Research A systems approach to improving maternal health in the Philippines Dale Huntington,a Eduardo Banzonb & Zenaida Dy Recidoroc Objective To examine the impact of health-system-wide improvements on maternal health outcomes in the Philippines. Methods A retrospective longitudinal controlled study was used to compare a province that fast tracked the implementation of health system reforms with other provinces in the same region that introduced reforms less systematically and intensively between 2006 and 2009. Findings The early reform province quickly upgraded facilities in the tertiary and first level referral hospitals; other provinces had just begun reforms by the end of the study period. The early reform province had created 871 women’s health teams by the end of 2009, compared with 391 teams in the only other province that reported such teams. The amount of maternal-health-care benefits paid by the Philippine Health Insurance Corporation in the early reform province grew by approximately 45%; in the other provinces, the next largest increase was 16%. The facility-based delivery rate increased by 44 percentage points in the early reform province, compared with 9–24 percentage points in the other provinces. Between 2006 and 2009, the actual number of maternal deaths in the early reform province fell from 42 to 18, and the maternal mortality ratio from 254 to 114. Smaller declines in maternal deaths over this period were seen in Camarines Norte (from 12 to 11) and Camarines Sur (from 26 to 23). The remaining three provinces reported increases in maternal deaths. Conclusion Making health-system-wide reforms to improve maternal health has positive synergistic effects. Introduction communities are located in isolated mountain regions of the country or in coastal areas that are difficult to reach. Also, Globally, there is renewed interest in applying systems thinking there are wide disparities in the use of health services across to health programming; that is, in using a broad understanding income levels. A recent study found that 94% of women in of the health system’s operations to reveal important relation- the richest quintile delivered with a skilled birth attendant, ships and synergies that affect the delivery of priority health compared with 25% in the poorest; and 84% of women in the services. Through a holistic understanding of a health system’s richest quintile had a facility-based birth, compared with 13% building blocks,1 systems thinking identifies where the system in the poorest.6 Fertility rates also vary widely: in 2008, the succeeds, where it breaks down, and what kinds of integrated total fertility rate for women in the richest quintile was 1.9, approaches will strengthen the overall system and thus assist compared with 5.2 for those in the poorest quintile.13 These countries in reaching the Millennium Development Goals discrepancies contribute directly to the country’s elevated (MDGs).2 This orientation towards designing, implement- maternal mortality ratio (MMR). The MDG target is 52 deaths ing and evaluating interventions that strengthen systems3,4 is per 100 000 live births, yet the Philippines’ official country- directly relevant to maternal health programmes.5 Reducing estimated MMR stands at 162 – this equates to seven women maternal mortality is the health-related MDG whose progress dying every 24 hours from pregnancy-related causes.14 The has been “the most disappointing” to date.6 This highly com- MMR in the Philippines is higher than in other middle-income plex, system-level issue must be addressed across the system countries in the region, such as Viet Nam. rather than in isolation from it.7–12 The Government of the Philippines has placed health (in By coordinating actions across different parts of the health general) and maternal health (in particular) high on its politi- system, programmes to improve maternal and neonatal health cal agenda of reform. In 2006, recognizing that “good maternal can increase coverage and reduce barriers to the use of various health services can also strengthen the entire health system”, the services. Effective programmes assemble packages of appro- Philippine Department of Health (DOH) launched the innovative priate reforms in each of the six main building blocks of the Women’s Health and Safe Motherhood Project 2 (WHSMP2).15 health system:1,3 governance of the health sector (to provide This project, funded in part by the World Bank, shifted the sectoral policy and regulatory mechanisms, and partnerships emphasis from identifying and treating high-risk pregnancies with the private sector); infrastructure and technologies (to to preparing all women for potential obstetric complications. provide emergency referral centres linked to primary care pro- It fast-tracked system-wide reforms in maternal health in a few viders); human resources (to scale up the availability of skilled selected provinces through a set of interventions, including: attendance); financing (to reduce financial barriers for patients • sector governance: improving accountability and regula- and incentivize providers), and services (to ensure quality and tory oversight; an appropriate configuration of maternal and neonatal health • infrastructure and essential medical products and equipment; services across all levels of care, including family planning). • human resource development: clinical skill-building and The Philippines faces unique challenges in aligning its formation of village-based women’s health teams (com- health system with the needs of its inhabitants, mainly because posed of a midwife, a pregnant woman and a traditional of the country’s geography and income distribution. Many birth attendant [TBA]); a Reproductive Health and Research Department, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland. b The World Bank, Manila, Philippines. c National Center for Disease Prevention and Control, Department of Health, Manila, Philippines. Correspondence to Dale Huntington (e-mail: [email protected]). (Submitted: 30 June 2011 – Revised version received: 23 September 2011 – Accepted: 11 October 2011 – Published online: 2 November 2011 ) 104 Bull World Health Organ 2012;90:104–110 | doi:10.2471/BLT.11.092825 Research Dale Huntington et al. Improving maternal health in the Philippines • financing: results-based financing because of its low socioeconomic and Results mechanisms and social health insur- maternal health status and because the ance coverage; Regulatory oversight and local government supported the proj- • service delivery: availability, quan- governance measures ect. The province began implementing tity and quality of essential health a series of reforms in 2006. Because The experience gained in the design services.6 of its participation in the World Bank and early implementation of WHSMP2 project, Sorsogon has received more was an important influence on the The project aimed to strengthen technical support, programme guid- development of the programme model the ability of the health system to deliv- ance and oversight from the DOH and articulated in the DOH administrative er a package of interventions, including Provincial Health Office than other order, “implementing health reforms maternal care, family planning, control provinces in the region. The World to rapidly reduce maternal and new- of sexually transmitted infections and Bank loan was not a major source of born mortality”, which was passed for adolescent health services – with a pri- revenue for Sorsogon province dur- nationwide implementation in 2008.19 ority on serving disadvantaged women. ing the study period and was slow to That administrative order spelt out key Implementation began in Sorsogon and begin disbursement. However, strong interventions covering several health Surigao del Sur provinces in 2006 and support from the provincial governor system building blocks, including is scheduled for completion in 2013. and mayors empowered the province regulatory oversight, human resources, The DOH developed a National Safe to access domestic health funding. The financing and service delivery. Subse- Motherhood Programme modelled on National Safe Motherhood Programme quent administrative orders targeted the design of the WHSMP2. The DOH and Maternal Mortality Reduction actions for different building blocks, e.g. has been introducing this national Initiative are being followed in the re- broadening the range of existing services programme into other provinces as an gion’s other provinces but only started that midwives could provide to include integrated element of a larger initiative recently. administration of life-saving drugs (such to reform the health sector. Despite as magnesium sulfate and oxytocin) slow initial implementation, progress Data sources and collection and other services necessary to prevent has been made; today, Sorsogon prov- methods maternal and neonatal deaths.20 These ince is seen as an early adopter of the Data collection was organized around administrative orders are seen as vital National Safe Motherhood Programme. a listing of key health system indicators contributions made by the WHSMP2 This paper reports the results of a drawn from international best-practice through its participatory design phase case study conducted in late 2010 to standards18 and from the DOH sectoral and national management strategy (e.g. assess the impact of the National Safe monitoring and evaluation framework. there is no project management unit in Motherhood Programme by comparing Statistical