapan sessions, which are deaths, and the RHU has received PhilHealth reimbursements facility-based or outreach group discussions on FP and safe motherhood that end with counseling and service provision, Photo top. A woman receives an injectable after being have been integrated with immunization and antenatal service informed and counseled during an Usapan session in Barangay provision in BHSs and RHUs. Pangascasan, Sual.

STORIES FROM THE FIELD 25 slight decline in the proportion of deliveries attended by a skilled birth attendant—from 99.3 percent in 2014 to 98.0 percent in 2016—because of the resurgence of hilots (traditional midwives), especially in some geographically isolated island barangays.

To solve this problem, the municipality has adopted a comprehensive approach encompassing all aspects of maternal and child health. It has procured a van for each barangay to be used during emergencies, such as precipitous labor and delivery. Moreover, in the Sual RHU, Mayor plans to adopt the point-of-care PhilHealth enrollment scheme, which is currently only available in hospitals. Under this plan, an unenrolled pregnant woman who goes to the RHU for her first prenatal check-up will be automatically enrolled in PhilHealth. The municipality will shoulder the annual contribution of PHP 2,400 and the Maternity Care Package, which amounts to PhP 8,000, on the condition that the patient completes all four prenatal check-ups. The amounting to PHP 116 thousand for the provision of Department of Health Regional Office I will also explore maternal and child health services. the possibility of mainstreaming hilots by employing them as auxiliary health workers. “I have always believed that “wala dapat namamatay sa pagbibigay-buhay” (nobody should die giving life). These To achieve zero FP unmet need, the municipality plans to results are very encouraging and tell me that it was all worth train midwives in all barangays in Expanded Program on the sacrifice,” Immunization and ANC integration and to conduct more Usapan sessions, particularly the Usapang Maginoo variant added Before taking on the responsibility as Sual’s designed to meet men’s FP needs. Municipal Health Officer, she had a profitable private practice in Metro Manila. Upon the invitation of Mayor , she Taking Ownership of Assistance returned to Sual in 2013 to serve her hometown and embark on a life of public service. The improvements in maternal and child health outcomes in Sual demonstrated the primacy of local ownership and “Transitioning from St. Luke’s Hospital to the Sual RHU was accountability in the success of development interventions. really challenging, but I am very happy that I did,” This sense of ownership provides an impetus for local leaders she explained. to be proactive and treat assistance not as a mere dole- out but instead as an important opportunity to turn their “Before we achieved this, Sual used to be the perennial situation around. laggard in maternal and child health outcomes in the Western Pangasinan Inter-local Health Zone,” Whether these improvements will be sustained remains to said a, a public health nurse. However, challenges be seen. However, with the level of commitment and sense remain, despite these achievements. One challenge is the of shared responsibility that Sual’s local leaders, such as have exhibited, the project is confident that its interventions will be sustained and even scaled up. Photo top. A mother being counseled on FP by a public health nurse during the scheduled immunization of her child

26 VOLUME I A New Approach to Assess the Skills of Health Service Providers

Field Health Service Information System data for Quezon City from 2005 to 2010 indicate increased facility-based deliveries by skilled birth attendants; improved antenatal care coverage, particularly in the city’s second district; and improved utilization of maternal health services. A decrease in the maternal mortality ratio (MMR) was noted during 2005–2009. However, there has been an uptrend in the MMR since 2009. From 68 per 100,000 livebirths in 2009, the MMR increased to 76 in 2010 and subsequently continued to increase, reaching 110 in 2011 and 129 in 2012.

In response, Quezon City has worked to improve access to expanded health care by building additional health facilities (i.e., hospitals and health centers), institutionalizing health 65 HSPs from seven health facilities. The three batches of systems, maintaining facility standards, and strengthening the OSCE for BEmONC were attended by 32 health workers capacities of health service providers (HSPs). Quezon City, from 31 facilities. The QCHD sustained the implementation through its City Health Department (CHD), is determined to of OSCE and capacitated two to three providers per health deliver its share of the national target for improving maternal facility or a total of 195 in all 65 public health centers. In April health. 2014, the QCHD also trained nine PhilHealth-accredited private lying-in clinic owners to strengthen public-private In line with the push to upgrade the capacities of its HSPs, partnership and establish a Service Delivery Network (SDN). the QCHD sent 14 representatives (four maternal, neonatal With the SDN in the works, the QCHD has included in its and child health and nutrition department chiefs; four plan the training of referral hospitals, both public and private, family planning [FP] department chiefs; two obstetrician- on OSCE. gynecologists; one chief midwife; one midwife from the CHD training office; and two Population Program Officers [PPOs]) Seasoned midwives were initially tapped as IUD insertion to the Facilitators/Assessors Training in Diagnostic Workshop trainers for selected city health physicians and service organized by LuzonHealth for its seven partner cities in the providers who exhibited poor performance in the IUD National Capital Region. Among the seven cities represented, insertion portion of the OSCE. PPFP/PPIUD Training was Quezon City showed interest in using the Objective also conducted for 55 service providers. The improved Structured Competency Evaluation (OSCE) to assess the competency of HSPs in IUD insertion could partly account clinical skills performance and competency of its HSPs. The for the increase in the number of IUD acceptors from 21,597 QCHD requested LuzonHealth’s assistance in conducting in 2013 to 30,208 as of June 2017. QCHD birthing facilities the initial Diagnostic Workshop Training and eight batches of have also been developed as training hubs for PPFP/post- OSCE: five on FP and three on basic emergency obstetrics partum IUD (PPIUD) to serve other cities in the National and newborn care (BEmONC). Capital Region. The comprehensive skills enhancement and series of training activities after the OSCE may have The Diagnostic Workshop was conducted in July 2013 for contributed to this development. 31 frontline health workers: 17 PPOs focused on OSCE for FP, and the remaining 14 concentrated on OSCE for BEmONC. The five batches of OSCE for FP were conducted Photo top. A health provider demonstrates how to do IUD insertion, while the assessor observes and checks if the proper between September and October 2013 for a total of procedures are followed.

STORIES FROM THE FIELD 27 The city-wide adoption of OSCE has produced the following results: • Standards were established and subjectivity eliminated, thereby ensuring consistency and quality in the performance of duties among HSPs. • An on-site monitoring tool was established for the day-to-day execution of duties among health center staff with the use of the BEmONC supervisory checklist and the standardized OSCE assessment checklist in each of the 65 health facilities. • The sharing of knowledge and clinical skills was encouraged, resulting in a more harmonious working environment. • The referral system between and among health facilities, which is considered an essential element in the establishment of an SDN, was strengthened. In view of these developments, the QCHD has institutionalized the use of OSCE as a tool to track skills • Service providers were motivated to improve on improvement among HSPs through periodic assessment, thus their weak points through a conscious effort to aim ensuring the sustained delivery of high-quality health services. for the ideal, leaving no room for deviation from set It has also used OSCE as a post-training evaluation tool. standards. • The confidence of service providers was boosted “The diagnostic workshop, specifically the OSCE, has evolved upon their completion of the required training from a mere assessment tool to address service quality identified by the OSCE (e.g., intrauterine device and training issues, to one that can be used to evaluate [IUD] insertion, Partograph, BEmONC, and FP actual skills of service providers so they can be certified as Competency-Based Training Basic Course [FPCBT1]). competent in a particular skill. It is also used for mentoring • Six of the 58 public midwives needing training based and on-the-job training. By using OSCE, you can easily on the OSCE were trained in BEmONC. determine which service providers are competent and which • Sixty service providers were trained in FPCBT1, 14 need re-training. So you actually save on training costs,” in Lactation Management, and 12 in postpartum FP said , Head of Quezon City’s Population Program Office. (PPFP).

Photo top. An assessor listens to a private practice midwife’s • Sixty-one service providers from 14 lying-in clinics explanation of the routine newborn care administered after were assessed on maternal and child health as an the first breastfeed during the OSCE for BEmONC for private- OSCE follow-though activity. practice midwives. • Twenty-six QCHD supervisors were trained in Supportive Supervision. • Twenty two out of the 99 private practice midwives (PPMs) were trained in BEmONC from August to September 2015 with LuzonHealth’s assistance. BEmONC training was provided only to PPMs from Districts 2, 3, and 5 considering the large number of priority populations in these areas. All 65 health centers were provided with a refresher course on Partograph.

28 VOLUME I Effective Tracking System Ensures Availability of Family Planning Commodities

In the Philippines, where the unmet need for family planning (FP) remains high—19.3 percent according to the 2011 Family Health survey—ensuring that quality FP commodities can reach their target users, especially the poor, is essential.

To do this, local government units (LGUs) must have an efficient and effective logistics management system to properly select and forecast the commodities they need to distribute, identify funding sources, procure products, and deliver them to health facilities and clients in a timely and reliable way. To enable LGUs to effectively implement this cycle, the US Agency for International Development, through its LuzonHealth Project, has trained LGU staff in the implementation of the Supply Management and Recording Public Health Nurses (PHNs) are usually an RHU’s or System (SMRS). hospital’s SMRS focal persons. All the RHUs implement The SMRS was originally designed to be used by Rural SMRS, but not all use its five recording forms: the Daily Stock Health Units (RHUs) and health centers (HCs) in tracking Record, Daily Dispensing Record, Daily Stock Issue Record, expendable commodities, such as those for FP. This system Baseline Physical Inventory and Drug Expiration Record, and helps them monitor the flow of FP stocks from receiving and Monthly Physical Inventory and Drug Expiration Record. The storing to dispensing stocks to barangay (village) midwives RHUs sometimes run out of forms, and thus, some improvise or health stations and issuing commodities to FP users. As of forms they can use that roughly follow the SMRS forms. June 2017, a total of 2,212 health personnel from 597 RHUs/ shared that she coaches and mentors RHUs and City HCs and 31 hospitals in 436 LGUs were trained in the use of Health Offices (CHOs) in the SMRS during their regular the SMRS. With the recent move to establish FP in hospitals, monthly meeting, which happens every second Tuesday of the hospital staff have also been trained in the SMRS. month. “I usually coach one or two PHNs during these meetings in Nueva Ecija is one of the provinces that implemented the using the SMRS forms.” SMRS. All of its 64 RHUs/HCs and 10 public hospitals were trained in the SMRS in 2014. To date, approximately 91 the SMRS focal person of the RHU in Licab percent of its RHUs/HCs and all of its public hospitals are Municipality, outlined how an RHU normally runs the SMRS. using the SMRS forms. When new stocks of FP commodities are delivered to the facility by the Department of Health (DOH) Central The Nueva Ecija Experience Office, the PHN uses the Daily Stock Record to record the n, the Province’s FP Coordinator, shared, delivery. He or she writes down the quantities and types “Conducting family planning services in the Province is quite of commodities received by the RHU in this form. When the PHN needs to provide FP commodities to midwives or difficult. Many of the RHU/HC staff have to handle many barangay HCs, he or she uses the Daily Stock Issue Record. clients a day, in addition to their other administrative tasks. This form specifies the name of the midwife or barangay The SMRS helps them because it reduces the time needed to track commodity flow within their facilities.” Nueva Ecija FP Coordinator reviews the SMRS records of Licab RHU in Nueva Ecija.

STORIES FROM THE FIELD 29 Benefits to the Licab RHU The system has made the recording and reporting of FP commodities easier for the Licab RHU. revealed, “Monitoring the RHU’s inventory is now faster with SMRS. I can immediately see, on a daily basis, which commodity moves faster, where we issue the most quantities to, and to whom we dispense a certain commodity more frequently.”

She recalled the time when the SMRS was not yet implemented in Licab. “Nung walang SMRS di namin agad nalalaman na ubos health station to which he or she issued the FP commodities. na pala ang supply (Before the SMRS, we did not know It also includes the name and quantity of the commodity immediately that we had already run out of supplies).” issued. When the RHU or CHO provides a commodity to Indeed, there were times when the RHU failed to respond an FP client or user, it then uses the Daily Dispensing Record. to FP commodity requests from barangay health stations The PHN records the quantities dispensed to each client in because stocks had already run out without the RHU staff’s this form. The PHN uses the Monthly Inventory and Drug knowledge. Expiration Record at the end of the month, when she or he counts the actual stocks left in his or her inventory. The results also said that the SMRS has helped them determine of this count are recorded in this form and compared with who among their FP clients are consistently using FP the Daily Stock Record to check for discrepancies. commodities. “However, we now send quarterly consumption reports to “In our RHU, we have more than 300 pill acceptors. We also the DOH Central Office, instead of monthly reports.” have injectable and condom users. SMRS helps us see who among them need FP commodities at any given time. We can said that she used to require PHNs to submit a easily follow them up.” monthly consumption report because the LGUs used to source their FP commodities from the Provincial Health “SMRS has made a big difference in the way we do our Office (PHO). However, since December 2014, when the work,” a added. “Now, I don’t have to physically count DOH Central Office began to distribute FP commodities stocks every day. I have my daily stock record, my daily stock directly to the RHUs and CHOs, the PHNs have submitted issue record, and my daily dispensing record. I just count at quarterly FP commodity consumption and inventory reports the end of the month. Now, I am always sure that I have FP to the Central Office, with copy to the PHO. The PHO now commodities on hand to provide to midwives and clients only augments a facility’s FP supplies upon request from the RHU/CHO. who need them.” The successful implementation of the SMRS in Licab RHU is not limited to the municipality alone. For the past nine months, no RHU or CHO in Nueva Ecija has reported any Photo top. The SMRS records of Licab RHU. stock out of pills, injectables, or condoms.

30 VOLUME I Local Government Institutionalizes Data Quality Check for Better Decision-making

“Talagang gusto rin naming maayos ang proseso ng pagkolekta ng tamang impormasyon sa health at kung may ganyan ngang tulong mula sa inyo [LuzonHealth-USAID], ay salamat nman; makakatulong nga yan para tama ang maging basihan namin ng pagbigay ng health service” (We truly wanted the process of collecting [health] information to be instituted in our LGU, and if you are truly helping us in this respect, thank you. This will help us establish a reliable basis for health service provision) – Mayor of the Municipality of Laguna.

The Local Chief Executive of the Municipality of Siniloan in and the LGU Score Card. Under the EO, the Municipal Laguna Province signed, Executive Order (EO) #25, Series Planning Officer, shall integrate the conduct of DQC in the of 2014, “Establishing Data Quality Check as a System for Municipal Investment Plan for Health. Generating Valid and Reliable Heath Data for Evidence- based Planning and Decision-making” on October 10, 2014. The US Agency for International Development (USAID), This EO demonstrates the local government unit’s (LGU’s) through the LuzonHealth Project, trained four nurses and commitment to continuously strengthen the capacities of nine midwives covering 20 barangays in Siniloan in conducting existing and newly hired nurses, midwives, and doctors DQC and were guided on the step-by-step process of on the Field Health Service Information System (FHSIS) correctly applying the definition, formula, and recording and recording and reporting tools with guidance from the staff reporting processes for each service indicator. The following of Department of Health (DOH) Regional Office IV-A and sources of inaccuracies were identified: 1) not all services Provincial Health Office. According to the EO, the Siniloan were recorded in the FHSIS recording tools, 2) the Target Rural Health Unit (RHU) shall regularly conduct a 3-day Data Client List was not updated, 3) services were not recorded Quality Check (DQC) of family planning (FP) and selected properly in accordance with the procedures for completing maternal, neonatal, child health and nutrition (MNCHN) the Target Client List, and 4) recording of some services indicators using the DOH-approved workshop design and did not follow the definition and formula for estimating tools and will support the logistical requirements related to service utilization. DQC provided the Municipality of Siniloan this activity. Under this local policy, the LGU also committed with a systematic approach to identifying and addressing to utilizing quality-checked facility data in the preparation of these sources of inaccuracies in key FP/MNCHN indicators the Municipal Health Office’s Annual Report, FHSIS reports, reported in the FHSIS. “We really can use DQC to ensure that correct data are used for health planning and budgeting and to provide us the real scenario for addressing gaps,” said during the LuzonHealth/USAID consultation meeting conducted at the RHU.

Photo above. and Rural Health Midwives, helping each other review their Target Client List and Monthly FP Report. Photo left. a Rural Health Midiwife, being assisted by a DQC facilitator during a DQC workshop.

STORIES FROM THE FIELD 31 INTEGRATED MATERNAL, NEONATAL, CHILD HEALTH AND NUTRITION/FAMILY PLANNING REGIONAL PROJECT IN LUZON (LuzonHealth)

32 VOLUME I

More Information

Project Development Specialist, USAID

Chief of Party, LuzonHealth, RTI International

RTI International. 2017. Volume I: Stories from the field. Washington, DC: USAID and DOH