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Acknowledgements
We would like to acknowledge with gratitude the following for supporting the
development of these Operations Guidelines:
Province of Sorsogon
Honorable Governor Sally Lee
Dr Edgar Garcia, Provincial Health Officer
PHO Technical Staff
Dr Maricel Fajardo, Project Coordinator
Chief of Hospitals
Municipal Health Officers
Center for Health Development Bicol
Bicol Regional Blood Center
Province of Surigao del Sur
Honorable Governor Vicente Pimentel
Dr Romeo de los Reyes, Provincial Health Officer
PHO Technical Staff
Ms Lingay Pareja, Project Coordinator
Chief of Hospitals
Municipal Health Officers
Center for Health Development Caraga
Adela Serra Ty Memorial Medical Center
National Commission on Indigenous Population
Philippine Health Insurance Corporation
Dr Jose Fabella Memorial Hospital
Quirino Memorial Medical Center
P100 Program
Health Human Resource Development Bureau
National Center for Health Facilities Development
National Center for Health Promotion
Bureau of International Health Cooperation
National Center for Disease Prevention and Control
Center for Economic Policy Research
Administrative Staff
Cyd Francis Dy Recidoro for the cover design
From the Project Team:
Bienvenido P Alano Jr,, PhD
Consultant
Zenaida Dy Recidoro, RN, MPH,
Chief Health Program Officer
National Center for Disease Prevention and Control
OPERATIONS GUIDELINES
WOMEN’S HEALTH AND
SAFE MOTHERHOOD PROJECT 2
TABLE OF CONTENTS
INTRODUCTION
Part 1: GETTING THE PROJECT STARTED
Chapter 1: Understanding the Project 4
Chapter 2: Getting the LGU Commitment 13
Chapter 3: Determining LGU Needs 22
Part 2: ENSURING LGU CAPACITY TO DELIVER QUALITY WHSM SERVICE
Chapter 4: Conditions for Establishing WHSM Facilities 46
Chapter 5: Quality Assurance for WHSM Service Delivery 65
Chapter 6: Assuring the Adequacy of Health Human Resource 77
Chapter 7: Encouraging Positive Behavior Change through Advocacy and
Communication 84
Part 3: MANAGING PROJECT OPERATIONS EFFECTIVELY
Chapter 8: Organizing the Service Delivery Teams 94
Chapter 9: Training the Service Delivery Teams 104
Chapter 10: Ensuring the Effective Delivery of the WHSM Integrated
Intervention Model 112
Chapter 11: Making the Health Facility Environment Clean 122
Chapter 12: Making the WHSM Facilities Operationally Sustainable 133
Chapter 13: Tracking and Evaluating Progress 154
Part 4: ANNEXES
Annex 1: The Memorandum of Agreement with LGUs in Project Sites
Annex 2: Rules and Regulations Governing the Regulation of Blood Service Facilities
(AO No. 2008-0008)
Annex 3: Implementing Guidelines for the Department of Health P 100 Project for
DOH and Pilot LGU Hospitals (AO No. 2008-0013)
Annex 4: Implementing Health Reforms for Rapid Reduction of Maternal and
Newborn Mortality (AO No. 2008-0029)
Annex 5: Regulation of Birthing Homes (AO No. 2007-0039)
Annex 6: Guidelines for the Release and Utilization of Performance Based Grants for
the Second Women’s Health and Safe Motherhood Project 2 (WHSMP2)
(DO No. 2007-0098)
Annex 7: Amendment to Implementing Rules and Regulations of Chapter XX -
Pollution of the Environment” on the Code of Sanitation of the Philippines
(PD 856) (AO NO. 2007-0033)
Annex 8: Biliran Provincial Resolution in Support of Facility Based Delivery
Annex 9: The Integrated Needs Assessment Tools
Annex 10: The Pregnancy Tracking Form
Annex 11: The Maternal Death Reporting Form
Annex 12: The WHSMP2 MERD Forms
Annex 13: The Floor Plans for WHSM Facilities
Annex 14: Powerpoint Presentations
Rationale for establishing emoc
Facility Mapping
Needs Assessment
INTRODUCTION
These Operations Guidelines seek to describe in sufficient detail the operational procedures
and systems for implementing the Second Women’s Health and Safe Motherhood Project in
an LGU project site. The Guidelines are presented in three major sections:
• Part 1: Getting the Project Started – describes the preparatory work that needs to be
undertaken to prepare the selected LGU site for Project hosting. These include the
planning and execution of various advocacy activities that are targeted at critical
stakeholders to generate local support for the Project. An important component of
this section is a description of the tools and procedures developed under the Project to
determine the investment needs of the LGU in order to upgrade its capability to
effectively deliver the needed women’s health and safe motherhood services.
• Part 2 Ensuring LGU Capacity to Deliver Quality WHSM Services – describes the
standards that LGU facilities have to meet in terms of infrastructure, service delivery
and human resource capability. It also presents the advocacy strategy for effecting
the desired behavioral changes on the part of critical Project stakeholders.
• Part 3: Managing Project Operations Effectively – describes the activities that need
to be undertaken in order to ensure that the LGU health facilities chosen to comprise
the Provincial Women’s Health and Safe Motherhood Network as well as their
respective service delivery teams are capable of taking on the operational burden of
Project implementation.
The Guidelines are accompanied by a comprehensive set of Annexes which includes relevant
DOH administrative orders and LGU executive orders and ordinances, sample memoranda of
agreement between the different Project proponents and major stakeholders, tools and
templates needed for data gathering and analysis, sample floor plans for civil works, sample
presentations for Project proponents and implementers and a host of other relevant materials
that have proven useful in the course of Project development and implementation.
The Guidelines seek to address a wide audience: from local chief executives and program
planners to community field workers. As a result, the discussion ranges from a thoughtful
treatise on the international evidence to support the choice of strategy to address the country’s
high maternal mortality ratio to a simple and straightforward set of step-by-step instructions
directed at health workers on the ground. It is hoped that such an approach would render the
document easily comprehended by the wide array of readers that it seeks to target.
The development of these Operational Guidelines has profited heavily from the
implementation experience of the first two WHSMP2 pilot sites: Sorsogon and Surigao Sur.
Valuable lessons were also learned from the experience of rolling out some features of the
Project model to the sixteen Fourmula One sites and other selected provinces. It is hoped that
this document would not only further facilitate Project implementation in the above-
mentioned pilot sites but would also ease the adoption of the Project strategy and the service
delivery model by other provinces in their effort to address women’s health and safe
motherhood concerns of their constituents.
PART 1:
GETTING THE PROJECT STARTED
Understanding the Project
Getting the LGU Commitment
Determining LGU Needs
2
Chapter 1
UNDERSTANDING THE PROJECT
The Women’s Health and Safe Motherhood Framework
The Philippine Situation
Learning from International Experience
The Philippine Strategy to Reduce Maternal and Newborn Mortality
in the F1 Context
The Project Development Objectives
The Intervention Model
The Paradigm Shift
3
Chapter 1
UNDERSTANDING THE PROJECT
The Women’s Health and Safe Motherhood Framework
The health of women, in all stages of the life cycle, is of immense importance for two
reasons:
1) Women comprise half of the country’s human resource. Women, especially of poor
families, usually not only manage the home and attend to the well-being of children, but also
contribute to the family income either as wage earners in the formal labor sector or as part
time participants in the informal sector. Thus, when women cannot work because of health
problems, the loss of their income and the costs of their treatment can seriously impact family
welfare and possibly drive their families to debt. The social and economic cost of women’s
disabilities and deaths is therefore enormous.
2) The health status of the mother has implications on the survival and the quality of life
of future generations. At least 30-40% of infant deaths are the result of the mother’s poor
health and the insufficient care that she receives during pregnancy and childbirth. Poor
maternal health and nutrition contribute to the low birth weight of about 20% of babies, who,
in turn, become at greater risk of infection, and malnutrition as well as of long term
disabilities including visual and hearing impairments, learning disabilities and mental
retardation. Motherless children are 3-10 times more likely to die within 2 years, while those
who manage to survive are likely to get less health care and education as they grow up
(www.safemotherhood.org).
THE PHILIPPINE SITUATION
Steady progress in the overall health situation of Filipinos has been observed in the past
decade. Such progress have resulted in extended life expectancies and decreasing mortality
rates of women. However, much still remains to be done. The maternal mortality ratio at 162
deaths per one hundred thousand live births (National Statistics Office, 2006 Family Planning
Survey) is still one of the highest in the region. Furthermore, a review of women’s
nutritional, maternal and overall reproductive health status reveals the continued inability of
the health system to adequately address critical women’s health needs.
Pregnancy and childbirth are among the leading causes of death, disease and disability in
women of reproductive age in developing countries. In 1990, the international community
therefore agreed to work towards the reduction of maternal mortality ratios by three-quarters
and under-five mortality by two-thirds by 2015 and designated these targets to be among the
Millennium Development Goals (MDG). Because of its moderately high maternal mortality
ratio and child health situation, the Philippines is one of 68 countries considered important for
tracking by the Countdown to 2015 Committee, an international body tasked to monitor
country-level progress in achieving the MDGs, In a meeting of the Committee in April 2007
to discuss the status of the effort towards the MDGs, the Philippines was cited as one of the
ten best performing countries as a result of its success in putting in place an effective strategy
for addressing maternal and child mortality.
The current level of maternal mortality in the Philippines is mostly attributed to the
predominance of home births (61% per the 2003 National Demographic and Health Survey
(NDHS)) and the relatively high proportion (37%) of these births assisted by traditional birth
attendants (TBAs) or “hilots”. TBA practice is usually handed down from one generation to
the next. This makes their knowledge and skills highly uneven. Thus, efforts to train them on
4
safe birthing practices have been largely unsuccessful, as the next section on the review of
literature on international experiences reveals.
The 2003 NDHS further shows that 88% of women who had a live birth during the survey
period saw a health professional for antenatal care. Yet, a significant number eventually
ended up giving birth at home, attended by a TBA. This indicates that women are generally
aware of the importance of skilled care by a health professional during pregnancy. However,
when it comes to childbirth, a significant number are either unwilling to seek the same level
of care or are unable to overcome obstacles to accessing such care. Thus, any intervention
that seeks to address the maternal mortality situation would need to find ways to help women
overcome these obstacles.
LEARNING FROM INTERNATIONAL EXPERIENCE
The bane of high maternal deaths is shared by many developing countries. A number of
strategies have been tried over the years to address it. Results have been uneven across
countries but the general view is that the strategies that have been popular since the 1970s
have barely made a dent in worldwide maternal mortality rates. Thus, there needs to be a
strategic shift if the international community is to achieve the mortality declines envisioned
by the MDGs. A review of the literature that surveys and analyzes international experience
in addressing maternal mortality over the past decade or so should provide insights on how to
shape a strategy that responds to the Philippine situation.
The Failure of Past Interventions: What Has Not Worked
Two basic strategies have underpinned past efforts to address high maternal mortality ratios:
(De Brouwere, et al. 1998).
1) Applying the risk approach through antenatal clinics and
2) TBA training.
The risk approach takes the view that a sufficient number of antenatal visits would allow the
attending health provider to identify at-risk pregnancies and anticipate complications. (Tucker
J, Florey CdV, Howie P, Mellwaine G and Hall MH. 1994, in De Brouwere, et al. 1998).i Thus the
focus during the 1970s and 80s was to promote the development of antenatal clinics and to
encourage mothers to make the necessary number of antenatal visits (V. De Brouwere et al.
1998).
The risk approach went practically unquestioned until a series of studies in the eighties
revealed the low predictive value of antenatal visits:
• In a study of antenatal clinics in Aberdeen, Hall et al. (1980) showed that antenatal clinics
were not effective in predicting and identifying obstetric problems;
• The above finding was subsequently reinforced by the results of the Kosongo study
(Kosongo Project Team 1984) showing women at risk to be only a small proportion (29%)
of all women with obstructed labor;
• Maine et al. (1991), in turn, used this finding to argue that antenatal clinics could not
effectively identify most complications that threaten a mother’s life (V. De Brouwere et al
1998).
5
“The current consensus is that even in developing countries where the prevalence of risk is
higher, antenatal screening has low predictive value because of -Its low sensitivity (30%) and
its relatively low specificity (around 90%) (Chang et al. 1980; Hall et al. 1980; Koblinsky et al.
1994; Walsh et al. 1994; Acharya 1995; Rohde 1995; Yuster 1995; Dujardin et al. 1996; McDonagh
1996)” (quote from V. De Brouwere et al. 1998)”.
TBA training was the other strategic axis. The health system’s reliance on TBAs as childbirth
attendants was justified as follows:
• There were not enough professional health providers to attend to mothers in need of
maternal care;
• TBAs were highly accessible, especially in the rural areas;
• TBAs were also culturally acceptable and were usually able to influence a mother’s
health-seeking behavior.
Training the TBAs on modern methods of delivery was therefore widely seen as a logical
solution to the health provider gap. Moreover, community empowerment was at the core of
the primary health care strategy in the seventies and training TBAs was fully consistent with
this overarching objective.
The mid eighties saw the emergence of studies evaluating TBA performance and voicing
skepticism about the strategy (Namboze 1985, Ross 1986). This gradually developed into a
shared conclusion that “the training of TBAs has had little impact on maternal mortality
and that the most effective measures were those that which make it possible to reach a
well-equipped hospital (Greenwood et al. 1990; Maine et al. 1991; Fauveau & Chakraborty 1994;
Koblinsky et al. 1994; Turmen & AbouZahr 1994)” (quote from De Brouwere et al. 1998).
De Brouwere attributes the failure of the TBA training strategy to a number of important
elements that were underestimated by its proponents (De Brouwere et al. 1998).
First was the degree of variability of the function, knowledge and experience of TBAs. In
some regions, the TBA is an experienced woman who has survived several pregnancies
herself and carries out several dozen deliveries a year. Elsewhere, the TBA may be a woman
whose sole role is to reassure and give comfort to the mother during the few deliveries that
she attends. Framing a strategy that does not take into account this wide variation would be
technically invalid.
Second was the amount of supervision needed to ensure the safety of TBA-attended child
birth. Since this amount is usually inversely proportional to the level of training of those
being supervised, the TBA therefore needs much more supervision than a professional
midwife. This need is underscored by the observation that some TBAs tend to delay or even
discourage women with complications from going to the hospital (Estrada 1983; Catfish 1987;
Viegas et al. 1987). However, such supervision intensity is hard to sustain in a situation where
the rural health physician is already overextended.
Maternal Mortality Reduction: What Works
There is a global consensus on what works to address maternal death. This is embodied in a
joint statement by WHO, UNFPA, UNICEF and the World Bank in 1999, calling on countries
to:
“Ensure that all women and newborns have skilled care during pregnancy, childbirth
and the immediate postnatal period.” (Reducing maternal mortality. A joint statement by
WHO/UNFPA/UNICEF/World Bank. Geneva, World Health Organization, 1999).
6
Such care is to be provided by a skilled birth attendant, defined as an accredited health
professional who has been educated and trained in the skills needed to manage the critical
stages in pregnancy and childbirth as well as in the identification, management and referral of
complications. Such a definition refers to either a midwife, nurse or a doctor.
To ensure the best possible outcome, childbearing women
should have access to a continuum of care provided by a
“functioning health care system with the necessary
infrastructure in place, including transport between the
primary level of health care and referral clinics
and hospitals” (WHO 2004).
In 2006, the Lancet came out with a five-article series on maternal survival called The Lancet
Maternal Survival Series. In the 2nd article, the authors contend that while “ the concept of
knowing what works in terms of reducing maternal mortality is complicated by a huge
diversity of country contexts and of determinants of maternal health, only a few
strategic choices need to be made”. They go on to make a compelling case for focusing on
just “one strategy based on delivery in primary-level institutions (health centers), backed
up by access to referral-level facilities”, labeling it their “best bet to bring down high
rates of maternal mortality” (Campbell et al 2006).
They contend that “most maternal deaths occur during labor, delivery or the first 24
hours postpartum, and most complications cannot be predicted or prevented” (this quote
from Campbell et al. is based on the results of the first report in the series: Ronsmans C, Graham WJ.
2006). Thus they argue that while the necessary level of skilled care could very well be
delivered at home for mothers who prefer to give birth there, a strategy encouraging home
deliveries has distinct disadvantages:
• Home conditions can be very basic and could limit the ability of the skilled attendant to
deal with emergencies, especially since the attendant has only the family to rely on to
assist rather than other providers such as doctors or nurses in health centers or hospitals.
• Home-based deliveries are inefficient in terms of not only the skilled attendant’s time but
also that of the supervisor (who is most likely the already overburdened rural health
physician).
Therefore, based on the evidence that they present, the authors conclude:
“The best intrapartum-care strategy is likely to be one in which women routinely
choose to deliver in a health centre, with midwives as the main providers, but with
other attendants working with them in a team” (Campbell et al. 2006)
7
THE PHILIPPINE STRATEGY TO REDUCE MATERNAL AND NEWBORN
DEATHS IN THE F1 CONTEXT: Sustainable Delivery of an Integrated Package of
Women’s Health and Safe Motherhood Services in Strategically Located Health
Facilities
In crafting a country strategy, it is important to focus interventions in areas that have the
greatest impact on reproductive health problems. These areas are well known. In the field of
maternal care, there is consensus on the four main complications of pregnancy and childbirth:
• Obstructed labor,
• Eclampsia,
• Puerperal sepsis, and
• Hemorrhage
These complications may be effectively addressed by having skilled attendance at delivery,
thereby reducing maternal deaths by as much as 16% to 33% (Graham, Bell, & Bullough 2001).
Antenatal care consisting of the following interventions also makes a difference (Bergsjo 2001)
• Immunization,
• Iron prophylaxis,
• Early detection of pre-eclampsia,
• Counseling on how the family could prepare to ensure a safe childbirth
Family planning, on the other hand, can reduce mortality and morbidity by 20%
(www.unfpa.org), aside from the direct result of lowering fertility by as much as 92% (Laing
1979), or limiting or spacing births, which is the expressed desire of many women at present.
Attention must also be accorded to adolescents, given the increase in unwanted pregnancies,
abortions, and STIs that are a result of their engaging in sex without the knowledge to make
the experience safe.
Management of symptomatic sexually transmitted infections can result in a 40% decrease in
HIV infection (Nazareno 1997) while an increase in condom use may consequently reduce the
incidence of sexually transmitted infections among sex workers (WHO & NCHADS 2001).
The Women’s Health and Safe Motherhood Project therefore seeks to put in place the above
interventions while trying out innovative ways to deliver them in a cost-effective and
sustainable manner.
Project Development Objectives
The Women’s Health and Safe Motherhood Project 2 contributes to the national goal of
improving women’s health by:
• Demonstrating in selected sites a sustainable model of delivering health services that
increases access of disadvantaged women to acceptable and high quality reproductive
health services and enables them to safely attain their desired spacing and number of
children;
• Establishing the core knowledge base and support systems that can facilitate countrywide
replication of the Project experience as part of the mainstream approaches to reproductive
8
health care within the framework of the Fourmula One for Health Program of the
Department of Health (DOH).
The Intervention Model
The Department of Health Women’s Health and Safe Motherhood intervention model seeks to
deliver in selected health facilities an integrated package of services that are critical to
improving women’s health and preventing maternal death.
The package of services consists of maternal and newborn care, family planning, STI
screening and adolescent and youth counseling and is offered to women and men of
reproductive age seeking care for any reproductive health concern. Such an integrated
approach to service delivery seeks to –
• Maximize client visits
• Avoid missed opportunities, and
• Ensure cost-effectiveness in the delivery of critical interventions.
The Paradigm Shift
The maternal and newborn care package is characterized by a paradigm shift from the risk
approach that focuses on identifying pregnant women at risk of complications to one that
considers all women at risk of such complications. This is mainly in response to the
previously mentioned findings that reveal the inability of antenatal protocols to accurately
predict the onset of complications during childbirth. The new strategy therefore seeks to
encourage women to give birth in conveniently located facilities that are suitably equipped to
render Basic Emergency Obstetric and Newborn Care (BEmOC). Complicated
pregnancies and those needing caesarian sections and blood transfusions are referred to higher
level facilities rendering Comprehensive Emergency Obstetric and Newborn Care
(CEmOC). The network of BEmOC and CEmOC provider facilities is deployed in such a
manner as to allow women to access the services they need within a timeframe that ensures a
safe outcome.
9
Paradigm Shift in Maternal Care Service Delivery
I dentifies hig h risk preg n ancies
Ri sk Ap pro ach f o r ref erral d uring the p ren at al
p erio d
C o nside rs a ll p re gna nt w o m en to
be at risk o f co m plic atio n s at
Em O C App ro ach childbirth .
W H SM T e a m s
Skill e d Atte nda nts
The fully specified integrated Women’s Health and Safe Motherhood Service Package
(WHSMP-SP) is as follows:
1. Maternal and newborn care services that recognize the difficulty of predicting the risk of
complications that may occur during delivery and therefore tries to address the risk for all
pregnant women by encouraging them to give birth in facilities that provide emergency
obstetric and newborn care where they can be assisted by skilled health
professionals.
2. Improved quality of Family Planning (FP) services through–
• More meaningful and client-sensitive counseling,
• Expanded service availability,
• Organization of more itinerant teams providing permanent methods and Intra-Uterine
Device (IUD) insertion on an outreach basis;
3. Integration of Sexually Transmitted Infection (STI) control services into maternal care
and family planning protocols, wherever appropriate; and
4. Outreach programs for
• Young adults
• Commercial sex workers, including those working freelance. –
10
This integrated service delivery strategy is focused on maximizing synergies among
these key services and on ensuring a continuum of care across levels of the referral
system. At the ground level, this implies that a woman, whatever her age and especially if she
is disadvantaged, who seeks care from a public health provider for reproductive health
concerns, could expect to be given a comprehensive array of services that addresses her most
critical reproductive health needs.
The Shift in Health Service Delivery
Centrally Governed Health Programs LGU Governed Health System
Maternal Maternal
Newborn Care Newborn
Care
Family Family
Planning Planning
STI Prevention and STI
HIV Control Prevention
and HIV
Control
Adolescent &
Youth Health Adolescent &
Youth
Equally important is the change in the management approach to the delivery of the WHSMP-
SP. Such a change involves a shift –
• FROM a centralized approach to managing national health programs (with the DOH
central office as the hub), where each program operates independently of the other
programs
• TO a decentralized approach where the LGU is viewed as the health system manager
and where services are delivered in an integrated fashion.
Such a devolved approach is envisioned to ensure that the implementation of the
integrated model is responsive to the local situation.
11
Chapter 2
GETTING THE LGU COMMITMENT
Getting Started
The Advocacy Process
The Project Strategic Covenant
Organizing the Buy-in
The Memorandum of Agreement
12
Chapter 2
GETTING THE LGU COMMITMENT
A devolved approach to service delivery requires that the LGU develop a sense of ownership
over the service delivery system and have a high level of commitment to its objectives. This
section suggests a collaborative process between DOH and the LGU towards achieving these
goals.
For maximum impact, cost-effectiveness and efficient governance, the WHSMP2 is
established province-wide. Provincial coverage allows the establishment of a
comprehensive referral network involving facilities at different levels of the health care
system, thereby ensuring that a significant number of target clients benefit from the
Project and that its contribution to the overall national goal is sufficiently felt.
GETTING STARTED
A critical objective of this phase is to develop a province-wide network of stakeholders
that would exercise ownership over the Project and take the lead in the implementation
of the service delivery model. Such a network starts with the governor of the province and
the provincial health officer. The provincial health officer, being the highest ranking health
care official in the province has to appreciate the technical feasibility of Project
implementation and the benefits that it would bring to the province. Being the chief technical
adviser to the governor, he is key in making the governor and the other political leaders in the
province (e.g., the provincial board, the municipal and city mayors and their respective
boards) appreciate the cost and benefits of embarking on the Project and in arguing that the
expected Project benefits to provincial constituents make the cost worthwhile. The provincial
health officer also leads the municipal health officers and selected hospital heads in
implementing the Project investment plan for the province and in making operational the
service delivery model.
Since the service delivery model relies critically on the role played by community-based
workers and on the support afforded by the community, it is likewise important to organize a
network of community advocates at an early stage. It is usually not difficult to organize such
community-based networks for a government sponsored project since the local leaders have a
vast network of groups that can be utilized to do much of the ground work needed to
introduce the Project to communities in the province. The challenge is getting these leaders to
realize the need for the Project in their communities.
The Advocacy Process
The process of advocating for the Project among critical LGU stakeholders may be expressed
in stepwise fashion as follows:
Step 1: Getting the stakeholders to appreciate the Project. Establishing LGU ownership
over the Project is key to successful Project implementation. This step is vital to generating
such a sense of ownership among critical stakeholders of the Project. The important Project
elements for them to appreciate are:
(1) The Project rationale
(2) The Project objectives
(3) LGU benefits from the Project
(4) Strategies and key activities
(5) Project partners and stakeholders
(4) Investments needed
13
(5) Fund sources to finance investments
Stakeholder Involvement ensures success in
Project Implementation.
The best way to ensure this is to develop
PROJECT OWNERSHIP by critical stakeholders
such as local leaders, health service providers,
communities and clients.
Step 2: The “BUY-IN”: Getting the LGU Commitment
Advocacy efforts at various levels of the political hierarchy should focus on generating a
consensus to support the Project. Once such a consensus is arrived at, the project team should
put down in writing points of agreement that would allow both the advocacy and planning
processes to move forward. Such a document may take the form of a strategic covenant as
was the case for Sorsogon and Surigao Sur. The covenant seeks to translate political support
for the Project into a document that manifests commitment to Project objectives.
THE PROJECT STRATEGIC COVENANT
A Strategic Covenant is a pledge made by both parties -- in this case, the Department of
Health and the Provincial Government -- signed and made public in a “Project Buy-In
Forum”. It is a pledge that manifests agreement with the objectives of the Project and to
support its implementation. Key stakeholders that include all mayors, members of the
Provincial or City Boards, Chair of the Municipal Health Boards, Provincial or City
Treasurer, other provincial and municipal officials are invited to participate in the Forum and
witness the signing of the Covenant. Members of the local media are also invited to help
make constituents aware of the Project.
The Strategic Covenants between DOH and the provincial governments of Surigao and
Sorsogon include the following provisions:
1. Agreement to jointly achieve the following important health goals:
1.) To reduce the risk of dying from childbirth-related causes by getting all pregnant
women to deliver in health facilities providing adequate emergency obstetric and
newborn care attended by skilled health professionals.
2.) To help women and men of reproductive age avoid unintended pregnancies by
enabling them to freely and with full information, practice legally permissible family
planning methods of their choice from among a full menu of methods made
universally available in the locality.
3.) To reduce the risk from sexually transmitted infections, including HIV, by
a. Limiting vulnerability to such infections among people involved in commercial
sex and
14
b. Assuring access to correct diagnosis and effective treatment by everyone exposed
to such infections while protecting their privacy.
4.) To pilot test measures and activities that would reduce the risk faced by adolescents
from sexual activity, such as exposure to unintended pregnancies and sexually
transmitted infections.
2. Service delivery agreements:
1.) Implement a locally appropriate version of the DOH-recommended women’s health
and safe motherhood service delivery model that call for the establishment and proper
maintenance of:
a. Strategically located health facilities that offer basic and comprehensive
emergency obstetric care, a wide range of family planning services, appropriate
STI and HIV diagnosis and treatment, and
b. A program for adolescent and youth health.
2.) Encourage selected public and private health care providers to apply a new harm
reduction approach that respects the client’s privacy, for those involved in and
affected by commercial sex so that they can better protect themselves from sexually
transmitted infections and thus reduce the risk of their wider transmission.
3.) Develop, implement and evaluate with assistance from an NGO, pilot activities to
reach and serve adolescents and youth most likely to be exposed to the risk of early
sexual activity, unintended pregnancy and sexually transmitted infections.
3. DOH support to LGUs in the form of:
1.) Policy and technical guidelines that will provide the enabling environment and
technical direction for the effective implementation of the service delivery model.
2.) Technical assistance to establish an effective Human Resource Development System
to assure that key health providers have the necessary skills and incentives to carry
out their respective roles.
3.) Project monitoring and evaluation system to allow the tracking of performance
against project goals.
4.) Grants for NGO contracting to make available specialized skills needed to address
STI-HIV as well as adolescent and youth concerns.
5.) Ensure readily available blood supply and essential life saving drugs for obstetric
emergencies.
6.) Assist in making PhilHealth benefits universally available to target clients of the
project.
15
4. Agreements relative to making appropriate investments in facilities, skills and
systems improvements:
1.) Create locally appropriate administrative mechanisms to efficiently and routinely
coordinate the planning and implementation of health programs serving the LGU for
their more effective performance in the context of health sector reform under the
FOURmula ONE strategy.
2.) Ensure that the Provincial and Municipal Health Offices are sufficiently staffed with
qualified personnel.
3.) Establish a system of accrediting private providers to address skill gaps and to
strengthen the service delivery network.
4.) Allocate sufficient local funding by creating a separate line item for women’s health
and safe motherhood concerns that will be used to finance procurement of service
essential goods and commodities, including a full menu of modern contraceptive
methods, in quantities necessary to achieve local goals.
5.) Adopt specific plans for financing local recurrent costs of service delivery through a
combination of increased local budgetary outlays, cost recovery by way of user fees
and increased access to PhilHealth financing by enrolling more members and
accrediting more service providers.
6.) Set in place systems to support financial sustainability such as
a. Client classification,
b. Facility-based revenue retention and
c. Enhanced revenue management
7.) Adopt local legislation that will mandate local administrative practices, fiscal
policies, and regulatory practices to support the implementation of the WHSM-SP
and its support mechanisms.
The strategic covenant is signed jointly by the Secretary of Health and the Provincial
Governor in the presence of their respective witnesses: the Director of the Center for Health
Development and the Provincial Health Officer.
Organizing the “Buy-In”
The buy-in forum is an important activity since it introduces the Project to the province as a
whole. It also makes public the commitment of the
political hierarchy to the Project through the signing of
the strategic covenant. The covenant establishes a
foundation of sorts upon which further advocacy efforts
and Project planning and preparatory activities could be
built.
It is therefore critical that the Buy-In Forum be
organized in such a manner as to ensure the widest
participation of stakeholders and be given the publicity it
needs to generate public awareness for the Project,
especially the benefits that it seeks to bring to the
province. The following gives a detailed, step-by-step
16
description of the process involved in organizing the Forum, including the respective roles in
the process of the DOH and LGU Project proponents.
The process of organizing the strategic covenant is initiated by DOH Project proponents: the
Center for Health Development (CHD) with assistance from the Central Office Project
Management Team. The CHD Project Coordinator consults with the Provincial Health Officer
(PHO) and the designated Provincial Project Coordinator regarding the conduct of the “buy-
in”. Together, they decide on the following details:
1) Schedule: date and time
2) Venue
3) Whom to invite at central, regional and local levels
4) Number of participants from central, regional and local levels
5) Cost of the activity, which should include venue, meals and accommodation of
central and regional participants.
The CHD coordinator informs the Project Management Team (PMT) of the decisions made to
allow the PMT to prepare the logistics required and transfer funds on time.
After the above details are defined, and the PMT is appropriately
informed, the Program for the “buy-in” is drafted by the CHD
Coordinator together with the PMT. To save on time and travel costs,
consultations to organize the “buy-in” are usually undertaken using
electronic communications media, unless face-to-face meetings are
deemed necessary to iron out issues.
A Sample Program for the Project Buy-In Forum
Women’s Health and Safe Motherhood Project
LGU Buy-In Forum
Welcome Remarks Director
Center for Health Development
Presentation and Introduction of Participants CHD or PHO Coordinator
Inspirational Talk Undersecretary of Health
Presentation: Overview of Women’s Health Project Technical Coordinator
and Safe Motherhood Project 2
o Objectives
o Intervention Model
o Project Investments
o Project Benefits
o Project Outcome
Presentation: The Strategic Covenant Project Technical Coordinator
OPEN FORUM
Covenant Signing Provincial Governor /City Mayor
and
Department of Health
Closing Program
Emcee: CHD or PHO Coordinator
17
The covenant, while not legally binding, signifies the LGU’s commitment to support and be
part of the Project. It also allows the proponents to intensify technical assistance for
preparatory activities. However, advocacy should not end with covenant signing. While
governors and mayors are key LGU stakeholders and their support is important it is equally
important to secure the commitment of the members of the Provincial, City and Municipal
Boards. Legislative board approval at these levels is necessary for the collaborative effort
between DOH and the province to move from one that is manifested by the Strategic
Covenant to a legally binding relationship. The following section describes the process of
progressing towards such a stage.
THE MEMORANDUM OF AGREEMENT
A legal document that defines the working relationship between DOH and the LGU in
implementing the Project is important not only to bind the proponents to their commitments
to the Project but also to give the LGU legal cover to share in the investment requirements of
the Project. While DOH tries to make available to the LGU possible funding sources in the
form of either loan or grant funds, the LGU may nevertheless have to commit some of its own
resources to finance some of the investment
and operational requirements of the service
delivery model. The local chief executive
would need approval from the legislative board
to be able to make such a funding commitment.
Women’s Health and This means a sense of ownership over the
Safe Motherhood Project 2 Project would need to be developed among the
members of the LGU legislative boards,
MEMORANDUM OF especially those who compose the committees
AGREEMENT
on health. They need to make the board
DOH and LGU members appreciate the following:
• The provincial health situation, especially
as regards women’s health,
• How the Project can help address maternal
and newborn deaths in the province and in
the process, improve the reproductive
health status of women and the rest of the
population;
• Investment and operational requirements of
the service delivery model;
• The share of the LGU in these requirements.
Experience shows that the greatest advocacy hurdle at this stage of the Project is getting
the Board Members to formally support the Project. This is usually because of the Project
requirement that such formal support be accompanied by a financial commitment by the
LGU. However, experience also shows that such initial reluctance is usually effectively
addressed by a clear presentation of Project costs and benefits. It is hard to argue against
saving mothers’ lives and those of their unborn children. Investing in health facilities and in
the training of health providers to allow the public health system to perform such life-saving
functions carries a lot of political weight and this is soon appreciated by astute politicians who
are sensitive to the need of their constituents. Such a presentation is usually delivered during
a meeting of the Legislative Board by the PHO (or the MHO in the case of municipalities).
The compact disk (CD) that accompanies this Manual contains such a presentation.
Concurrence by the Board comes in the form of a resolution that authorizes the Governors
18
and the Mayors to sign the Memorandum of Agreement (MOA) with DOH to implement
WHSMP2 in the province and its constituent municipalities.
However, before such a presentation could be made, the Project Management Team needs to
do a lot of ground work first. The Signing of the Strategic Covenant gives the Project
proponents the “go signal” to undertake social and technical preparation activities,
primarily to determine the investment requirements of the LGU and developing an
investment plan. Such activities are conducted in parallel with a continuing advocacy effort
directed at local board members and officials that are involved in planning and
implementation stages such as the treasurer, budget officer and the planning officer. The
preparation phase can take from 6 months for grant projects to 3 years for loan projects.
The process usually involves:
• The mapping of facilities that would be
upgraded to be able to deliver Basic Emergency
Obstetric and Newborn Care (BEmOC) and
Comprehensive Emergency Obstetric and
Newborn Care (CEmOC)
• An assessment of the upgrading needs of each of
the facilities that constitute the BEmOC-
CEmOC network of the province
• The formulation of an investment plan that
addresses these needs.
Outputs from the above activities give a clear sense of
the investment costs of the Project. This equips the
Project Team with the hard numbers needed to make a
presentation before the Local Board. The process of
generating these estimates is described in detail in
Chapter 3.
LGU participation in the Project is formalized through the enactment of a Memorandum of
Agreement (MOA) signed by the local chief executives and supported by a resolution issued
by the Sangguniang Panlalawigan (Provincial Board) and the various Sangguniang
Pambayan (Municipal Boards) authorizing the Governor and the Mayors to enter into formal
agreement with the Department of Health. The MOA commits the Provincial and
Municipal LGUs to the overall implementation and financing obligations of the Project,
with technical guidance from the DOH.
The MOA for WHSMP2 contains the following provisions:
To set Project into operation, the governors are made to essentially commit to the following:
1. Invest in civil works to upgrade health facilities identified in the provincial BEmOC-
CEmOC map.
2. Procure equipment essential to the delivery of quality women’s health services and
provide adequate funds for operating costs of the selected LGU facilities.
3. Provide the required equity for the loan (in cases where the chosen financing mechanism
is a loan).
4. Organize inter-local health zones (ILHZs).
19
5. Provide policies and operating plans for client classification, revenue retention and cost
recovery.
6. Ensure that health facilities are fully staffed.
7. Provide adequate support for staff training.
8. Make funds available for the procurement of essential women’s health drugs and family
planning commodities.
9. Organize Women’s Health and Safe Motherhood Teams and finance their activities.
10. Enroll indigent families to PhilHealth-Sponsored Program and support initiatives towards
accreditation of health facilities.
While the Provincial Government takes the lead role in Project negotiation, all municipalities
in the Province are critical partners. It is therefore important to get the mayors to participate
fully in all Project activities. This is best accomplished by organizing meetings and
conducting an intensive advocacy effort directed at mayors and the local boards to enlist their
support in getting the municipal governments to effectively carry out their assigned tasks and
to come through on their financial commitments to the Project.
To demonstrate their intent to participate fully in the Project, and hence to be eligible to
benefit from Project support, the Municipal Mayors are also made to sign a Memorandum of
Agreement with the Provincial Governor, supported by a resolution passed by the
Sangguniang Bayan (Municipal Board). The resolution authorizes the Mayors to enter into
an agreement with their respective provincial governors relative to WHSM Project
implementation and operation. The MOA specifies the implementation and financing
obligations of the signatories and commits each mayor to issue a local order that
includes the following key provisions:
1. Designate the MHO as the Project Coordinator responsible for Project implementation in
the municipality.
2. Instruct the MHO to organize WHTs from among the midwives of the Municipal Health
Office, BHWs and TBAs in the community in accordance with the Operational
Guidelines.
3. Enroll qualified indigent families in the PhilHealth Sponsored Program in accordance
with the guidelines set by Philippine Health Insurance Corporation (PHIC).
4. Establish and maintain a Project Account equivalent to operating expenses for 3 months.
5. Require the full participation of LGU officials, particularly health care providers in
Project activities.
Organizing a series of advocacy and orientation meetings with Local
Chief Executives including the Local Boards, health officers and other
stakeholders is a process that is essential in getting them to appreciate
the benefits that they may gain from the Project. This eventually leads
to an official commitment to support the initiative.
The MOA signing officially starts Project implementation.
20
Chapter 3
DETERMINING LGU NEEDS
Analysis of the Women’s Health Situation
Identification of Issues that are Critical to the Successful Implementation
of the WHSM – SP
Presenting the Results
Establishing a Cost-Effective Provincial Women’s Health and
Safe Motherhood Facility Network
Facility Mapping Exercise
Needs Assessment: A Process of Determining Investment Requirements
Estimating Project-Related Incremental Changes in Operating Costs
The Investment Planning Process
21
Chapter 3
DETERMINING LGU NEEDS
Towards Rational Investments and Actions
With the covenant already signed, Project proponents from both the DOH and the LGU now
have the green light to undertake further preparatory work towards building a case for
implementing WHSMP2 in the province. The overarching objective of the effort is to
generate estimates to allow a fairly rigorous analysis of the costs and benefits to the province
of implementing the Project. The estimates should, however, be disaggregated enough to
allow drilling down to the municipal level.
These cost-benefit estimates are to be incorporated into the presentations that need to be made
before the Legislative Boards at both the provincial and municipal levels. The presentations
have to be simply and directly stated so as to be appreciated by even those without medical
backgrounds. The arguments also need to be compelling enough to convince the Board to
allocate the necessary counterpart funding that the Project requires.
The process of generating the Project cost estimates are described below and consists of four
major activities:
• An analysis of the situation
• Establishing a cost-effective Provincial Women’s Health and Safe Motherhood Facility
Network
• Estimating the cost of setting up and operating the network
• Crafting an investment plan
The resulting investment plan identifies investment inputs from DOH as well as counterpart
investments from the LGU. The plan is to be incorporated into the broader Provincial
Investment Plan for Health (PIPH).
AN ANALYSIS OF THE WOMEN’S HEALTH SITUATION
An assessment of the local health situation is carried out mainly to:
• Identify major reproductive health problems in the province, particularly the most
common causes of mortality and morbidity among women,
• Spot mitigating or aggravating environmental, socio-economic and demographic
factors,
• Establish the location and dispersion of target groups, and
• Map the existing public health network to identify service delivery gaps.
The required data is collected using a Demographic and Facility Mapping Questionnaire
incorporated into the Integrated Needs Assessment Tool (this tool is described in
comprehensive detail later on in this section). The Provincial or City Health Office (P/CHO)
administers the questionnaire and compiles information on:
1. The population and women’s health profile disaggregated by age group, and geographic
(rural-urban) distribution.
2. The population size and geographic distribution of the target population of each of the
four components of the WHSM-SP.
3. Service data (e.g., skilled birth attendance and home-based vs. facility-based deliveries,
22
PhilHealth membership, etc.)
4. All health facilities in the province at each level of service delivery (barangay,
municipal, district, provincial), with detailed information for each on:
1.) Its sector classification (i.e., government, private, NGO, Cooperative, etc.)
2.) Catchment population size
3.) Crude birth rate in the facility’s catchment area
4.) Catchment area size, measured in square kilometers
5.) Travel time to the facility from each catchment LGU and each household in the
catchment area.
6.) Travel time between the facility and the nearest referral facility
7.) Current women’s health services offered, bed capacity, key staff such as obstetric-
gynecology specialist, general practitioner trained in surgery, anesthesiologist, nurses
and midwives
5. All Social Hygiene Clinics (SHCs) and Adolescent and Youth Centers (AYHCs) in the
province and city, including their geographical location
6. Communities that host groups seen to be prone to high risk sexual behavior (e.g.,
adolescents and the youth, commercial sex workers) and the NGOs that address their
reproductive health needs.
7. The information collected from the questionnaire is compiled and organized to allow an
assessment of each health facility’s relative suitability to become a service delivery point
for integrated women’s health services. The assessment includes:
1.) An analysis of the geographic distribution of identified risk groups
2.) Gaps in service delivery
3.) Accessibility of facilities
4.) Current utilization of services by intended beneficiaries.
Issues That are Critical to a Successful Implementation of the WHSM-SP
In addition, information that would give insights on the following issues that are critical to the
success of Project should also be generated. It is important to have a sense of how these
issues would play out in the local situation. Such knowledge could guide the crafting of a
strategy that fits the local environment and addresses the most pressing needs of the target
population:
1. An important objective of the project is to encourage mothers to give birth in BEmOC
provider facilities rather than at home. It is therefore important to get a sense of the
reasons behind the current preference of almost half of the pregnant women to give birth
at home. Experience reveals that many have to do with the economics of the choice but
there are also reasons that are situational in nature and are therefore location specific.
These reasons will have to be discovered. The following is a list of the most common
reasons given. However, it is not exhaustive. There may be others that are just as critical
to addressing this issue:
• Distance from the home of the nearest facility
• Cost of transportation and the unreliable trip schedules of public transport
carriers
• Rough terrain and poor road network
• Cost of medical care in a facility
23
• Condescending attitude of health workers especially towards the poor
2. A critical ingredient in effecting this behavioral shift on the part of mothers is the
success of advocacy efforts of the Women’s Health Team (WHT). The TBA plays an
important role as a member of the WHT, since it is the TBA who usually assists in a
home birth scenario. The support of the TBA in the advocacy effort to convince
mothers to give birth in a facility instead of at home is therefore critical to success.
Among the questions that need to be answered in this regard are:
• How widespread is the perception among the TBAs and health workers that
the TBA could best serve as an assistant to the midwife?
• What could serve as an incentive towards encouraging the TBA to abandon
her independent practice and join the WHT and be a subordinate to the
midwife?
3. The major causes of maternal death (e.g., obstructed labor, eclampsia, puerpal sepsis
and hemorrhage) are partly addressed by increasing geographic access to facilities that
are capable of rendering emergency obstetric and newborn care. The approach of
WHSMP2 in this regard is to strategically locate possible BEmOC and CEmOC
provider facilities so that they form a cost-effective network that ensures timely access
to the needed emergency procedure at the appropriate level of care. This makes the
geographic location of the facility relative to the households in the community quite
critical. To ensure timely access to the facility, travel time by the most common
means is the measure of choice. Aside from geographic distance, travel time is usually
influenced by such factors as:
o The geography of the
province (it could have
island municipalities, rivers
that need to be crossed or
mountains to trek),
o Terrain,
o The weather,
o Road conditions (assuming
there are roads, which is not
always the case for remote
communities), and
o The transport system (its
presence and efficiency).
Since not all of the above factors may
conspire at the same time to delay (or
speed up) travel, an estimate of travel
time can be quite subjective. However,
measuring access in terms of distance is
not necessarily better. Even in urban
areas where the roads are usually paved,
travel time over a certain distance may
vary a lot depending on the traffic. The
same is true for a remote mountain
passage where travel time is hostage to
the weather, the size of potholes and the
24
consistency and depth of mud on the road.
A sample accessibility profile is shown in the following table that presents a summary of
approximate travel time for Sorsogon and Surigao Sur, from a reference site to the nearest
secondary or tertiary referral facility.
Accessibility Profile of Sorsogon and Surigao del Sur
Accessibility
Province Health Facility (approx. travel time and frequency
of commercial transport)
Surigao del Sur Bislig 2 hours to Agusan del Sur, Provincial Hospital in
Prosperidad. Last bus trip to Butuan City leaves the city
at 4:30 p.m. The facility is 15-20 minutes by tricycle
from the city center (Mangagoy).
Lingig 2.5 hours to Provincial Hospital in Agusan del Sur; 30-45
minutes to Bislig District Hospital via unpaved road
through central jeep terminal in Mangagoy.
Sorsogon Donsol 1 hr by van from Daraga, Albay terminal, the nearest
access to Albay Provincial Hospital. From Sorsogon City,
passenger usually has to catch the van at the Putiao
junction and then take a jeepney from Daraga to Donsol
Sorsogon 1.5 hrs. by commercial transportation from Daraga, Albay
Provincial and from Sorsogon city proper (by tricycle).
Magallanes 1 hr by private vehicle. Public transport can take up to
1.25 hours from the city central jeepney terminal. Jeeps
leave every hour up to 5 or 5:30 p.m.
Irosin 45 minutes to 1 hr by public transport to Sorsogon City,
along winding but well-paved roads. The district hospital
is a short tricycle ride away from the town proper. Jeep
and bus rides are regularly available. Buses are available
from Bulan and Matnog.
Matnog Travel time is 15 to 20 minutes to Irosin District Hospital.
Matnog is the gateway (through a 45-minute ferry boat
ride) to the Visayas island province of Samar. The
community hospital is located along the highway and is
about 5 minutes away from the town center.
In addition to determining the approximate travel time from homes to health facilities and the
frequency of travel of public utility vehicles, it is also important to establish the accessibility
of the road network from the community. For remote and isolated communities, reaching the
road where public transport is available may take hours or even days of walking or traveling
through unconventional means (e.g., horseback, banca, etc.) Reaching a health facility on
time is crucial in saving lives, especially in the case of childbirth. Thus it is important to
determine the obstacles that stand in the way of achieving this objective so that appropriate
measures could be taken to address them.
25
Road Accessibility Map of Sorsogon
Legend:
■ Provincial Capital / Center ● 2WHSMP site ♣ Regional Center
Developed / paved road access Unpaved road access
26
Road Accessibility Map of Surigao del Sur
Tandag
Butuan♣
Surigao del Sur
Prosperidad
Agusan del Sur PHILIPPINES
Bislig
Lingig
Legend:
■ Provincial Capital / Center ● 2WHSMP site ♣ Regional Center
Developed / paved road access Unpaved road access
Presenting the Results of the Situational Analysis
The results of the situational analysis should be laid down to give the LGU a sense of what
they need to do in order to achieve the Project objective. Findings should be focused on the
following concerns:
1. The overall health condition of the population.
1.) Number of babies born every year
2.) Number of women dying due to maternal causes
3.) Number of contraceptive users
4.) Other relevant information
27
2. The availability and accessibility of health facilities
1.) Number of hospitals, rural health units and barangay health stations in each
municipality and their location
2.) The travel time from the homes to the facilities
3.) Availability of transportation facilities
4.) Road conditions
3. Women’s preferences as to place of delivery (home versus facility) and attendant at
delivery (TBA versus skilled professional).
4. Conclusions.
The conclusions arrived at during the situational analysis should lead to concrete and
actionable recommendations as in the example shown below.
Conclusions Community Diagnosis Recommendations
The women in the community High maternal mortality due to 1. For the LGU to invest in
exhibits the following profile: poor access of women to health upgrading facilities that are
facilities that offer emergency nearest to homes to allow
• Majority is of reproductive obstetric and newborn care. them to deliver emergency
age and is childbearing. obstetric care.
• 90 % of women give birth at
home. 2. For the health workers to
• 80% of those giving birth at advocate and cause the
home are attended by TBAs. women and their families to
• Around 15 % of pregnant give birth in facilities
women developed assisted by skilled health
complications at the time of professional.
delivery during the past
year.
• 2 women died of maternal
causes every month during
the past year.
Above conclusion is further
influenced by:
• Inaccessibility of needed
services at the BHS or RHU
near the homes.
• Emergency obstetric
services are only available
at the Provincial Hospital
located in the Poblacion.
• Public transport system to
the Poblacion is available
only in the morning.
28
ESTABLISHING A COST-EFFECTIVE PROVINCIAL WOMEN’S HEALTH AND
SAFE MOTHERHOOD FACILITY NETWORK
The Provincial Women’s Health and Safe Motherhood (WHSM) Facility Network is a
network of strategically-located BEmOC and CEmOC provider facilities. The choice of
public health facilities that form the network is guided by the following considerations:
• Network coverage should be comprehensive enough as to encompass the whole
province,
• Facilities should be within easy reach of each community in the catchment area,
• Facilities should be sufficiently dispersed as to allow each facility to eventually
become sustainable, and
• Facilities should be cost-effectively deployed.
In order to be able to establish such a network, a Facility Mapping and Needs Assessment
Exercise is first carried out. The exercise consists of two inter-related and highly
participatory activities involving stakeholders to the provincial health system. Facility
Mapping seeks to identify and select strategically located health facilities to be designated as
either a BEmOC or a CEmOC provider facility. The Needs Assessment Exercise, on the
other hand, is designed to assist LGUs determine the investment needs of each facility chosen
to be part of the WHSM Network. Each of these activities is described in detail below. Step-
by-step instructions for their conduct are also presented.
Facility Mapping
The exercise is part of the social preparation phase and is an important activity to
undertake prior to drafting the Provincial Investment Plan for Health (PIPH). It is a
well-defined process for choosing strategically-located health facilities to form the Provincial
WHSM Network. In particular, the Facility Mapping Exercise:
1. Systematically determines the size and location of risk groups,
2. Spots the public health provider network,
3. Defines service delivery gaps,
4. Identifies potential WHSM facilities to address the gaps, and
5. Develops customized facility maps showing the WHSM referral network.
The following describes the process of organizing and conducting such an exercise:
Step 1: Organize a Facility Mapping and Needs Assessment Workshop
To ensure that the intervention model is implemented in a manner that is tailored to the local
situation, a participative Facility Mapping and Needs Assessment Workshop is carried out at
the provincial level. The workshop is participated in by the:
1. Provincial Health Officer,
2. Provincial health office technical staff,
3. Chief of Hospitals, and
4. Municipal Health Officers.
5. If possible, the Mayors and Municipal Planning Officers are invited to participate.
The workshop objectives are:
1. To generate a consensus on the appropriate BEmOC-CEmOC network provider facilities
in the province, and
29
2. To conduct a needs assessment survey of each facility to determine investments required
to upgrade its capability to the standards of the WHSM delivery model.
This exercise is best organized as collaboration between the Center for Health Development
(CHD) and the Provincial Health Office (PHO).
FACILITY MAPPING AND NEEDS ASSESSMENT WORKSHOP
Who Organizes?
The Provincial Health Office (PHO) in coordination with the Center for Health Development
(CHD) Technical and Local Health and Development Divisions organizes a two-day Facility
Mapping and Needs Assessment Exercise.
Who Participates?
All Municipal Health Officers (MHOs) and Chief of Hospitals (COHs) as well as selected
technical staff of the PHO are required to attend.
Local Chief Executives (LCEs): Provincial and Municipal Planning Officers (P/MPDOs), Finance
and Budget Officers, Administrative Officers, Local Board Members and Mayors are enjoined to
attend.
Who Facilitates?
The CHD and the PHO staff collaborate to facilitate the activity with the assistance of the
Provincial Health Officer.
To initiate the activity, participants are first given fairly comprehensive presentations on:
1. The Rationale for Establishing EmOC provider Facilities,
2. The Integrated Service Delivery Model and its Support Structure,
3. The Facility Mapping Process, and
4. The Needs Assessment Process.
(A sample Power Point presentation covering the above topics is found in the accompanying
CD)
The workshop is conducted in two stages:
The first stage involves the selection of proposed CEmOC provider facilities and is done in
plenary.
The second stage involves the selection of proposed BEmOC provider facilities, where the
participants are grouped by inter-local health zones (ILHZ) and are asked to map the proposed
BEmOCs within their respective ILHZ.
30
Sample Program: Facility Mapping and Needs Assessment Workshop
Women’s Health and Safe Motherhood Program
Facility Mapping and Needs Assessment Workshop
Venue__________________________
Date___________________________
Day 1: Opening Program
• Singing of the National Anthem
• Invocation
• Welcome Remarks
Objectives of the Workshop
Presentations:
• Rationale for Establishing EmOC Facilities
o Open Forum
• Facility Mapping
o WORKSHOP: Constructing the BEmOC-CEmOC Map
Day 2: Recapitulation
Presentation of the BEmOC-CEmOC Facility Map
Needs Assessment
• Orientation on the Forms
Synthesis: The Investment Planning Process
Planning for Next Steps
Closing Program
A Manual on Facility Mapping and Needs Assessment has been published and can be
downloaded from the DOH website (www.doh.gov.ph). The manual describes the process in
full detail.
Step 2: Identify and Select WHSM Facilities
The Facility Mapping Process generally involves the following:
1. Do an Inventory of Health Facilities
Inventory of health facilities is done to determine which among them are to be designated
as WHSM facilities, listed as follows:
1) Basic Emergency Obstetric and Newborn Care (BEmOC) provider facilities,
2) Comprehensive Emergency Obstetric and Newborn Care (CEmOC) provider
facilities,
3) Family Planning (FP) service provider facilities,
4) Social Hygiene Clinics or STI service provider facilities, and
5) Teen Centers.
As part of the provincial inventory, the following public health facilities are appropriately
identified and their catchments noted:
1) Barangay Health Stations (BHSs);
2) Rural Health Units (RHUs);
3) Hospitals: District Hospitals, Community Medicare Hospitals, etc.; and
4) Provincial Hospital (PH).
31
The inventory should be able to:
1) Determine the number and location of all BHSs, RHUs, DHs, and PHs.
2) Determine the network of WHSM facilities and show access to those facilities with
emergency obstetric and newborn care capability by carefully plotting each facility in
a provincial map.
If the public health provider network is inadequate to meet the model requirement
for access, the mapping exercise should try to identify and locate the private
providers in the locality and make them part of the network. The responsible health
officials (the PHO and the MHO of the municipality where the private provider is
located) will have to meet with the identified private providers to negotiate their
respective roles in the network and the parameters within which they may function as
members.
The mapping process is easily done using a digital map of the province that could be
downloaded for free from the wikepedia website (www.wikepedia.org). This would
allow one to cut and paste on to the map the chosen color-coded shape for each type of
facility and subsequently plot the chosen BEmOC and CEmOC provider facilities during
the mapping exercise itself, thereby enhancing the interactive nature of the exercise.
Facility assessment and selection are guided by the following parameters, using the
information listed below:
1.) Given each type of facility’s standard range of services, a BEmOC provider facility
can either be:
a. A Barangay Health Station (BHS),
b. Rural Health Unit (RHU),
c. Municipal Hospital (MH), or
d. District Hospital (DH)
A CEmOC facility is either a:
a. District Hospital or
b. Provincial Hospital (PH)
2.) The relative size of each facility’s present catchment population and catchment area
in square kilometers.
3.) The strategic dispersion of the facilities selected across the LGU, to ensure that the
entire population is adequately served.
4.) The concentration across the province of groups at high-risk for sexually
transmitted infections (STIs) or human immunovirus infection (HIV) and of
adolescent and youth groups especially those that demonstrate a high need for
health information and services. This parameter is used to identify sites for
more focused STI control and HIV prevention and adolescent and youth health
(AYH) services.
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2. Select and identify the proposed BEmOC and CEmOC provider facilities and construct
the map. The facility selection process is guided by the following criteria:
1.) Population coverage
There should be at least 1 BEmOC provider facility for a population of 125,000 and
at least 1 CEmOC provider facility for a population of 500,000.
2.) Travel time requirement
A BEmOC provider facility should be at most 30 minutes away from each
barangay in the BEmOC provider catchment and a CEmOC provider facility should
not be more than 1 hour away from each BEmOC in the CEmOC catchment.
3.) Adequacy of human resource.
A BEmOC Team should have a full staff complement of:
• doctor,
• nurse, and
• midwife.
For BHS BEmOC provider, a midwife should be assigned to the BHS full time
with the municipal health officer and nurse available “on call” and alternately
making supervisory visits. Thus, the number of BHS BEmOCs is constrained by the
ability of the doctor or the nurse to supervise them, especially if the BHSs are in
remote barangays.
A CEmOC Team should have the following staff complement providing duty time
per 8-hour shift:
• an obstetric-gynecology specialist or a general practitioner (GP) trained on
CEmOC service provision,
• an anesthesiologist or GP trained in anesthesiology,
• a pediatrician,
• at least 1 medical technologist,
• 2 staff nurses in the maternity ward and
• 1 operating room nurse.
4.) Ensure Financial and Operational Sustainability
Careful selection of BEmOC and CEmOC provider facilities should be observed to
ensure that catchments do not overlap significantly as to hamper operational and
financial sustainability. This serves as an additional consideration in the application
of the travel time criterion. For the catchment areas not to overlap significantly,
BEmOCs should be at least 30 minutes away from each other and CEmOCs 1 hour
apart.
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Criteria for Selection of Emergency Obstetric and Newborn Care Facilities
Criteria Basic Emergency Obstetric Comprehensive Emergency
and Newborn Care Obstetric and Newborn
Facilities (BEmOC) Care Facilities (CEmOC)
Population coverage At least one per 125,000 At least one per 500,000
population. population.
Travel time Thirty (30) minutes from One (1) hour from each
each catchment area using BEmOC facility within the
the most common mode of catchment area.
transportation.
Adequacy of human The BEmOC Team should CEmOC Team has full staff
resource have complete staff complement of Ob-gyn
complement of doctor, nurse specialist or GP trained on
& midwife. CEmOC services provision,
For BHS BEmOCs: There anesthesiologist on call,
should be at least a midwife pediatrician, OR nurses (at
assigned with the MHO and least 1 per shift), staff nurses
PHN “on call” and alternately (at least 2 per shift), medical
making supervisory visits. technologist (at least 1 per
shift).
Financial and Operational Catchments do not overlap significantly as to hamper
Sustainability operational and financial sustainability
Step 3: Spell out other important considerations related to the target population to
justify the selection of the facilities.
These factors may be beyond the set of criteria described above but could be unique to the
community and could therefore entitle the community to some consideration. Examples of
such factors are:
• The community is isolated by natural obstacles (e.g., mountains, ocean, rivers, etc.)
• There is no viable road network and access is only through walking trails
• The area is densely populated and the patient load per facility is such that there is a
need to designate more than one BEmOC provider facility in the catchment area.
Step 4: Define any existing Inter-local Health Zone (ILHZ) arrangement.
This ensures that the provincial BEmOC-CEmOC network is consistent with previously
defined ILHZs. If the ILHZs are effectively functioning, sharing of resources and referral of
patients across municipalities is easier to arrange and coordinate.
The Output
The output of the exercise is a facility map showing the various health facilities in the area
and the identified strategically located WHSM facilities and referral network. The
identification of health facilities for various services is an important component of the model
since it encourages risk groups to avail of services in appropriate health facilities and for
pregnant women who tend towards home births to shift to giving birth in facilities where
emergency obstetric care is available.
34
Under this model –
1. Women who have no pre-determined obstetrical nor medical conditions are referred to
BEmOC provider facilities, and
2. Those having complicated pregnancies and will most likely have difficult childbirth is
referred to CEmOC provider facilities.
Constructing the Facility Map
FACILITY MAPPING
Materials Needed:
• Scale map indicating the health facilities in the Provinces*
• Laptop and
• Liquid Crystal Display (LCD) Projector
• Microphone
Data Requirements:
• Population
o Province and Municipalities
o Facility catchment
• Name of Health Facilities and location
• Travel time from barangays and between facilities using the most common mode of
transportation
• Mapping the CEmOC Facilities
o Based on the facility to population ratio of 1:500,000 determine the minimum
number of CEmOC facilities required for the Province
o Based on the travel time criterion of 1 hour from each BEmOC facility, identify the
best location for a CEmOC facility
o Identify the municipalities covered by each CEmOC catchment area defined in terms
of a one hour travel time radius around each CEmOC facility.
o Assess the extent of areas not covered by this arrangement
o Determine if additional CEmOC facilities is justified based on the travel time
criterion.
o Decide on the number and location of CEmOC facilities.
• Mapping the BEmOC Facilities
o Based on the facility to population ratio of 1:125,000 determine the minimum
number of BEmOC facilities required for the Province.
o Based on the travel time criterion of 30 minutes from each barangay within the
catchment area, identify the best location for a BEmOC facility.
o Identify the municipalities covered by each BEmOC catchment area defined in terms
of a 30-minute travel time radius around each BEmOC facility.
o Assess the extent of areas not covered by this arrangement
o Decide on the number and location of BEmOC facilities
o Determine whether the resulting configuration of facilities in the network is
consistent with requirements of the Family Planning and STI-HIV components of the
intervention model
• Indicate the strategic location of the facilities in the map by assigning color codes for easy
reference.
• The map should also define the catchment boundaries and the referral network.
*Ad l f h b d l d d h h h k d b
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Final Output of the Facility Mapping Exercise.
SORSOGON BEmOC-CEmOC Facility Map
ALBAY
Prieto
Diaz
Sorsogon City
Pilar
Donsol Castilla
Gubat
Casiguran
Barcelona
Juban
Magallanes
Bulusan
Irosin
Bulan
CEmOC Sta.
Magdalena
BHS BEmOC
RHU BEmOC Matnog
HOSP BEmOC
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SURIGAO DEL SUR BEmOC-CEmOC
Facility Map
S UR I G A O
D EL NO RT E
Carrascal
Cantilan
A G US A N
D EL NO RT E
Cortes
Madrid
Carmen
Tandag
Lanuza
Tago Bayabas
San Miguel
Cagwait
A G US A N
D EL S UR Marihatag
San Agustin
Lianga
Barobo
Hinatuan
Tagbina
CEmOC
BHS BEmOC
RHU BEmOC Bislig
HOSP BEmOC
Lingig
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Needs Assessment: A Process of Determining Investment Requirements
After the facility map for the province is agreed on and deemed final, a Needs Assessment
Exercise is carried out to:
1. Assess the capacity of each facility in areas of operation that are seen to be critical to the
effective implementation of the intervention model, and
2. Determine the inputs needed to upgrade the selected facilities to be able to effectively
function as either BEmOC or CEmOC provider facilities.
The needs assessment approach involves a critical look at existing capacity by comparing it
with the requirements of the intervention model. The inputs needed to fill in the gaps that are
identified are then the focus of an investment plan.
The Needs Assessment Process is designed to determine the inputs needed by each
proposed BEmOC and CEmOC provider facility in order to upgrade its capability to
the requirements of the service delivery model.
1. Each facility head is asked to accomplish a survey form that elicits a detailed description
of the existing infrastructure, equipment and staff skills.
2. This is then compared with the requirements of the service delivery model to determine
the resource gaps that would need to be filled using as benchmarks the WHSM-SP
requirements that integrate DOH licensing and PhilHealth accreditation standards.
3. The costs of the inputs to fill these gaps are eventually incorporated into the Provincial
Investment Plan for Health (PIPH).
The second Needs Assessment Workshop involves the following activities:
Step 1: Orient the proposed BEmOC provider facility heads (MHOs and COHs) on the
Integrated Needs Assessment Tools (INAT).
Needs assessment is undertaken using the Integrated Needs Assessment Tool (INAT) and the
resulting BEmOC-CEmOC facility map, which are designed to:
1.) Analyze how well the current health system in the project areas carries out vital functions
relative to WHSM service provision, resource generation, financing, and guardianship.
Analysis is done by:
a. Making an inventory of WHSM services and resources currently available in the area
and their levels of utilization among different groups of disadvantaged women. This
inventory includes public and private providers.
b. Making an assessment of the principal causes of unmet need in the service areas to
determine priorities to fill these needs, identifying both:
a) Supply-side factors such as service availability, service quality, etc. and
b) Demand side factors such as ability to pay, cultural beliefs, etc.
2.) Compare how each facility in the WHSM Network fares in relation to the WHSM-SP
requirements, which integrate the licensing and accreditation standards of DOH and
PhilHealth.
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The INAT consists of 8 sets of questionnaires
(Forms 1 to 8), each designed to capture
specific information on a facility’s services,
Women’s Health & resources, and support systems relating to
Safe Motherhood Maternal and Newborn Care, Family Planning,
Project 2
and STI-HIV. The questions are specific to
each type of facility (BHS, RHU and District
Integrated
Hospitals for upgrading to BEmOC standard;
Needs Assessment
District and Provincial Hospitals for upgrading
to CEmOC standard) so that each proposed
facility has its own set of Forms 1 to 8. Each
form is described as follows:
Form 1: Facility Management Tool collects
general information on the human resources in
each facility (principally the skill set of the
staff), service accessibility and availability as
well as information on the catchment
population.
Form 2: Facility Functioning Assessment Form, lists the services provided by the facility
for each component of the service delivery model (MC and NB, FP, STI-HIV).
Form 3: Infrastructure is a checklist of physical space provided and utilities, means of
transport and communications available for the conduct of services.
Form 4: Furniture and Linen, determines the available and functional furniture and linen
used for each type of service.
Form 5: Equipment, lists each piece of functional and non-functional machine, apparatus,
and tools (classified as vital, standard and special) and the quantities available in each
facility.
Form 6: Drugs and Commodities, is a checklist of quantities of un-expired medicines and
commodities.
Form 7: EmOC Recording System, addressed only to emergency obstetric care facilities,
asks about data or information sources, the manner in which they are used, and the
information to be obtained.
Form 8: Financing, asks how the facility projects demand, monitors the budget, classifies
clients, recovers costs, determines service rates, and manages funds. It also asks about rates
charged, PhilHealth reimbursements, expenditures on each component, and financing sources.
A similar set of questions plus services and programs offered, is addressed to Provincial and
Municipal Health and Population Offices.
Step 2: Provide each Municipal Health Officer and Chief of Hospital whose facility is
being proposed for upgrading to BEmOC and CEmOC provider with a set of the INAT.
Step 3: Plan for the Next Steps.
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As the accomplishment of the Needs Assessment forms cannot be completed during the 2-day
workshop, a plan for follow on activities is drafted. Essentially, this plan will consist of:
1. Time frame for the conduct of the Needs Assessment.
2. Date of submission of filled-up forms to PHO and CHD.
Step 4: Consolidate and analyze data using the Facility Needs Assessment Manual as
reference. This task is to be performed by the CHD coordinators.
An estimate of the cost of the needed inputs is also presented. The Manual on Facility
Mapping and Needs Assessment has dedicated a section that describes how the results are
analyzed and offer templates for consolidating and analyzing the data. Please access the DOH
website at www.doh.gov.ph. for a copy of the manual.
The analysis of Needs Assessment results focuses on three main areas:
1. Human Resource,
2. Infrastructure and Equipment Upgrading, and
3. Technical Assistance Needs for Financial Sustainability.
Use the data generated by the Needs Assessment exercise to identify investment priorities.
The Needs Assessment exercise seeks to ensure that facilities are adequately equipped and
staffed. Based on the results of this assessment prepare the following:
1. List of Equipment, which the LGU needs to procure for its WHSM facilities. The
facility needs assessment identifies equipment upgrading requirements for each facility
based on its role in the network and ensures that these are in accordance with international
and national standards. The equipment is categorized into vital, standard and specialized:
1.) Vital List – Identifies the most basic equipment needed to operate BEmOC, CEmOC
and SHC facilities in accordance with the standards of the service delivery model.
This list is considered “first priority” in judging the operational capability of
the facility.
2.) Standard List – Identifies equipment deemed important but not critical to the
delivery of essential WHSM services.
3.) Special Equipment List - Identifies specialized equipment needed for more
sophisticated treatment protocols.
2. A Human Resource inventory that compares the staffing requirements of the model
with the current number of staff in the public sector and their skill set. A final output is
the local adaptation of the WHSMP2 Human Resource Training and Development
(HRTD) strategy that includes:
1.) A staffing complement list for each of the following Women’s Health and Safe
Motherhood Teams (WHSMT):
a. Women’s Health Team (WHT),
b. BEmOC Team,
c. CEmOC Team,
d. Itinerant Team for family planning outreach activities and
e. Social Hygiene Clinic Team.
40
2.) Inter-LGU staffing arrangements (including arrangements with private sector
providers, if needed),
3.) Training needs, and
4.) Incentive schemes.
3. A Communications Plan defining the local adaptation of the Behavior Change
Communication strategy that includes identification of priority areas for change and
target groups.
4. A Sustainability Plan to support the establishment of systems for:
1.) Client segmentation,
2.) Safe blood supply,
3.) Drug and contraceptive security, and
4.) Local financing.
Step 5: CHD coordinators to present the results of the Facility Mapping and Needs
Assessment to concerned LGUs and CHD stakeholders.
Step 6: CHD and provincial stakeholders drafts an investment plan for WHSM
initiative and cause it to be inputted into the Provincial Investment Plan for Health
(PIPH).
Step 7: CHD coordinators to submit the Facility Map and Needs Assessment Results of
each province under the CHD catchment to the National Center for Disease Prevention
and Control (NCDPC).
Step 8: NCDPC presents results to the DOH technical committee for approval.
Step 9: NCDPC allocates funds to support the provinces’ plans in coordination with –
1. The National Center for Health Facilities Development (NCHFD) for the infrastructure
and safe blood requirements,
2. Health Human Resource Development Bureau for the training requirements,
3. Bureau of Health Devices and Technology for the equipment specifications, and
4. National Center for Health Promotion for the behavior change communication plan.
ESTIMATING PROJECT-RELATED INCREMENTAL CHANGES IN OPERATING
COSTS
It is important to have a fairly robust estimate of the Project-induced incremental increase in
facility operating costs since these costs are to be funded out of the LGU counterpart. LGU
budgets, especially at the municipal level, are usually quite tight and could therefore not
accommodate too much variance. Thus precision is important in generating these cost
estimates. “The Provincial Investment Plan for Women’s Health and Safe Motherhood” need
only to focus on 2 categories of operating costs:
1. Operating costs for service delivery and
2. Operating costs for support activities.
Operating costs for the integrated service delivery model:
1. Costs for “normal spontaneous deliveries” including the Performance-Based Grant for
Facility-Based Childbirths (PBG-FBC).
2. Costs for caesarian section
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3. Family planning commodities for the poor
4. Supplies for permanent FP methods: BTL, NSV
5. Cost for operating the STI control and HIV prevention program as well as the Adolescent
Health Program
Operating costs for support activities:
1) Maintenance of infrastructure and equipment
2) Enrollment of indigents to social insurance
3) Operating costs for ensuring safe blood supply
Estimates of operating costs are based on the assumptions described below, most of which are
driven by Project targets. The estimation process is as follows:
Step 1: Determine the demand for services.
The demand for services in the CEmOC and BEmOC deliveries is premised on two factors:
1. The increase in total number of deliveries which is assumed to be the same as the
population growth rate of the province or city.
2. The projected target of a 100 percent increase in deliveries performed in BEmOC or
CEmOC provider facilities and a 50% reduction of NSDs in CEmOC provider facilities.
The demand for Family Planning services is determined from:
1. The projections on contraceptive prevalence rate (CPR).
2. The Project targets of :
1.) Increase in CPR by 10 percentage points
2.) Increase to 16% the total proportion of women and their partners using permanent
methods.
Step 2: Estimate the cost of delivering WHSM services
For normal spontaneous deliveries (NSDs), consider 5 types of NSD-related costs:
1. Professional fees pegged at PhP 2,000.00 by the PhilHealth Maternal Care Benefit
Package.
2. Newborn screening at the current PhilHealth-pegged cost of PhP 650.00
3. Delivery room supplies and medicines estimated to be within the range of PhP 500.00 to
700.00. (The LGU should be able to determine the cost of these provisions according to
local rates).
4. Facility operating costs (MOOE): room, electricity, water, and other costs that may be
incurred by the facility estimated to be about PhP 1,500.00
5. Performance-Based Grant for Facility –Based Childbirth (PBG-FBC) amounting to PhP
1,500.00 for every facility birth (PhP 1,000.00 for the WHT and PhP 500.00 for the
mother to cover childbirth related expenses).
For caesarian section, the cost is estimated to be around PhP 5,000.00-10,000.00.
For cost of FP commodities, use the current price prevailing in the province.
42
Step 3: Identify financing sources
For purposes of this Project, there are four possible fund sources:
1. LGU budget
2. DOH grant
3. User fees
4. PhilHealth reimbursements
Thus,
1. All PhilHealth-covered cases will be financed through PhilHealth reimbursements.
2. All non-PhilHealth-covered non-poor cases will be charged user fees.
3. All non-PhilHealth-covered poor cases will be subsidized by the municipal LGU.
4. All other operating costs will be covered by LGU budget, PhilHealth claims, user fees
and grants from DOH.
THE INVESTMENT PLANNING PROCESS
The estimates of investment and operating costs that would result from the processes
described above are eventually incorporated into the Provincial Investment Plan for Health,
which the DOH requires from LGUs wanting to avail of grant funds from DOH. The process
flow of the costing protocols described above is shown in the diagram below, shown in the
context of the investment planning process.
The Investment Planning Process
43
R
PA T 2
EN IN U PA
SUR GLG CA CITY TOD ELIVER
QUA H V E
LITY W SMSER IC
44
Chapter 4
CONDITIONS FOR ESTABLISHING WHSM FACILITIES
Environmental Safeguards
Environmental Concerns During Facility Construction and Operation
Implementing the DOH Environmental and Health Care Waste
Management Action Plan for Facilities
Framework for Environmental Management
Social Safeguards
Indigenous People’s Framework for Health
Land Acquisition and Resettlement
Civil Works
Requirements
Cost
45
Chapter 4
CONDITIONS FOR ESTABLISHING WHSM FACILITIES
Environmental and Social Safeguards and Civil Works Standards
Although facilities chosen to be part of the Provincial WHSM Facility Network are existing
public health facilities, their acceptance of membership in the network implies commitment to
upgrade their capability and the level of services that they deliver. To this end, the
WHSMP2 imposes conditions that govern either the establishment of a new facility or the
upgrading of an existing one. These conditions are:
1. Environmental safeguards that ensures population safety during construction and
operation of the health facility,
2. Social safeguards to ensure that intended beneficiaries are not displaced or marginalized,
and
3. Civil works standards set by DOH and the WHSM intervention model.
ENVIRONMENTAL SAFEGUARDS
Before any infrastructural improvement is carried out, an
environmental study is made to assess the environmental and health
impacts of the activities proposed to be undertaken in BEmOC and
CEmOC provider facilities. The two broad-based concerns are:
1. The environmental and health risks of construction, renovation
(including expansion), operation and maintenance of health
facilities; and,
2. The establishment of environment-friendly and sustainable
health care waste management program that apply to small
(i.e., barangay health stations, rural health units, city health offices and district hospitals)
and/or large-scale (i.e., provincial and tertiary referral hospitals) facilities.
The environmental assessment exercise identifies the
environmental and health risks and/or hazards attendant to
project components with a view to recommending
interventions in any of the following aspects, as applicable or
necessary:
1. Project design,
2. Operational procedures (e.g., sub-project screening, design
specifications, construction specifications, etc.) and
3. Environmental measures to mitigate identified risks.
Assessment of the Project Environment
The Project environment is conceived to consist of three aspects:
1. Primary impact or influence zone consist of factors that occur within the immediate
sphere of project activities;
2. Secondary impact or influence zone consist of the physical, social, biological situations
that host the Project; and
46
3. Tertiary impact or influence zone consist of bigger set of values that influence or may
be affected by the Project. This last, is usually expressed in terms of a legal
environment.
Environment Safeguard Assessment Model
An assessment model showing the project’s relation to its environment is drawn in the figure
below.
Relationship of the Project with Its Environment
Larger set of entities with interest on the Project
STAKEHOLDERS – scope of project impacts
Boundaries of A
are defined Scope of control
according to who by project Other private
contributes equity management / entities with
to Project owners narrower scope of
control / influence
A
B C
Boundaries of C are
defined by value systems
of society and usually
Boundaries of B are expressed through
defined by ecological and statutory requirements or
economic systems / processes regulations
The assessment model illustrates, an internal project setting that is within the control of a
BEmOC and CEmOC provider facility’s management but influenced by attributes of a bigger
environment whose stake or interest has to do with its being the social, biological and
physical host to the project; and, the broader scope of influence, as well, of society’s values in
the form of legal regulations that provide the Project the direction and manner in which to
operate.
In the context of the WHSMP2, the facilities relate to the delivery of a package of services as
follows:
1. Maternal Care & Family Planning Services based in Rural Health Units (RHUs)
Barangay Health Stations (BHS)
2. Rural Health Unit with Social Hygiene Clinic
3. Basic Emergency Obstetric and Newborn Care (BEmOC) provider facility
4. Comprehensive Emergency Obstetric and Newborn Care (CEmOC) provider facility
5. Adolescent and Youth Health Centers
6. Social Hygiene Clinics serving high risk groups
47
The WHSMP2 service delivery structure, on the other hand, is illustrated in the figure below.
The project does not necessarily require the putting up of or building a physical structure.
The Project simply entails the utilization and expansion on existing facility arrangements to
accommodate WHSMP2 activities for the integrated WHSM service delivery package.
Women’s Health & Safe Motherhood Project 2
Service Delivery Structure
COMMUNITY
WHT
BHS MNC
referrals
Midwife
Clinic in
Remote
AYH Areas
referrals
AYHC RHU
SHC
BEmOC
NSV Maternal
itinerant District emergency
team Hospital referrals
CEmOC
Provincial Hospital
As the hierarchy in delivery level ascends, a more complex and comprehensive set of
services and support equipment becomes available that determine the necessary
physical structure to be put up or provided.
Planning for the delivery of appropriate WHSM range of
services considers the following aspects:
1. Setting and location
2. Technology and support equipment most applicable
3. Facility and ease in implementation or operations
4. Sustainable financing
5. Available infrastructure resources (particularly the
possibility of utilizing already existing arrangements
48
or facilities and exploring need to renovate / improve / modify)
6. Presence of a support /interest group that will facilitate entry in the delivery of the
range of services as well as ensure continuity in implementation and operations.
Applying the Influence or Impact Zones
Influence and/or impact zones of WHSMP2 are of primary, secondary and regional
orientation. The structure of the service delivery package proposed to achieve the objectives
of the WHSMP2, as shown in the Service Delivery Structure indicates the influence zone of
the project as reliant on the nature of the facility.
1. Primary
Primary influence or impact zones (PIZs) are those areas occurring within the immediate
locale of a project and thus comprising a small, confined geographic area. For example,
delivery of maternal and newborn care and family planning service is integrated at the
BHS and RHU level where such service is most needed. The primary impact zone for the
project in this instance is, therefore, at the barangay and municipal level.
The host facility to the WHSMP2 constituting principally of the Project’s PIZ has, in part,
some form of ongoing environmental activity, particularly in relation to waste
segregation.
2. Secondary
The secondary impact zones (SIZs), on the other hand, consist of the peripheral areas
around the project and thus have a wider geographic scope and demographic reach,
encompassing as much as the entire region.
In CEmOC provider facilities e.g. Provincial Hospitals, District Hospitals or Tertiary
Hospitals, the socio-demographic impact or influence zones extend beyond the most
immediate barangay or municipality that host the health facility as its clientele will
include those from contiguous municipalities, even from another nearby province.
Usually, this is the result of proximity of one against another facility and the
comprehensive or complete availability of services required by a particular client or
patient’s needs and likewise, on the referral from one health facility to another.
3. Tertiary
The tertiary environment consists of the larger environment of entities with interest on the
Project and equated with society’s set of values usually expressed in regulatory
instruments, eg. the milk code relative to breastfeeding, facility-based delivery, etc.
Associated Project Activities
From the illustration of the WHSMP2 service delivery structure, the simplest set of activities
will be those at the level of the BHSs, where provision for maternal care and family planning
services are availed of and/or operated through midwives and the Women’s Health Team,
backed-up by skilled health professional in the nearest BEmOC provider facilities. The
delivery of natal care services does not need any physical structure but entails the selection
and assignment of service delivery teams and the provision for the acquisition of technical
guidelines and supplies complementary to WHSMP2 objectives at this service delivery level.
49
The delivery package for adolescent and youth development entails working out the necessary
arrangements with existing institutions in the community that will be able to integrate the
WHSM-adolescent and youth health package of services at this delivery level. Likewise,
this will entail the selection and assignment of an Adolescent and Youth Health Team at
municipal level as well as the delivery of technical guidelines and supplies necessary for the
service package intended at this level.
The more complex activities are those associated with the implementation of the BEmOC and
CEmOC service delivery, since the intended service package is to be integrated into the
already existing operations and activities of proposed facilities for upgrading to EmOC
standard. A list of basic expected associated activities relative to civil works at the BEmOC
and CEmOC level at various stages in its implementation is provided in the Table below.
Associated Activities at Project Implementation Stages
Project Phase Associated Activity
Pre-construction Preparation of plans and drawings
Finalization of funding source and requirements
IEE or PD preparation/submission to Regional EMB for ECC
application
Preparation of bid plan and terms of reference
Bidding and contracting
Mobilization
Construction Civil works for floor, wall to ceiling repairs & provision for
waste management collection, storage area and placenta pit;
housing for genset and fuel storage area
Electrical and mechanical works
Pre-treatment against termite infestation
Delivery and installation of equipment and instruments,
including standby diesel power generating set
Commissioning and turnover
Operations Patient admission, etc.
And maintenance Cleaning and repairs
Waste handling, collection, storage, treatment and disposal
Environmental monitoring, reporting and audits
The activities in WHSMP2 are to be firmly entrenched and integrated as part of any facility’s
regular program or service package.
Environmental Concerns during Facility Construction and Operation: Emissions,
Discharges and Wastes
1. Air Emissions
Any emission is the likely result of equipping BEmOC or CEmOC provider facilities with
a power generating set so as not to disrupt the delivery of maternal and newborn services
at any given time.
The primary pollutants from internal combustion engines are:
1.) Oxides of nitrogen (NOx),
2.) Oxides of sulfur (SOx),
3.) Carbon monoxide (CO),
4.) Hydrocarbons (HCs) and
5.) Particulates, which include both visible (smoke) and non-visible emissions (US EPA,
1996).
50
Nitrogen oxide is related to the nitrogen content in the fuel oil and the high pressures and
temperatures during the combustion process. SOx emission is proportional to the sulfur
content in the fuel oil. The other three pollutants CO, HC and particulates, are primarily
the result of incomplete combustion.
2. Noise Emission
During the operation of the BEmOC and CEmOC provider facilities, sources of noise
emission are the power generating set. The emission sources are the engine, engine
exhaust, air-cooling fans and pumps. The expected emission from the generating set at a
distance of one meter, without the proper housing, is approximately 90dB(A).
3. Associated WHSM Wastes
For the simplest delivery structure of the WHSMP2, specifically the BHS, wastes consist
mostly of administrative or housekeeping-related with very little wastes generated of
potentially hazardous and infectious nature.
1.) Wastes generated at BHS level are classified acceptable for municipal landfill or
onsite (within Health Facility compound) disposal.
2.) Wastes generated from the operation of Social Hygiene Clinics, by the nature of their
intended operation or service delivery, are going to generate infectious wastes and
will need to either be treated prior to disposal onsite or brought to a tertiary level
health facility where treatment capability for infectious wastes is available.
3.) The principal waste of concern in operating BEmOC and CEmOC provider facilities
will be those relating to delivery and birthing, particularly the generation of placenta
wastes.
Waste Category by WHSM Facility Type
WHSM Facility Type Waste Types Generated
Mostly general wastes, with limited level of
BHS infectious and pharmaceutical wastes generated
Limited level of general wastes; principally
STI Clinics infectious wastes
General as well as pathological wastes, some
RHUs level of pharmaceutical wastes
Limited general wastes, mostly pathological;
BEmOC provider some level of pharmaceutical wastes; chemical
wastes generation more associated with operation
of genset
Limited general wastes, mostly pathological;
CEmOC provider some level of pharmaceutical wastes; chemical
wastes to be generated principally associated with
operation of genset
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Implementing the DOH Environmental and Health Care Waste Management Action
Plan for Facilities
The health facilities existing structure, particularly those in fully-staffed community hospitals,
district and provincial hospitals, is used as basis for the framework. The rationale is to
ensure minimum disruption to the existing organization.
An illustration of this structure is shown below:
SRA HCF STAKEHOLDERS
Hospital Engineer Adviser,
Or Head, Technical Infection Control /
Services Pharmaceutical /
Radiation
Department Heads
Medical/Dental
Pharmacy Matron and
Radiology Environmental Hospital
Laboratory Management
Blood Bank Administrator
or
Administration
Finance
Pollution
Housekeeping Control Officer
Eng'g / Tech. Services
Transportation
Systems
Ward sisters
Nurses
and
Support Staff Medical Assistants
Hospital Attendants & Ancillary Workers
Framework for Environmental Management
The object is to integrate rather than introduce a totally new set-up. This is not so difficult as
the responsibilities of the operating units or departments in a Health Facility are not going to
be altered but enhanced to define the respective roles towards environmental care and
management. The framework indicates the re-orientation of the Health Facility as being both
a health care and maintenance provider and as a contributor to environmental health.
1. Framework for Smaller Health Facilities
Smaller Health Facilities (i.e., BHS, RHUs and SHCs), with their highly focused
activities and limited personnel complementation, will require environmental
management responsibilities to be assumed by the head of facility. In this instance, the
head of the facility acts in the capacity of a one-man team but draws on the support
of a municipal engineer or municipal sanitation officer, and if further necessary,
calls on the support of the municipal council where there is a committee on health,
environment and sanitation. An illustration of this framework is shown in the next
page.
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DENR / DOH
MUNICIPAL COUNCIL Community
Committee on Health, Organizations
Environment and Safety
Municipal Municipal
Engineer Sanitation Officer
BHS, RHU or SHC
FACILITY HEAD /
ENVIRONMENT OFFICER
Helper
Municipal Infrastructure /
Utility Services
Support Group
Institutional Framework for Smaller Health Facilities
(BHS, SHC, RHU)
1.) Liaison and Line Management Paths
The framework suggests organizational units in the health facilities with line management
as well as those with liaison responsibilities in environmental management. The broken
lines refer to the liaison paths while the full lines are those with line management
responsibilities.
As shown in the figure, the environmental management or pollution control officer
reports or is directly responsible to the Facility’s Head. In the smaller establishments, this
is practically a one-man team.
The EMO/PCO (Environment Management Office/Pollution Control Office) liaises with
the various (government) departments as well as with the Hospital Hygienist or Infection
Control Officer (ICO) or its equivalent in the current set up, as the broken lines in the
preceding figure suggests. The relationship of the health facilities as an environmental
organization to its external environment, particularly its relationship with the statutory
regulatory authority (SRA) as well as with its stakeholders, is depicted as a liaison path.
The interconnectivity of the individual elements in the framework depicts the interactive
relationship of one against another, reiterating further that synergy among stakeholders.
2. Framework application
The framework for environmental management, as suggested and depicted, is not
prescriptive. The structure may be adjusted accordingly to suit the particular needs of the
health facility. There actually is a skill mix among the personnel, depending on the
complexity in operations of the Health Facilities. The institutional framework suggests
that environmental management initiatives by the Health Facility are management-driven,
principally emanating from the head of facility.
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3. Regulatory and Administrative Support
1. Department of Health (DOH)
To ensure that infectious wastes and other medical wastes go into proper treatment
and/or disposal, DOH, as a regulatory agency, can require documentary evidence to
be submitted or reported to the nearest regional office, in much the same way that
DENR-EMB requires the submission of quarterly monitoring reports on compliance
of facilities to air and water quality standards. The requirement addresses two
aspects:
1.) Ensuring the safe management of wastes from health care establishments and
2.) The marketability of government treatment facilities to generate funds needed for
the continuous operation and regular maintenance of the facilities.
An avenue to implement the requirement is to include this in the licensing
requirements of health care establishments. These establishments can be required
to show verifiable proof that prior to actual operations, arrangements or agreements
have already been forged to have hospital wastes properly treated and disposed.
To ensure proper segregation, collection and handling, and ultimately the treatment
and disposal of medical establishment wastes, the DOH national color-coding
system for waste disposal should be followed. This coding system immediately
and distinctly labels the type of waste. A nationally recognized and adopted color
codes is seen to facilitate sourcing processes since suppliers only have to deal with a
defined color set.
2. Inter-agency and LGU Coordination and Cooperation
Critical support to realizing and implementing local-level environmental health
management initiatives can be provided by active coordination and cooperation
among government agencies:
1.) Department of Environment and Natural Resources-Environment Management
Bureau (DENR-EMB),
2.) Department of Science and Technology (DOST),
3.) OSHC, an attached agency to the Department of Labor and Employment
(DOLE), and
4.) Local Government Units (LGU).
The LGU can pass regulations, by way of municipal ordinances, that will support the
establishment of user fees. It also can pass ordinances through Council Resolutions
that will support the set up of municipal wastewater treatment systems and address
the bigger share in wastewater generation by households as well as from other
wastewater sources, including old public cemeteries that still operate to old practices.
Being the immediately available resource on health and safety, the Municipal Health Officers
and Chief of Hospitals can work hand-in-hand with the LGU in crafting sustainable options to
address solid and liquid waste management concerns, with technical and even training support
from EMB, DOST and the OSHC.
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SOCIAL SAFEGUARDS
Social safeguards are applied to make sure that intended beneficiaries are not displaced and
marginalized. Social safeguards also provide assurance of the Project’s acceptability. In this
regard, where appropriate, an Indigenous Peoples’ Strategy as well as a Land Acquisition
(LA) and Resettlement Framework (RF) should guide Project preparation.
Drafting the Indigenous People’s Framework for Health
The Indigenous Peoples Rights Act (IPRA) defines indigenous peoples or IPs as “a group of
people or homogenous societies identified by self ascription and ascription by others, who
have continuously lived as an organized community on communally bounded and defined
territory, and who have, under claims of ownership since time immemorial, occupied,
possessed and utilized such territories, sharing common bonds of language, customs,
traditions and other distinctive cultural traits, or who have, through resistance to political,
social and cultural inroads of colonization, non-indigenous religions and cultures, became
historically differentiated from the majority of Filipinos.”
Crafting the IP framework is guided by the following principles:
1. IP should be actively engaged in the decision-making process, particularly in
planning and implementing interventions in areas within ancestral domain claims or
areas where IPs depend for their livelihood.
2. The IPs’ interests should be assured by making certain that they receive social and
economic benefits that are compatible with their culture.
3. Implementation of any initiative should foster full respect for IPs’ dignity, human
rights and culture uniqueness.
4. Whenever necessary, consensus of all IP members who are affected by any initiative
must be obtained in accordance with their respective laws and practices, free from
external manipulation, interference and coercion, and obtained after fully disclosing
the intent and scope of the initiative, in a language and process understandable to the
IPs.
5. Prior to implementation of projects, field-based investigation should be conducted
and the process of obtaining the Free and Prior Informed Consent should consider the
primary and customary practices of consensus building and should conform to section
14 (Mandatory Activities for FPIC) of NCIP AO 3, series of 2002.
6. Project implementation should ensure that damage to non-replicable cultural property
does not occur. In cases, where infrastructure improvements affect sites considered as
cultural properties of the IPs, best effort should be exerted to relocate or redesign the
planned renovations so that these sites can be preserved and remain intact in site.
7. Infrastructure design must at all times be consistent with the traditional and cultural
practices of the IPs in the area.
Drafting the Indigenous People’s Framework and its accompanying Development Plan
(IPDP) requires consultation with representatives from:
1. National Commission on Indigenous People (NCIP),
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2. The IPs as represented by their tribal leaders,
3. PhilHealth,
4. Health workers assigned in IP areas and
5. DOH-CHD key staff.
The IP Framework outlines the general direction towards accomplishing the IP agenda and
defines structure that leads to implementation of critical project activities. The consultation is
thus necessary to make certain that the general approach outlined in the IPDP is valid and
acceptable.
An important component of the IP agenda is a pilot test of an intervention model that is
envisioned to encourage IP women to give birth in a health facility. Such a model includes
the establishment of a birthing facility with EmOC capability designed to suit IP needs and
preferences. Important features of this facility are:
• Culturally sensitive architectural design,
• Culture and gender sensitive birthing equipment and furnishings, e.g., birthing chair
for women who opt to deliver in a sitting or squatting position, or a pole to hold on
for those who opt to give birth in standing position, etc.
• Provision for visual and auditory privacy, and
• Provision of adequate space for family.
The basic approach involves the mainstreaming of indigenous people’s involvement in the
various activities and interventions envisioned in the overall project design by building on the
existing partnerships among stakeholders that includes the active participation of the tribal
leaders.
Consonant with the overall targets set for the project, the IPDP specific for each site includes
activities to:
1. Increase birth planning among IP couples
2. Increase the number of IP women giving birth in health facilities
3. Qualified IP women trained as skilled birth attendants and
4. PhilHealth enrollment of IP households.
Among the facilitating factors towards the achievement of targets for IP communities are:
1. The presence of LGU-supported WHTs in IP communities,
2. The stepladder program for midwife training coupled with NCIP scholarship support,
3. Existence of trained, but currently unemployed, IP midwives in Project areas and
4. The presence of IP focal points at the DOH Central Office and CHDs.
Among the challenges that may be identified and should be appropriately responded to in the
plan are:
1. Non-registration of IP births and marriages,
2. The remoteness of IP communities,
3. Political interference in the selection of PhilHealth enrollees, and
4. Communication and cultural barriers between IPs and non-IPs.
Land Acquisition and Resettlement
The land acquisition requirements for infrastructure sub-projects are generally limited.
However, the project needs to have the appropriate structure, trained staff and processes in the
event land acquisition and resettlement becomes necessary or unavoidable. Local government
56
units are oriented on the requirements of the policy to avoid confusion and delay should the
issue of resettlement arise.
A basic consideration for the LGU is to locate the affected families to a safe site and the
provision of financial aid to allow them to start livelihood activities in their new home
communities.
Employment Opportunities
An important feature of the Social Safeguards is the assurance that displaced families brought
about by the building of a health facility are assured of being prioritized for employment
during construction, where a considerable number of workers will be needed. When facility
operations commence (assuming that operations are disrupted by construction activities),
health facilities employ a certain number of health staff and ancillary workers. The more
complex facilities will usually have:
1.) Doctors
2.) Sanitation Engineers
3.) Administrative staff
4.) Staff nurses
5.) Medical assistants,
6.) Hospital attendants
7.) Waste management or pollution control officer
8.) Ancillary workers
The BHSs are operated by midwives and assisted by Women’s Health Teams (WHTs). The
services of nurses, doctors, dentists and so on, are provided on a rotating visiting schedule
basis and/or on referral. Community, district, provincial and regional hospitals have
regularly reporting medical personnel in attendance to cater to particular medical service
requirements of their clientele with a head of hospital and various support staff,
administrative, technical and laboratory support and medical and other allied services. From
the usual 1 or 2 barangay health workers available at the BHS level, employment
correspondingly increases in the more complex health facilities. Displace persons shall also
be given priority where new hires are needed so long as their skills fit the skill requirements
of the vacant positions.
Opportunities for indirect employment are also generated from the need to procure WHSMP2
supplies and equipment as well as the skill needed to do ground level work in communities.
While the WHSMP2 essentially operates within established structures of existing health
facilities, its implementation will create opportunities for employment linkages, particularly in
coming up with a pool of professionals whose expertise will be tapped to deliver a particular
service, e.g., the creation of women’s health teams, at the local level.
Disclosure
In compliance with good governance and the local disclosure requirements, the DOH and its
partner LGUs ensure that the safeguards documents are known to the public. Disclosures are
done through:
1. Web site posting,
2. Public fora,
3. Announcements on radio and TV,
4. Through publication in local newspapers.
Disclosure is a way of informing the public about the Project activities, the benefits that they
57
may derive from the Project and their rights should Project activities affect their safety,
livelihood and general welfare.
Safeguards Implementation and Monitoring Arrangement
The National Center for Health Facilities Development (NCHFD) and the National Center for
Disease Prevention and Control (NCDPC)-Environmental Health Office (EHO) oversee
implementation and monitoring of Environmental Safeguards. The NCDPC–Family Health
Office (FHO), on the other hand, oversees implementation and monitoring of Social
Safeguards. All activities related to Project safeguards are coordinated with the CHDs and
LGUs concerned.
STANDARDS FOR CIVIL WORKS
The National Center for Health Facilities Development and the National Center for Disease
Prevention and Control collaborate to establish infrastructure standards for the licensing of
health facilities. PhilHealth, on the other hand, imposes standards for accreditation purposes.
The standards described below combine the licensing standards of DOH and the accreditation
standards of PhilHealth. Aside from the engineering considerations that are required of sound
and well-built infrastructure, these standards were driven by the following objectives:
• Infection control
• Gender sensitivity
• Sound management of human traffic
These standards should govern the envisioned infrastructure improvements of health facilities
chosen to be part of the Provincial WHSM Network. While the LGUs are given the
autonomy to decide on the facility design using the Philippine Building Code as reference,
they should work their design within the parameters of these standards.
1. Basic Emergency Obstetric and Newborn Care (BEmOC) provider Facilities
A BEmOC provider facility is a primary level health facility tasked to provide the
integrated WHSM service package that include basic emergency obstetric and newborn
care (BEmOC) and is either a –
1.) Barangay Health Station (BHS),
2.) Rural Health Unit (RHU),
3.) Lying-in Clinic,
4.) Birthing Home,
5.) District Hospital, or
6.) Any other similar structure.
These facilities are duly identified and designated by the local health officers by virtue of
its strategic location and on the basis of the selection criteria set by DOH in consultation
with LGUs and receives referral from the community-based Women’s Health Teams
(WHTs).
WHTs refer cases considered not having difficult pregnancy to these facilities.
Facilities of this type should be appropriately constructed in locations most accessible to
women.
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BHSs and RHUs are facilities that are nearest to homes and are therefore significant
structure in the BEmOC-CEmOC network. The following access factors are
considered in building a BHS and RHU as BEmOC providers:
Geographic access
A baseline study conducted by the Center for Economic Policy Research in the WHSMP2
sites and Western Samar pointed out that women and clients in general are discouraged to
access health services if the travel time to reach a health facility is more than 30 minutes.
These finding validated the observation that the BHS is the only facility that is most
accessible to at least 60% of the population in any given locality. Thus the call for women
to give birth in a facility with capability to provide basic emergency obstetric and
newborn care should consider the BHS as most rationale for upgrading.
The WHSMP2 Baseline Study pointed out that women and clients in
general are discouraged to visit a health facility if the travel time
is more than 30 minutes. These findings made health planners
realize that the BHS is the only facility that is accessible to at least
60% of the population in any given locality. Thus women would
most likely respond to the call for them to give birth in a facility with
capability to provide basic emergency obstetric and newborn care if
they have access to such a facility in their community. This makes
the BHS an attractive strategic option for upgrading to BEmOC.
Gender and culture sensitivity
A situational analysis conducted in 2004 for WHSMP2 Communication and Advocacy noted
interesting reasons why women opt do deliver at home rather than at a health facility, among
them: “There is no one to be left at home to take care of my other children”. This is in
addition to cost of medical care and transportation.
The Barangay Health Stations then could be upgraded to BEmOC standard provided
that the MHO or RHU doctor and PHN commit to be available “on call” and that a
midwife with permanent appointment is assigned at the BHS and resides in the
barangay where the BHS is located.
To enable the BHS and RHU BEmOC providers to function effectively, the following
amenities should be considered in the structural design:
a) Delivery room
b) At least a 2-bed capacity Ward: 1 bed for the mother and newborn and another bed
with a “pull-a-bed” feature for the birth companion and small children. The ward also
doubles as a labor room.
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c) A small kitchen appropriately furnished.
d) A toilet and bath with appropriate fixtures.
e) A sleeping quarter for health staff.
f) A waste management facility that includes a placenta pit.
A BEmOC provider facility should likewise be equipped with:
o radio or telephone for easy contact with a designated higher-level facility should
advice or referral be needed,
o An emergency transport system based at the
community for a reasonable fee. An efficient system has
the following features:
• It is efficiently managed by the local government or
private entity.
• A vehicle is well maintained and made available at
all times.
• It has an established fee considered reasonable
and socially accepted.
o The BEmOC provider facility contributes to
its efficiency by:
• Having its WHTs making sure that
transport provision is part of the Birth Plan.
• Posting a public notice of the availability of vehicles for hire at the admission
area with the following information:
Contact person’s name and number, and
Rental fee
Hospital BEmOC providers offer the same amenities except for the structural design
which should include:
a) Labor room appropriately furnished
b) Delivery room
c) A scrub room for the doctors and nurses
d) A maternity ward with rooming-in feature for the newborn
e) A toilet and bath with appropriate fixtures
f) A sleeping quarter for health staff
g) A waste management system that includes a placenta pit
Since a hospital BEmOC provider also caters to other cases, small children are not
allowed to accompany their mother to the hospital. This is to protect them from
hospital- acquired infections. An arrangement should be made with the concerned WHT
for either a TBA or BHW to take care of the small children at home while their mother is
giving birth in the hospital.
These facilities are made attractive and comfortable with privacy and space for an
accompanying “birth companion” (family member, friend, TBA or BHW) as well as for
minor children in cases where leaving them at home is not possible.
2. Comprehensive Emergency Obstetric and Newborn Care (CEmOC) Provider
Facilities
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The Facility Mapping exercise identified strategically located secondary level facilities
that can be appropriately staffed, upgraded or improved so that these become capable of
providing comprehensive obstetric and newborn care services. These facilities are
considered the First level referral hospital or core referral hospital in a locality with a
population of at least 500,000. Women who develop serious maternal complications are
referred to these facilities.
CEmOC provider facilities are departmentalized are adequately and appropriately
equipped and staffed by competent CEmOC Teams (CTs). Clients referred from BEmOC
facilities can reach these facilities within 1-hour travel time.
The CTs and the Itinerant Teams (ITs) are based in these facilities.
This type of a hospital is departmentalized according to medical specialties and is usually
large.
Its structural design features more facilities:
1.) Emergency Room
2.) Admission Room
3.) Pharmacy
4.) Well equipped laboratory
5.) Blood station appropriately equipped and furnished
6.) Labor room
7.) Delivery room
8.) An obstetric operating room
9.) Sterilization or autoclave room
10.) A recovery room
11.) A Newborn Intensive Care Unit
12.) A breastfeeding room
13.) A scrub room for the doctors and nurses
14.) A dressing (change) room for the doctors and nurses
15.) A maternity ward with rooming-in feature for the newborn
16.) A nurses station
17.) A toilet and bath with appropriate fixtures
18.) A sleeping quarter for health staff
19.) Waste management system that includes a placenta pit.
It is likewise equipped with –
20.) Radio or telephone for easy contact with a designated higher-level facility should
advice or referral be needed
21.) An emergency transport system based at the community for a reasonable fee. An
efficient system has the following features:
a. It is efficiently managed by the local government or private entity.
b. A vehicle is well maintained and made available at all times.
c. It has an established fee considered reasonable and socially accepted.
d. The BEmOC provider facility contributes to its efficiency by:
a) Having its WHTs making sure that transport provision is planned by the
family by having them part of the Birth Plan.
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b) Posting a public notice of the availability of vehicles for hire at the admission
area with the following information:
o Contact person’s name and number
o Rental fee
Just like in a BEmOC provider facility, small children are not allowed to accompany
their mother to the hospital. This is to protect them from hospital-acquired infections.
An arrangement should be made with the concerned WHT for either a TBA or BHW to
take care of the small children at home while their mother is in the hospital.
3. Social Hygiene Clinics (SHCs)
Special clinics that serve clients identified as high risk for sexually transmitted infections
are enhanced to improve quality of service delivery. These clinics are appropriately
constructed and designed to provide the privacy needed by such clients. A specially
trained team (STI Team) is based in this facility.
Women in the commercial sex work and persons with manifestations of sexually
transmitted infection who wish to seek medical care and counseling are referred to this
facility. The structural design should therefore consider the provision of –
1.) Comfortable waiting area that can double as a resource center,
2.) Examination room and counseling area with auditory and visual privacy,
3.) An area for washing and sterilizing instruments, and
4.) A call center where a counselor may answer phone in inquiries from clients.
4. Adolescent and Youth Center (AYC)
Depending on the needs of the adolescents and youth in a locality, an AYC or Teen
Center is established on a pilot basis to serve as a healthy venue for adolescents and
youth, whether out of school or in school, to converge and socialize. Designed as activity
and resource facility it provides any of the following amenities:
1.) Sports area,
2.) Music and theatre venues,
3.) Library,
4.) Information Center with facility related to career development and employment
opportunities,
5.) Venue for other organized activities such as fora on topics of interest to the clients,
sports fest, music fest, community theatre, and the like.
6.) Counseling room with visual and auditory privacy for services provided by trained
peer counselors.
7.) Professional counseling and referral services are available whenever necessary. The
AYC serves as the base of the MAYHT (Municipal Adolescent and Youth Health
Team).
5. Rural Health Units (RHUs) and Barangay Health Stations (BHS)
Rural Health Units and Barangay Health Stations not proposed for upgrading to BEmOC
standard should continue to provide the usual health services that they offer.
1) STI prevention and control services
a. Health education,
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b. Screening using modified syndromic approach,
c. Appropriate treatment and
d. Referral
2) Adolescent and youth health
a. Counseling
However, in consideration of the services provided, these health facilities are required to have
a certain degree of infrastructure upgrading that includes minor modification in its design to
allow them to comply with the standards for gender sensitivity and infection control:
a. Comfortable waiting area that can double as resource center,
b. Examination and counseling room with visual and auditory privacy.
c. Separate examination room for STI clients with the same provision of privacy.
Cost of Civil Works
The infrastructure cost per facility varies depending on the current state of the facility.
Normally, upgrading a Barangay Health Station costs more since this facility does not usually
have the necessary facility needed by a BEmOC provider such as a delivery room and ward.
In addition, the WHSM model requires that a BEmOC facility be gender as well as culturally
sensitive so it can appropriately respond to the needs of women in the community and in the
process, successfully address known barriers to facility birth. Thus, the model requires that
BEmOC facilities provide a sleeping area for family members particularly the small children,
a kitchen to enable them to cook food and a toilet and bath.
Facilities, whether it is a Barangay Health Station or Rural Health Unit with existing lying-in
or birthing facility will require very modest infrastructure investment that could range from
PhP 500,000.00 to PhP2.5 million.
BEmOC facilities shall be so designed as to be sensitive to local needs and preferences,
particularly those of indigenous women. Such culturally sensitive designs hope to make
facility birth more attractive to women, especially those who have so far not been reached by
the public health system. For instance, investments may not be used to buy a delivery table
that requires women to assume a lithotomy position when personal preferences as well as
cultural and religious standards of the community frown against giving birth in such a
position. Instead a delivery chair may be designed to allow women to assume a sitting
position while giving birth. A pole to hold on may also be provided at the delivery room if
women in the community feel more comfortable giving birth in a standing position, as is the
custom among some cultural minorities. Such designs may be piloted in communities with
indigenous populations.
On the other hand, infrastructure upgrade of CEmOC designates involve physical plant
improvement and will vary in cost. CEmOC hospital renovation may cost from 10 to 15
million pesos depending on the extent of civil works needed.
In general, cost of civil works will require a more detailed engineering assessment.
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Chapter 5
QUALITY ASSURANCE IN WHSM FACILITIES
The Women’s Health Safe Motherhood – Service Package
The Human Resource Requirement
The Vital Equipment for Emergency Obstetric and
Newborn Care Provision
The Standard Infrastructure Features
Access to Safe Blood
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Chapter 5
QUALITY ASSURANCE IN WOMEN’S HEALTH AND SAFE MOTHERHOOD
SERVICE DELIVERY
Quality is crucial in service delivery, especially in the public sector where public health
facilities cater to the needs of the majority of the population. A reputation of high quality
encourages clients to avail of the “good” or “service” that is being offered. In health service
delivery quality is the standard of excellence set relative to the over–all provision of care and
is often judged relative to:
• The competence and attitude of health workers,
• physical attributes of the facility,
• completeness and appropriateness of equipment,
• overall client satisfaction relative to the services received.
The standards in WHSM service delivery is governed by the global call for governments to
respond to the alarm raised on maternal health by taking drastic measures to reduce if not
totally prevent maternal and newborn death.
To assure the safety of mothers and newborns, the following standards of care are
required to be observed in all WHSM facilities:
Standard 1: The Integrated WHSM –Service Package that includes the newborn care
package shall be provided in all WHSM facilities.
1. Maternal care in BEmOC provider facilities -
1.) Parenteral administration of anti-convulsants, antibiotics, oxytocics
2.) Manual removal of placenta
3.) Removal of retained products of conception
4.) Assisted vaginal delivery/during eminent breech delivery
5.) All services provided in a non-BEmOC provider facility
2. Newborn care in BEmOC provider facilities -
1.) Cord care
2.) Breastfeeding
3.) Vitamin K injection
4.) Provision of warmth
5.) BCG and Hepatitis B immunization
6.) Newborn screening
7.) Newborn resuscitation
3. Maternal care in non-BEmOC provider facilities -
1.) Complete prenatal care package
2.) Maternal and newborn care counseling
3.) Complete postnatal care package
4. Services in BEmOC and non-BEmOC provider facilities
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Family Planning
1.) FP counseling and
2.) Contraceptive provision
STI screening
1.) Syndromic Approach
Adolescent and youth health –
1.) Peer counseling
2.) Professional counseling
3.) RH education
5. WHSM services in CEmOC provider facilities
1.) All services provided in BEmOC provider facilities
2.) Caesarian section
3.) Safe blood transfusion
4.) Medical management of obstetric complications
5.) Comprehensive newborn care
a. All basic newborn services
b. Management of complications
c. Emergency referral to specialists/in specialty hospitals
6.) Surgical FP procedures
a. BTL
b. NSV
c. Management of complications resulting from contraception
7.) STI-HIV Services
a. Laboratory screening procedures
b. Medical management of cases
c. Management of complications
The package is offered to women and men of reproductive age, including the adolescents and
youth seeking care for any reproductive health concern. The integrated approach to service
delivery enhances quality of the service as it maximizes client visits and avoids missed
opportunities.
Standard 2: Adequate and appropriate Human Resource is assured at all levels. This
shall consist of Women’s Health Teams at the community level and competent
professionals at the health facility level.
The current public health service delivery model designates the BHS as a satellite facility of
the RHU. The objective of this arrangement is to enable the health system to reach out to
clients in remote barangays. A BHS BEmOC therefore requires that the MHO and PHN,
who are based at the RHU make regular supervisory visit and be available “on call” to
assist the midwife in BEmOC provision.
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The staffing requirements of the service delivery model are as follows:
1. Conditions to Ensure the Effectiveness of the WHSM Service Model
Conditions Requirements
1) Organization of Service Delivery Teams • 1 Women’s Health Team per barangay
• 3 BEmOC Teams per Hospital BEmOC
facility
• 1 BEmOC Team per RHU/BHS BEmOC
Facility
• 3 CEmOC Teams per CEmOC facility
• 1 Itinerant Team per CEmOC facility
• 1 SHC Team- Social Hygiene Clinic or
RHU-based
2) Assignment of Health Staff
1 midwife per BHS
3) EmOC facilities sufficiently staffed for a 24-
hour operation
2. WHSM Service Model Staffing Requirement
Community Level:
BHS and RHU BEmOC Provider Facility
1 Midwife per Barangay Health Station (BHS) 3 BEmOC Teams per hospital BEmOC
provider
(1 Team per 8-hour shift)
1 BEmOC Team per RHU/BHS:
1 Women’s Health Team (WHT) per barangay. Composition of the BEmOC Team:
Hospital:
Composition of the WHT: • 3 doctors (1 per shift)
• Midwife • 3 nurses (1 per shift)
• Barangay Health • 3 midwives (WHT)
Workers (BHWs) (1 per shift)
• Traditional Birth • 1 medical technologist on call per ILHZ or
Attendants CEmOC-BEmOC Cluster
(TBAs)
For RHU: 1 doctor, 1 nurse, 3 midwives (1 per
8-hour shift).
For BHS: 1 RHU doctor and 1 PHN “on call,” 1
midwife with WHT members as assistants
(TBAs and BHWs)
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3. CEmOC provider facilities staffing requirement.
CEmOC Provider Facility
3 CEmOC Teams
(1 Team per 8-hour shift)
Composition of the CEmOC Team:
• 3 doctors preferably obstetric – gynecology specialist or GP trained in CEmOC (1 per shift)
• 1 anesthesiologist or GP trained in anesthesiology
(on call)
• 1 pediatrician (on call)
• 3 OR nurses (1 per shift)
• Maternity ward nurses
(2 per shift)
• 3 Medical technologists (1 per shift)
Composition of the Itinerant Team
• 1 doctor (surgeon)
• 2 nurses (or 1 nurse 1
midwife)
1. Women’s Health Safe Motherhood Teams required competencies are as follows:
1) Barangay – based Women’s Health Teams should be guaranteed to be competent in
the conduct of their assigned tasks that include among others:
a. Pregnancy tracking using the recommended tool
b. Assisting pregnant women in Birth Planning using the Mother and Child Book as
guide
c. Reporting maternal deaths occurring in the assigned community using the form
designed for WHTs.
d. Organizing outreach activities as necessary.
2) Facility-based Teams
a. The BEmOC Teams should be competent in the provision of the following
services:
a) Basic maternal care to include prenatal and postnatal care
b) Basic emergency obstetric and newborn care services as defined to include
newborn resuscitation
c) Newborn screening
d) Family planning services
e) Breast and cervical cancer screening
f) Risk assessment and clinical screening and diagnosis of STI and HIV
g) Laboratory screening
h) Syndromic case management of STIs
i) Counseling
j) Monitoring, evaluation, research and dissemination
k) Referral
l) Recording and reporting
m) Maternal death reporting using the recommended facility reporting form
n) Civil registration of births and deaths
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b. The CEmOC Teams should be competent in the delivery of the following
services:
a) BEmOC services as defined
b) Surgical childbirth (caesarian section)
c) Safe blood transfusion
d) Management of newborn complications
e) Surgical family planning methods in addition to basic FP methods
f) Breast and Cervical screening including interpretation of laboratory results
g) Management of breast and cervical cancers
h) STI risk assessment and screening
i) Management of STIs and its complications
j) Counseling
k) Referral
l) Recording and reporting
m) Maternal death reporting using the recommended facility reporting form
n) Civil registration of births and deaths
c. The Itinerant Teams are competent in the conduct of:
a) Surgical sterilization
b) Gender sensitive Counseling
c) Coordination for related outreach activities
d. The Social Hygiene Clinic Teams are competent in:
a) Laboratory screening and diagnosis of STIs
b) Syndromic and etiologic management of cases
c) Gender sensitive counseling
Standard 3: Emergency Obstetric and Newborn Care (EmOC) provider facilities
should have the required vital equipment to enable them to deliver quality WHSM
services to clients.
1. Basic Emergency Obstetric and Newborn Care Equipment
1.) Vital Equipment
a. Vaginal speculum set of 6
b. NSD Kit
c. Adult ambubag
d. Pediatric ambubag + mask
e. Simpson’s forceps (optional)
f. Suction machine portable 2 L capacity
g. Oxygen tank with regulator/gauge
h. Spare oxygen gauge
i. Kelly pad
j. Bassinet
k. Cervical inspection set
l. NSV set
m. IUD kit
n. Cut down or minor set
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o. Microscope
p. Obstetrics outlet forceps
q. Nebulizer
r. Pediatric stethoscope
2.) Vital Furniture and Fixtures
a. Delivery bed with stirrups
b. Revolving stool
c. Droplight
d. Emergency light
e. Ward beds with side railings
f. IV stand
2. CEmOC Equipment
1.) Vital Equipment
a. Vaginal speculum set of 6
b. Caesarian section kit
c. Portable anesthesia machine
d. Incubator
e. Curettage set
f. NSD kit
g. Adult ambubag
h. Pediatric ambubag + mask
i. Simpsons forceps
j. Suction machine (mobile 6 L capacity)
k. Suction machine (portable 2 L capacity)
l. Oxygen tank with regulator/gauge
m. Nitrous oxide with regulator/gauge
n. Cervical inspection set
o. BTL set
p. IUD kit
q. Microscope
2.) Standard Equipment
a. Ultrasound machine
b. Anesthesia machine upright model
c. Vacuum extraction set
d. Pediatric stethoscope
e. Adult laryngoscope
f. Pediatric laryngoscope
g. EKG machine
h. Cut down minor set
3.) Special Equipment
a. Cardiac monitor
b. Cardiac defibrillator
c. Pulse oximeter
d. Glucometer
e. Automated blood chemistry analyzer
f. Water bath
g. Coulter blood counter
h. Spectrophotometer
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4.) Basic Furniture and Fixtures
a. Delivery bed with stirrups
b. Operating room table
c. Revolving stool
d. Operating room light
e. Drop light
f. Emergency light
g. Ward beds with side railings
h. IV stand
Standard 4: BEmOC and CEmOC provider facilities are required to provide easy
access to safe blood supply at all times.
Easy access to safe blood requires the local health system to establish a network that assures
availability of this vital commodity whenever it is needed. The standard defines the local
network as comprising the following organizational structure:
1. Regional Blood Supply Network
a. Regional Blood Center
b. Blood Bank
c. Blood Stations
d. Blood Collection Units
2. Local Blood Council
a. Community-Based Blood Donation Program
Current evidence in maternal mortality points to hemorrhage as the main cause of maternal
death in the country, causing 26% of total maternal deaths in 1998 (NDHS). Thus, the setting
up of a Safe Blood Supply Network is seen as an important condition in the establishment of
a Provincial WHSM Facility Network.
Organizing a Safe Blood Supply Network
At the central level, the National Center for Health Facilities Development (NCHFD) of DOH
manages the National Voluntary Blood Program (NVBP) and supervises the operation of the
National Blood Center (NBC) based at the Philippine Children’s Medical Center (PCMC) in
Quezon City. The NBC takes care of all blood needs of the country, including ensuring
adequacy of supply.
In addition a limited number of separately organized, and strategically located blood centers
to serve the blood transfusion needs of all hospitals within a given but wide catchment area
has been developed and established by the National Voluntary Blood Program. The Blood
Center Network is configured as follows:
Blood Center could be hospital or non-hospital based
Blood bank is hospital-based
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Blood Collection Unit could be hospital or non-hospital based. This takes charge of
Community-Based Blood Collection Activities.
Blood Station could be hospital or non-hospital based. This dispenses blood coming from
the Blood Center (blood distributor).
The Sub-National Safe Blood Supply Network
The sub-national approach uses regional supply hubs to collect, process and distribute blood
to facilities in the region. This network configuration replaces the previous centralized
approach where network coordination and control was exercised at the central level. This
new approach is seen to have the following advantages:
1. It builds and sustains true voluntary blood donation programs by reaching a large
population from where a relatively small portion of the lowest risk donors can be
found and convinced to make regular repeat donations for philanthropic reasons;
2. It develops and sustains high levels of technical proficiency in blood collection,
testing and processing by handling a high volume of blood unit throughput; and
3. It achieves economies of scale in the procurement of the main material inputs for
blood processing such as reagents, blood bags and other supplies.
In Project sites a network of Blood Service Facilities (BSFs) are established to meet
anticipated needs for safe blood for obstetric and other emergencies in CEmOC provider
facilities. To enhance the provision of safe blood, the following blood supply management
configuration is implemented:
1. A sub-national Blood Center (BC) that takes charge of blood collection, processing, and
distribution is identified as a source of safe blood for the whole region. Blood screening is
done at the Regional Blood Centers. The Region Blood Centers for the current
WHSMP2 pilot sites are:
o Bicol Regional Blood Center (BRBC) for the province of Sorsogon, and
o Davao Regional Blood Center for the blood needs of the whole Caraga Region
o Adela Serra Ty Memorial Medical Center (ASTMMC) operates as a Blood Bank
for Surigao del Sur.
The case of Surigao del Sur is unique because the Caraga Region does not have a Blood
Center. The region’s safe blood supply needs are sourced from the Davao Regional
Blood Center (DRBC). However, the 6-hour travel time from Davao to Surigao del Sur
makes it important to invest in enhancing the capability of ASTMMC (which is in
Surigao Sur) to allow it to function as a Blood Bank.
Operational Features
1.) Regional Blood Centers (RBCs) have the following functions:
a. Blood collection through the Community Based Blood Donation (CBBD) in
coordination with the Local Blood Councils, BEmOC provider facilities as
the Blood Collection Units and RHUs through their WHTs.
b. Blood testing - a screening process done on donated blood to rule out STI,
HIV-AIDS, Hepatitis B and other infections that can be transmitted through
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blood and blood products.
c. Blood distribution.
2.) For fresh supply, RBCs require LGUs to submit an inventory of blood in their
facilities that contains the following information:
a. Number blood units received
b. Number blood units used
c. Balance
2. All CEmOC provider facilities function as Blood Stations (BS). A BS receives and stores
processed blood for transfusion when needed. However, in the meantime that the National
Voluntary Blood Program is re-organizing and is on transition, all CEmOC provider
facilities with capability to do screening tests, such as the Sorsogon Provincial Hospital,
are allowed to do blood tests using Elisa Immuno Assay (EIA).
For quality assurance in blood collection and storage all CEmOC provider facilities are
also designated as Blood Banks. A Blood Bank has the following functions:
1.) Cross Matching
2.) Submit blood requirement to RBC and pay the required “screening fee”
3.) Store blood supply properly to assure its safety and inventory stocks regularly
4.) Transfuse blood as necessary
5.) Conduct transfusion reaction work-up
6.) Advocate for voluntary blood donation
7.) Ensure rational blood use through the creation of Hospital Blood Transfusion
Committee.
An exception is Bislig District Hospital (BDH) which functions as a Blood Station
despite being designated a BEmOC provider (but with CEmOC capability). Bislig is a
remote municipality in the southern part of Surigao del Sur and is near the municipality of
Lingig where maternal mortality due to hemorrhage is high. BDH is well staffed,
appropriately equipped and can be upgraded to provide blood transfusion, thereby
effectively addressing the blood supply issue in an area rendered remote by the
topography of the province.
3. All BEmOC provider facilities and Rural Health Units (RHUs) function as Blood
Collection Units (BCU). A BCU recruits volunteer donors and organizes a “community-
based blood donation” activity (CBBD) with the assistance of the barangay-based
Women’s Health Teams (WHTs). On blood collection day, a team from the Regional
Blood Center comes to screen donors and collect blood.
The Community – Based Blood Donation (CBBD) Activity
The Community – Based Blood Donation activity is a collaboration between the Blood
Collection Units and the Regional Blood Centers (RBC) (or the Blood Banks in cases where
the CHD does not have an RBC, such as the case of ASTMMC in Surigao del Sur). While
the RHU is the main organizer of the CBBD, the RBC provides all the needed supplies for
blood collection and storage. The CBBD systematizes blood donation and triggers the
operation of the Network, which is tasked to assure safe blood availability at all times.
1. LGUs are required to organize Local Blood Councils (LBC) composed of –
1.) Local Chief Executives,
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2.) NGOs and
3.) Hospital administrators
To ensure the continuous supply of safe blood and safeguard the integrity of the Safe
Blood Supply Network LBCs are required to conduct CBBDs regularly.
2. For the WHSMP2, the Women’s Health Teams (WHTs) under the supervision of the
MHO will be tasked to organize CBBD activities in coordination with the LBC who in
turn will coordinate with the RBCs. A more detailed discussion on the WHT organization
of CBBD is found in chapter 10, “Delivering the WHSM Intervention Model.”
3. As a matter of policy, the RBC requires all municipalities in a province to undertake
CBBD. The blood collected is used to supply the blood needs of the province. This
manner of blood collection is seen to:
1.) Systematize the process of blood collection and distribution,
2.) Assure availability of safe blood,
3.) Improve access,
4.) Assure equity in blood distribution as blood use is rationalized, and
5.) Be widely acceptable to clients as it eliminates the inconvenience of the previous
“blood replacement scheme” where a patient is required to have at least 2 blood
donors.
4. The Regional Blood Centers (RBC) charges fees for blood screening which either the
LGU or patient pays. But while there is a fee involved, this is also socialized. Likewise,
every RBC has a way of rewarding their donors or LGUs. For instance –
1.) The Bicol RBC, which charges PhP 1,500.00 as screening fee per bag of 250 ml
of whole blood, waives the fee for the Province of Sorsogon if on CBBD done in
the municipalities of the Province, the number of blood collected is more than the
number of bags the Province need and actually use.
2.) In the case of Surigao del Sur, the ASTMMC Blood Bank screens all blood
collected from the different LHADZs. While blood is made available to anyone
in need, those patients from the donating LHADZ are given priority. Patients for
surgery are no longer required to bring along 2 blood donors but are charged PhP
1,000.00 per pack as screening fee. Poor patients are charged according to the
socialized scheme below, which is based on income class categories:
a. Class D: 2 units FREE; but if they need more than 2 units –
a) 3rd unit is charged to LGU
b) 4th unit is charged to congressman/congresswoman
b. Class C1: 75% of PhP 1,000.00
c. Class C2: 50% of PhP 1,000.00
d. Class C3: 25% of PhP 1,000.00
3.) ASTMMC maintains a Blood Donor Registry (per blood type). Blood Donors are
entitled to free annual workup. In addition, they are entitled to the following
privileges that are awarded according to their status as donor:
a. Regular donor – donates 3x a year. They are allocated 2 units of blood for
free, which is consumable for one year.
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b. Irregular donor – donates less than 3x a year. They are allocated 1 unit of
blood for free, which is consumable within the year.
c. All donors are asked to undergo FBS (fasting blood sugar) and cholesterol
determination every time they donate blood. These tests are free of charge.
Facility upgrading to ensure safe blood provision follow these guidelines:
1. Civil works for blood services in facilities designated to provide CEmOC services are
included in the civil works requirement of these facilities. The requirement is modest as
CEmOC facilities are expected to perform only storage, cross matching and transfusion
functions.
2. Equipment for storing and transfusing blood is included in the equipment list for CEmOC
provider facilities.
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Chapter 6
ASSURING THE ADEQUACY OF
HEALTH HUMAN RESOURCE
The Role of the Health Workers in WHSM Service Delivery
Human Resource Deployment in Proposed BEmOC and CEmOC
Provider Facilities
LGU Health Human Resource Profile
Short Term Solutions Employed by the LGU
LGU Options for Addressing the Human Resource Gaps
Inter-LGU Human Resource Sharing Arrangements
Hire and Deploy New Staff
Invite Private Practitioners
Organize a Network of Community-Based Service Delivery Teams
Sustain Health Human Resource through Incentives
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Chapter 6
ASSURING THE ADEQUACY OF HEALTH HUMAN RESOURCE
THE ROLE OF HEALTH WORKERS IN WHSM SERVICE DELIVERY
The shift in paradigm in maternal care resulted to changes in duties of critical health staff
and in their relationships with each other. Among the changes are:
1. Selected Barangay Health Stations and Rural Health Units are upgraded to a standard that
allows its staff to deliver basic emergency obstetric and newborn care. This change
requires these facilities to make BEmOC service available for 24 hours and its staff
readily available on call beyond the usual 8 working hours.
2. The MHOs and PHNs of BEmOC provider facilities are required to adapt to the new role
of their RHUs and BHSs by providing duty time as necessary and to be readily available
at all times should there be a call for assistance by the BHS midwife.
3. The role of the Traditional Birth Attendant (TBA) changes to that of a midwife assistant.
Under the new model, TBAs cease to be direct providers of childbirth services but will
continue to provide supportive care to the mother and the newborn as a member of the
Women’s Health Team.
HUMAN RESOURCE DEPLOYMENT IN PROPOSED BEmOC AND CEmOC
PROVIDER FACILITIES
LGU Health Human Resource Profile
At the LGU level, gaps of varying degrees are currently experienced in the deployment of
health staff. The most common concerns are:
1. The lack of such special skills as: obstetrics, anesthesiology, surgical nursing, and
medical technology in proposed CEmOC provider facilities.
2. Compliance with the human resource standards is a challenge, particularly in areas
where geographic location and terrain serve as serious obstacles to access. Such
situations mandated the designation of a number of BHS BEmOCs in an effort to
make services available in these remote and isolated areas.
3. The LGU staffing patterns reveal an increase in the hiring of contractuals to provide
nursing and medical technology services, mainly as a result of a mismatch between
existing government plantilla positions and the demand for these services.
4. The human resource standard for hospital BEmOC providers also pose a serious
challenge as it require 3 doctors per facility to allow it to operate for 24 hours.
5. In like manner, BHS BEmOC providers require that the RHU doctor and nurse be
available on call to provide assistance to the BHS midwife when the need arises. This
requirement would entail a strong commitment from the MHOs and the Public Health
Nurses.
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The concern therefore relates not just to competence but to adequacy in numbers as well.
Short Term Solutions Employed by the LGUs
Among the short term solutions employed by the LGUs to ease the human resource lack are:
1. Hiring of staff on “job order” basis to serve contractually as staff nurses, midwives and
medical technologists.
2. Engaging private visiting consultants in the fields of obstetrics – gynecology and
anesthesiology to fill the skill gaps in these areas in CEmOC provider facilities.
While the current remedy seems to work, it does not give assurance of quality care in the long
term. Furthermore, such short term, temporary solutions may eventually seriously disrupt
health service provision especially in relation to staff with special skills since these
arrangements do not require permanent and long-term commitments from the staff concerned.
LGU OPTIONS FOR ADDRESSING THE HUMAN RESOURCE GAPS
Inter-LGU Human Resource Sharing Arrangements
The cost-effectiveness objective of the facility mapping criteria implies that not all
municipalities will house a BEmOC provider facility. Furthermore, all BEmOC and CEmOC
providers are to render 24-hour service. Although RHU and BHS BEmOCs may not be open
24 hours, their staff are required to be available on call. The fact that most WHSM facilities
are to serve not only women from the municipality but from neighboring municipalities as
well, coupled with the need for facility staff to render extended duty, could very well lead to
patient loads that would be difficult for existing staff to handle, especially if those currently
giving birth at home shift to facility birth. This situation creates a need to consider resource
sharing options across municipalities.
The conditions imposed by the service delivery model give rise to two instances that may
require resource sharing across municipalities:
1. When a WHT from a non-BEmOC municipality refers a patient to a BEmOC in a
neighboring municipality.
2. When the patient load of a BEmOC is such that augmentation is needed in the form of
provider duty time to be rendered by providers from neighboring non-BEmOC
municipalities. This is most likely to be the case for RHU and BHS BEmOCs where the
lone RHU doctor can be easily overwhelmed by an upsurge of client referrals.
Memorandum of Agreement
Such resource sharing arrangements need to be agreed on between the municipalities
concerned and should ideally be covered by a Memorandum of Agreement (MOA) between
them. The MOA should authorize the following:
1. Allow WHTs from non-BEmOC municipalities to refer patients to a BEmOC and to
assist in their deliveries,
2. Allow the visiting WHT to receive its share of the WHSMP2 Facility-Based Childbirth
Performance – Based Grant (FBC PBG) when it refers poor clients and PhilHealth
reimbursements when referring PhilHealth members in accordance with the sharing
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scheme provided in DOH Department Order no. 2007-0098 promulgating guidelines for
the release and utilization of PBGs for WHSMP2. User fee sharing should follow the
sharing scheme for PhilHealth reimbursements.
3. Allow non-BEmOC doctors to render duty time in BEmOCs and availing of their share in
the above incentives. The conditions for rendering such duty time should be spelled out.
Hire and Deploy New Staff
The LGU staffing pattern has shown the hiring of more contractuals for nursing and medical
technology, a reflection of a mismatch between the existing plantilla positions and the service
demand for these skills. Moreover, the shortage of such special skills as: obstetrics,
anesthesiology, surgical nursing, and medical technology in proposed CEmOC provider
facilities is an area of urgent concern that needs to be addressed by local governments. The
ideal long-term solution would be to create more plantilla positions for the following
general and special skills-
1. The special skills (e.g., obstetrics-gynecology, anesthesiology) for CEmOC provider
facilities to function more effectively over the long term.
2. General Service skills such as those of general practitioners (GPs), nurses assigned to
provide bedside nursing in the wards and medical technologist. GPs are an important
part of the team as they could be trained to take on the role of a specialist should the
need arise. A general practitioner is also tasked to medically manage uncomplicated
cases brought to the facility.
While hiring new staff involves a long and circuitous process, the timeframe can be
substantially reduced with swift action on the part of the Local Boards (Sangguniang
Panlalawigan and Sangguninag Pambayan).
Invite Private Practitioners
1. Visiting midwives in BEmOC provider facilities
Where the number of public midwives is insufficient to meet the midwife-to-population
ratio requirements for WHTs and BEmOC Teams, private midwives may be invited to
join the teams. The process of engaging them is similar to the current practice of inviting
private doctors as visiting consultants in public and private hospitals.
1.) Midwives are invited to apply to the MHO or Chief of a BEmOC facility to allow
them to practice midwifery in the facility.
2.) Under this arrangement, the private midwife accesses public health facilities and
essential supplies to enable her to carry out maternal care, family planning and STI
services for her private clients while providing services to public health clients when
the need arises.
3.) The private clients that the midwife brings in to the facility pay for the use of the
facility (e.g. board and lodging, fees for delivery and labor room use, etc.) and the
professional fees for services rendered. This way the BEmOC provider facility
provides the midwife a better facility to practice and earn professional fees while at
the same time earning from a share of the user fees paid by non-poor clients. The
sharing scheme will depend on the negotiations between the private midwife and the
facility.
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As added incentive, private midwives under this arrangement shall be invited to
participate in DOH-sponsored training activities for free.
2. Visiting medical specialists in CEmOC provider facilities
The lack of doctors, particularly in the specialized fields of obstetrics-gynecology,
pediatrics and anesthesiology, severely constrain the delivery of the WHSM-SP. A
scheme for engaging private practitioners would be a quick way to fill these critical skill
gaps. Under this scheme private doctors shall be invited and be given the privilege to
practice in a public health facility as visiting consultants. The terms of their agreement
with the facility shall follow existing arrangements for consultants in big government and
private tertiary hospitals.
MHOs assigned in non-BEmOC provider facilities with specialty training in
anesthesiology, obstetrics and pediatrics may enter into such arrangements but should
take into account his or her main role as MHO. A special arrangement could be devised
for this purpose.
Organize a Network of Community-Based Service Delivery Teams
1. Organize and train members of the Women’s Health Team
Key to addressing the high maternal mortality ratio is the reduction of the incidence of
home birth, especially those attended by TBAs. Estimates cited indicate that more than
half of current deliveries are at home, mostly attended by TBAs - a situation that is seen
to have led to the current high mortality ratio. The TBA is usually seen as the
neighborhood healer, consulted for various illnesses as well as for childbirth. The TBA’s
childbirth services usually go beyond assisting in the delivery. Massaging the mother,
helping in household chores and minding the children are often part of the package.
The strategy to encourage the mother to deliver in health facilities instead of at home
should fully recognize the TBA’s influence on the mother’s choice on where to deliver. It
is important to make the TBA an ally in pursuing the above advocacy objective. Key to
this effort is the recognition that the shift from home to facility birth would deprive
the TBA of an important source of livelihood since she currently attends to the majority
of home deliveries in the community. Thus, the goal should be not to remove the TBA
from the scene but instead make her an important part of it by designating her as member
of the community-level Women’s Health Team (WHT) led by the rural health midwife.
By assigning the TBA to assist the midwife in carrying out the functions of the WHT, one
therefore merely changes the TBA’s job description and opens the door for her to still
look to deliveries as an important source of job satisfaction and livelihood (although
facility births will be attended by a skilled professional, the TBA can still be tasked to
perform auxiliary functions such as comforting the mother during labor, looking after the
children and the household, etc.). She should therefore share in whatever remuneration
the WHT receives.
The Provincial and Municipal Health Offices are encouraged to organize a network of
community health workers composed of BHWs (barangay health workers) and TBAs
(traditional birth attendants), and with midwives as team leaders to provide assistance in
implementing ground level activities.
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Sustain Health Human Resource through Incentives
1. LGU to Establish Incentive Packages to Attract New Personnel and Minimize Turn-
over
Health worker incentives could be monetary and non-monetary.
Monetary incentives
There is no doubt that financial incentives are key drivers of employment-seeking
behavior. This has been shown by the recent exodus of nurses for abroad, which was
further reinforced by the subsequent exodus of doctors who have chosen to give up their
medical practice in favor of working as expatriate nurses. One way to address this brain
drain would be to augment the present meager salary of public health workers with
financial incentives. However, the perennial stumbling block to such a measure is the
financing source. The health budget, especially at the LGU level, is just as meager.
LGUs would therefore have to craft innovative ways to broaden the sources of financing
of their health facilities. There are no lack of options, since good health is a commodity
that is always in demand. All that is needed is for local chief executives (LCEs) to think
out of the box and have the political will to implement seemingly unorthodox solutions.
WHSMP2 has offered to pilot LGUs a host of such out-of-the-box financing options and
has designed incentive schemes to encourage LCEs to summon the political will to try
them out. These options include:
1.) User fee collection from non-poor clients
2.) LGU enrollment of poor families into PhilHealth Sponsored Program and
PhilHealth accreditation of facilities. This allows LGUs to take full advantage of
insurance reimbursements while providing an effective health safety net for the
poor.
3.) Availing of franchising options for socially-marketed drugs and commodities.
These franchising schemes lead to the establishment of revolving funds to
sustainably finance the supply of these drugs and commodities. The franchising
schemes are described in more detail in Chapter 12 (Making the WHSM
Facilities Operationally Sustainable).
4.) Implementation of DOH performance-based grant (PBG) mechanisms.
WHSMP2 offers the following grant mechanisms to participating LGUs:
• PBG for facility-based childbirths. This PBG offers incentives to WHTs and
poor mothers to encourage the desired shift from home to facility birth.
• PBG for the universal PhilHealth coverage of the poor. This PBG offers
incentives to LGUs to encourage the attainment of enrollment targets for the
poor in the PhilHealth Sponsored Program.
• PBG to promote sustainability in essential drugs and contraceptive
commodities. This PBG offers incentive for LGU participation in grant and
franchising schemes that could lead to sustainability in the supply of essential
drugs and contraceptive commodities. Such schemes involve the
establishment of revolving funds that not only leads to sustainability in drugs
and contraceptives but could also be the source of additional LGU revenue.
These PBG mechanisms are described in more detail in Chapter 12.
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The above–mentioned revenue generating activities should come with a revenue –
retention mechanism to allow the health facility to use the revenue that it generates
to fund operations and health workers incentive. Authorizing the facility to retain and
utilize revenue would avoid having to go through the usual bureaucratic government
process in order for the facility to gain access to these funds and allow the facility to
make needed disbursements with a minimum of delay.
It is strongly encouraged that LGUs…
1. Allow for FACILITY REVENUE
GENERATION AND RETENTION.
2. Allow the overburdened HEALTH
WORKERS TO HAVE A SHARE IN THE
REVENUES EARNED.
3. Provide for WHT INCENTIVES.
Non-monetary incentives
While money seems to be a major motivation, health workers need non-monetary
rewards that acknowledge their competence and accomplishments:
1.) Scholarship grants,
2.) Sponsored travels to represent the LGU in an important meeting or conference,
3.) Sponsorship to short training courses,
4.) Recognition of an award giving body for outstanding performance, and
5.) Simple praise from superiors.
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Chapter 7
POSITIVE BEHAVIOR CHANGE
THROUGH ADVOCACY AND COMMUNICATION
Changing Women’s Behavior: The Focus of Behavior
Change Communication (BCC)
The BCC Strategy
Making the Strategy Effectively Affect Clients, Providers,
Communities and Local Government Executives
Key BCC Messages for Each Target Audience
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Chapter 7
POSITIVE BEHAVIOR CHANGE THROUGH
ADVOCACY AND COMMUNICATION
The shift in paradigm in maternal care and its consequent call for drastic reforms in health
service delivery entails behavior change among critical stakeholders. To effect the desired
behavior, LGU health officers and implementers are required to focus their actions on issues
that matters only in improving women’s health and consequently saving lives of mothers
and newborns. This should include:
1. Promoting knowledge, attitude and behavior of disadvantaged women relative to the goal
of making pregnancy and motherhood safer by giving birth only in facilities assisted by
professionals with competence to provide basic emergency obstetric and newborn
care.
2. Increase popular understanding by women and men particularly the adolescents and youth
of the barriers and risks to better reproductive health, including a greater appreciation of
the risk of STI and HIV infection through irresponsible sexual practices.
3. Reduce stigma and exclusion of disadvantaged and risk groups such as men and women
in commercial sex work and indigenous people to high quality reproductive health
services being offered in WHSM facilities.
4. Engage LGU leadership support and create broad constituencies for vigorous, enlightened
and forward-looking local government responses to delivering WHSM services, including
increased public support for the full menu of family planning methods.
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CHANGING WOMEN’S BEHAVIOR: THE FOCUS OF BEHAVIOR CHANGE
COMMUNICATION (BCC)
The BCC strategy supports the implementation of the WHSM integrated service delivery
package and helps ensure the achievement of over-all Project objectives by making known to
clients the following:
I. The benefits to every mother and newborn of having a competent professional assisting
during childbirth in a sufficiently equipped BEmOC provider facility.
This advocacy should result to the following expected behavior:
1. Women, particularly the disadvantaged deciding to seek care in BEmOC
provider facilities assisted by competent BEmOC teams only as manifested by:
1.) A visit to a BEmOC provider facility nearest to her home to seek advice and
prenatal care.
2.) A visit to the nearest facility – barangay health station or rural health unit- for
health services on maternal care, family planning, and STI control and HIV
prevention.
II. The positive changes in the service facilities and referral system, and of the need for all
families to consider the eventuality of a complicated delivery.
This should lead to:
1. LGU s upgrading their strategically located health facilities to BEmOC standard
1.) Infrastructure upgrading of BHSs and RHUs proposed to be BEmOC
providers,
2.) Equipment upgrading of BHS, RHUs, and Hospitals, and
3.) Organization and training of BEmOC Teams to enhance their competence.
2. Competent gender sensitive staff providing high quality reproductive health
services to clients particularly the disadvantaged women of reproductive age.
1.) Health team is respectful and gender – sensitive in their language.
3. LGUs and their health officers establishing a referral system backed up by
efficient communication and transport systems as exhibited by –
1.) Presence of telephone or radio transceivers or cellular phone at WHSM facilities
solely for official communications and referrals.
2.) Presence of stand-by vehicle in running condition in the vicinity of health
facilities solely for use during referrals, either for free or for a fee. Or the
presence of a notification board within the health facility’s waiting area relative
to available vehicles for hire with their suggested fees and contact numbers.
3.) Readiness of committed MHOs and PHNs to be available at all times to provide
assistance to a midwife at the BHS BEmOC provider within their jurisdiction.
4.) LGUs forging an alliance among them or through the inter-local health zones to
systematize referrals.
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4. Families convinced that “all pregnant women are at risk” decide to consult only
competent professionals in EmOC provider facilities near their homes.
III. The concept of the birthing plan and the new measures provided by the community and
LGU to overcome barriers to utilization of the services.
Consequent behavior change relative to this advocacy involves –
1. Organization of community-based Women’s Health Teams by LGUs through
their health officers to –
1.) Help track pregnancies and assist the women in birth planning,
2.) Give the woman practical advice on personal hygiene,
3.) Accompany the woman to a BEmOC provider facility during referrals or when
labor pains starts,
4.) Provide company to small children while their mother is giving birth in a
BEmOC provider facility, and
5.) Provide post childbirth care to mother and newborn at home.
2. Every pregnant woman has a Birth Plan (Mother and Child Book) as manifested
by-
1.) The willingness to pay for a Mother and Child Book (that contains a Birth Plan).
2.) The woman brings her Birth Plan with her whenever she visits the health center
to seek care or consult a health worker.
3.) The woman filling up her Birth Plan.
4.) Refers to the Mother and Child for information relative to pregnancy and child
care.
IV. The availability of STI screening and counseling as part of the service package as shown
by the following change in behavior –
1. STI screening and counseling being mainstreamed into regular RHU service.
2. All pregnant women and those who are sexually active and of reproductive age
availing themselves of the service.
V. The availability of the full range of FP methods, their relative costs in the short- and long-
term, and the financial subsidies or cost-sharing available for the longer term and the
availability of PhilHealth financing part for permanent methods.
This advocacy has positive effect on behavior change when the following are exhibited:
1. Procurement of contraceptives by LGUs resulting to health facilities not
experiencing stock-outs.
2. “Proceeds from the POP SHOP” is utilized by the LGU to subsidize
contraceptive needs of poor clients.
3. LGUs facilitating the accreditation of their health facility by PhilHealth and
enrolling poor families to PhilHealth Sponsored Program.
4. More couples of older reproductive age and who have attained their desired
number of children are using their PhilHealth Card to avail themselves of
permanent methods of contraception.
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VI. The impending changes in availability of temporary methods and the options for response
to this change. This advocacy should result to –
1. LGUs allotting funds to procure contraceptives for their poor constituent.
2. Health facility operating a “POP SHOP” or a similar business model for the
contraceptive needs of non-poor clients.
VII. The benefits accruing to PhilHealth members, how to become a PhilHealth member,
and how to access PhilHealth benefits.
1. LGUs meeting their PhilHealth enrollment targets.
2. PhilHealth staff and Health officers providing correct information on PhilHealth
membership and benefits,
VIII. The objectives of market segmentation, benefits accruing to the poor under the
Project, and how to find out if the family are eligible for benefits.
1. LGUs maintaining an updated list of poor families to equitably distribute health
services and goods.
THE BCC STRATEGY
The advocacy strategy is supported by the National Center for Health Promotion (NCHP) and
the National Center for Disease Prevention and Control and seeks to create an enabling policy
and social environment among LGUs. Success of the strategy is shown by:
A. Demonstrated leadership support by the governors, mayors and barangay leaders for
implementing the quality integrated service package, covering the four focus areas of the
project:
1. Maternal and Newborn Care
2. Family Planning
3. STI Prevention and HIV Control
4. Adolescent and Youth Health
B. Increase in recurrent budgets for WHSM at provincial, municipal and barangay levels.
C. Passage of laws and ordinances, with implementing rules and regulations, to ensure
aggressive implementation of the integrated service package and related financing
arrangements and performance awards as applicable.
D. Repeal of existing laws, ordinances, rules, and regulations that impede early and thorough
implementation and utilization of the integrated service package.
E. Support for attaining target of universal coverage by PhilHealth, including financing of
membership for indigents under the Sponsored Program.
1. A media mix strategy is employed in delivering the BCC and Advocacy messages. The
strategy consists of:
(1) Interpersonal and group communication;
(2) Community participation; and
(3) Radio and print (both text and visual) support.
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The strategy allows the NCHP to identify credible people in the national and local community
as “media sources” to transmit the messages, as well as training and capacity building so that
they can play this role effectively.
2. Interpersonal communication (IPC) is the main media carrier for BCC. It plays a
pivotal role in influencing individual decision-making and behavior change because it
allows a very high level of interaction. IPC is also the media channel of choice for
Advocacy, which entails selection of advocates or spokespersons among clients and
community leaders and identification of “champions” within each government system or
community location.
The WHTs will be trained on IPC to enable them to effectively bring the message across
the population and influence women’s decision making towards facility-based birth.
3. Community Participation is the main BCC channel for social support. Community
participation is a key part of the media mix, in particular for sustaining social support and
in advocating for institutional support. Community Participation is the core of the
Advocacy strategy. Its essence lies in mobilizing people in the community to be involved,
not as passive receivers of the messages or services, but as active participants who
demand change because they know that change is good for themselves, their families,
their neighborhood, and the community at large.
Barangay officials, teachers, social workers, informal community leaders, religious
leaders where appropriate, and youth leaders can be tapped as advocates for
positive change.
4. Radio and Print channels are used to support messages and reinforce information
exchange and agreements reached during interpersonal and group communication. The
project makes use of TV reporting of local advocacy events, and coordinates with
relevant national mass communication campaigns.
The LGU may tap the machinery of DOH National Center for Health Promotion to
provide technical assistance in media sourcing and in the production of TV and
radio ads.
MAKING THE STRATEGY EFFECTIVELY AFFECT CLIENTS, PROVIDERS,
COMMUNITIES AND LOCAL GOVERNMENT EXECUTIVES
A. Key BCC Messages for each target audience
Local health officers and implementers with technical assistance from the CHDs may
formulate relevant messages for intended audience that leads to change in health practice
and behavior. The following targets should be used in crafting messages.
Behavior Change Communication Objectives and Targets for each focus area of the
project and principal stakeholders are as follows:
1. Maternal Care
1.) Project Objectives:
a. Eighty percent (80%) of births delivered by a skilled health professional;
b. 75% of childbirths are facility-based; and
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c. Reduce the proportion of normal childbirths taking place in CEmOC
facilities.
2.) Stakeholder BC Objectives:
a. LGU and Health managers:
a) Endorse and support changes in roles and functions of health providers
and TBAs.
b) Institute financial incentives, such as sharing of PhilHealth and other
resources to compensate providers for their tasks.
c) Endorse and support policy and procedures for improving blood
availability.
d) Make increased Philhealth enrollment and accreditation a priority.
b. Provider:
a) Consistently provide client-focused, client-friendly, complete maternal
care package of services to pregnant women.
b) Adopt the new functions and relationships required under the new service
model.
c) Ensure that every pregnant woman develops and implements her birthing
plan.
d) Implement “no missed opportunities” strategy for FP as well as for STI
screening and subsequent management.
e) Identify clients with unplanned pregnancies for more focused FP
counseling and services.
c. Community:
a) Provide social support for the decision of women and their families and
partners to make use of the services available, especially in relation to the
shift from home deliveries to skilled-attended facility deliveries.
b) Provide social support to facility-based childbirth, birth planning
and important components of the birth plan.
c) Such support includes: provision of emergency transport, communication
facility, savings and credit schemes, etc.
d. Client:
a) Prepare and implement the birth plan with focus on childbirth
assisted by skilled provider in a suitable birthing facility.
2. Family Planning and Contraceptive Security
1.) Project Objectives:
a. Ten (10) percentage points increase in contraceptive prevalence of modern
methods;
b. Maintain contraceptive security in project areas in the light of national
changes in supply.
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2.) Stakeholder BCC objectives:
a. LGU:
a) Provides budget and policy support; and
b) Participates in new procurement arrangements.
b. Provider:
a) Consistently provides client-focused services to women of reproductive
age (WRAs) and their male partners.
b) Offers choice of the full range of FP methods based on full information,
including cost-effectiveness.
c) Ensure that method choice is a joint decision by both partners and is
driven by the health and well-being of the woman and the family.
d) Applies market segmentation in the provision of free contraceptives.
c. Community:
a) Zero tolerance for lack of availability of modern methods.
b) Support for more effective counseling on cost-effective options for
various client needs.
d. Client:
a) Begin to use or continue to use a cost-effective modern FP method.
b) More non-poor clients pay for contraceptives.
c) More NSV clients.
3. Adolescent and Youth Health
1.) Project Objectives:
a. 70% increase in utilization of AYH services in the pilot areas.
2.) Stakeholder BC Objectives:
a. Provider:
a) Provide services to adolescents and youth that respect privacy, ensure
confidentiality in a non-judgmental manner.
b) Tailor information and activities to the interest of the youth.
b. Community:
a) Establish partnership with the AYH Team in the conduct of youth-related
activities in the community.
b) Supports and monitors the provision of youth-friendly AYH services to
ensure that they are available to all those who need them, particularly in
public health facilities.
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c. Client:
a) Seeks and avails of reliable information, counseling and other services
for AYH and development needs.
4. STI Control and HIV Prevention
1.) Project Objectives:
a. 100% of MC and FP clients are screened for STI; and
b. 70% of high-risk groups practice primary prevention measures.
2.) Stakeholder BC Objectives:
a. Provider:
a) Consistently provides STI screening to all pregnant women and FP
clients.
b) No missed opportunity for STI clients with unmet FP needs.
c) Ensure provision of maternal care services to pregnant STI clients.
b. Community:
a) Increased involvement of leaders, community, youth and school based
organizations in STI control and HIV prevention.
c. Client:
a) Increased health-seeking behavior among the general population and
HRGs;
b) 100% condom use among HRGs.
GIVE BIRTH IN A FACILITY ….
IT SAVES LIVES!!!
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Part 3
A A IN
M N G G PR CT A
OJE OPER TIONS
E
EFF CTIV ELY
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Chapter 8
ORGANIZING THE SERVICE DELIVERY TEAMS
With the critical capacities to provide quality WHSM services already established, the
LGU is ready to implement the Project. An important first step to implementation is the
organization of a network of Women’s Health and Safe Motherhood (WHSM) Teams at
various levels of the Health Service Delivery System. The network consists of:
At the community level:
• Women’s Health Teams (WHT)
At the facility level:
• BEmOC and CemOC Teams
• Itinerant Teams
• Social Hygiene Clinic Teams
At the Local Government Level:
• Provincial Adolescent and Youth Team
• Municipal Adolescent and Youth Team
The Teams are strategically dispersed throughout the Province to ensure timely access to
obstetric and newborn emergency care by mothers. The Teams provide the full maternal and
newborn care, family planning, and STI and HIV service packages to the general population.
In addition, on a pilot scale, the DOH and the PHO tests new approaches to reaching high-risk
groups, including young adults as well as registered and freelance commercial sex workers.
Thus, teams for STI control (Social Hygiene Clinic Teams) and youth services (Adolescent
and Youth Health Teams) are also organized.
THE ORGANIZATION PROCESS
As envisioned, the Women’s Health and Safe Motherhood Teams (WHSMTs) are to consist
of only qualified health workers with a wide range of competence for the care of women
during pregnancy, childbirth, and the immediate postnatal period. The process of organizing
the WHSMTs and selecting its members, described below, helps to achieve this.
A. The Community-Based Women’s Health Teams (WHTs)
The organization of Women’s Health Teams (WHTs) guarantees an
effective community level support system in the implementation of
the women’s health and safe motherhood intervention model. WHTs
are organized and established in every barangay.
The Team is composed of:
A Rural Health Midwife is the Team Leader of all WHTs
organized in her catchment areas. Her Members include
barangay-based:
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Barangay Health Worker(s) and
Traditional Birth Attendant(s)
The Municipal Health Officer acts as the supervisor of all WHTs within the RHU
catchment area and shall be on call to give advice and attend to cases which are beyond
the capacity of the WHT to handle.
TBAs as WHT Members
As mentioned previously in the review of international experience, the mid 80’s saw the
emergence of studies evaluating TBA performance and voicing skepticism about the
strategy (Namboze 1985, Ross 1986). This gradually developed into a shared conclusion
that “the training of TBAs has had little impact on maternal mortality and that the
most effective measures were those that which make it possible to reach a well-
equipped hospital.” (Greenwood et al. 1990; Maine et al. 1991; Fauveau & Chakraborty 1994;
Koblinsky et al. 1994; Turmen & AbouZahr 1994)” (quote from De Brouwere et al. 1998).
Thus training TBAs to attend to women giving birth is an approach that did not
work in reducing maternal mortality.
TBAs however can become an important partner in the delivery of women’s health and
safe motherhood services. It is now generally accepted that one of the main reasons why
many TBA-based maternity care programs of the past did not work was that these
programs failed to effectively link TBAs to the health care system as most of these
programs hardly went beyond training TBAs.
Training TBAs to attend to women giving birth is an
approach that did not work in reducing maternal mortality.
An effective way of ensuring that the TBA is linked to the health care system is by
formally installing her as a member of the Women’s Health Team (WHT). Such a
strategy is seen to accomplish two things that serve to enhance efforts to encourage
mothers to shift from home to facility birth: 1) it eliminates the TBA as a provider of the
home birth option, 2) it enlists the TBA as an advocate for skilled professional care
during delivery, in facilities providing basic emergency obstetric and newborn care. In
line with the “EmOC approach” the TBA shall act as assistant to the midwife or any other
professional health care provider during delivery.
Steps in Organizing the Women’s Health Teams in a Municipality
The Municipal Health Officer and the Public Health Nurse with assistance from the Rural
Health Midwives organize the Teams for the municipality.
Step 1: Inventory of Midwives, BHWs and TBAs.
It is important for the Municipal Health Officers and the Public Health Nurses to have an
inventory of the Barangay Health Workers (BHWs) and traditional birth attendants
(TBAs) within the municipality catchment area. Such a list could be generated with the
help of the midwives. The objectives of this step are:
1. To determine the adequacy of members versus the number of teams that need to be
organized, and
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2. To define the geographic dispersion of the teams.
Step 2: Determine the Criteria for Selection of WHT Members
The qualification criteria for WHT membership shall be decided on by the MHO, in
consultation with the RHU staff and other stakeholders. Such criteria may therefore vary
across municipalities and may largely depend on:
• The number and dispersion of TBAs and BHWs across the barangays of the
municipality,
• The number of midwives available to supervise the WHTs,
• The number and geographic location of households in the municipality,
• The prevailing health seeking behavior of mothers,
• The budget available to fund WHT operations.
The province of Surigao Sur made it a policy to have all TBAs and BHWs be part of the
WHTs. Other LGUs may choose to impose criteria that would limit membership to those
with a certain level of skill or those who would satisfy certain specific needs of the
community. For instance, in areas where most TBAs are old and under- schooled, it
might be prudent to ensure that WHTs include younger members who could help their
older but more experienced colleagues carry out WHT tasks.
To ensure team efficiency, certain basic qualifications are recommended (but not
required):
1. Ability to read and write,
2. With good vision and hearing,
3. Ability to walk without assistance, and
4. Not more than 65 years old.
Step 3: Determine the number of teams that needs to be organized.
The minimum requirement is for one barangay to have at least 1 team. Some
municipalities may opt to have a team in every street or “purok” and to have as many
members as possible.
If the finding of the inventory in step 1 point to an inadequacy of WHT members, then
recruitment of members should be done before organizing the teams.
Step 4: Call for an Orientation Meeting
Organize a forum to orient the midwives and their members (TBAs and BHWs) and to get
their commitment to be WHT members.
Because of the number of participants involved, the midwives may need to be oriented
first on the rationale for organizing the WHT and their functions. The TBAs and BHWs
may need to be organized in batches of not more than 50 participants per batch. This is to
allow for better interaction between the MHO, the PHN and the WHT members and in the
process maximize everyone’s understanding of the tasks at hand.
This meeting is also a venue for getting commitments to join the team. The MHO and the
RHU should exert as much effort as possible to convince the practicing TBAs to be part
of the team. This is to make sure that they will not continue with their practice of
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assisting in childbirth at home and instead be part of the advocacy effort to shift mothers
to facility birth.
Step 5: Enlist the members and meet the team regularly.
List down the members of the WHT per barangay, labeling them as Team 1, Team 2, etc.
and their respective areas of assignment. For example, Team 1: Purok 1, and so on.
Ensure that the teams are appropriately deployed in a manner that ensures that all women
in the community have easy access to a WHT member.
In an IP (indigenous people’s) community, it is best to have IPs as members of the Team.
This would serve to encourage IP women to access WHSM services and give them some
level of assurance that their unique needs are taken into consideration in the delivery of
these services.
If the barangay is large, it may need to be divided into clusters or puroks and several
WHTs may need to be organized with a team assigned in each cluster, purok, or street.
Furthermore, if a barangay is in a mountainous area and is hard to reach, recruiting men
members of the WHT should be considered. In communities where hiking the trail is the
only means of travel, men would make good assistants during referral. In this case, the
name “Women’s Health Team” may be changed to “Community Health Team”, or
whatever local name is appropriate.
Step 6: Train the Teams on their functions.
Step 7: Orient the Teams on their incentives.
Step8: Build team spirit and teamwork through team-building exercises.
A. Organizing the Facility-Based Teams
Aside from the community-based WHTs, the Project mobilizes networks of facility-based
public and private health providers to help efficiently deliver the integrated WHSM-SP. The
facility-based teams are:
o BEmOC Teams in every facility designated to provide basic emergency obstetric and
newborn care,
o CEmOC Teams in every facility designated to provide comprehensive emergency
obstetric and newborn care as well as surgical contraception and IUD insertion.
o Itinerant Teams in every CEmOC provider facility to deliver outreach FP services.
o Social Hygiene Clinic Team in a Social Hygiene Clinic or RHU where STIs are
prevalent.
Organizing the Facility-Based Teams is not difficult since the members of the Teams are the
staff of the Facility itself. However, problems may arise when the facility staffing requirement
is not complied with. In this case, there is a need to recruit members from the private sector or
from other public health facilities such as the RHU or the Community Hospital.
1. The BEmOC Teams (BTs)
BEmOC Teams as the name implies are set up in every BEmOC provider facility,
whether Hospital, RHU or BHS.
Its Team Leader is a Doctor who may be the Chief of Hospital, Chief of Clinics, Head of
the Obstetric and Gynecology Department, or a General Practitioner trained in BEmOC
service provision, or the Municipal Health Officer in the case of RHU or BHS BEmOCs.
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For RHU and BHS BEmOCs, the Team Members are:
1.) The Public Health Nurse,
2.) All Midwives as head of the WHT, and
3.) All members of the WHT
In a BHS BEmOC provider, the MHO or the RHU doctor heads the team with the
RHU nurse, BHS midwife and the WHTs assigned in the surrounding barangays as
members.
For Hospital BEmOCs , the Team Members are:
1.) All staff nurses of a non-departmentalized hospital,
2.) All staff nurses of the OB ward and delivery room nurses of a departmentalized
hospital
3.) The medical technologist whether in-house or visiting status under the inter-LGU
or ILHZ staffing arrangement or private practicing Med Tech invited to work on
call in the public health facility.
4.) Optional members are:
a. WHTs – the midwife and her members
WHTs may be tapped to help in a hospital BEmOC specially when there is a
serious staffing shortage. The midwives who head WHTs shall undergo a
BEmOC training course to ensure that their knowledge and skills are up to
the task. The WHT members, on the other hand, can be tapped to lend a extra
hand in the ward with supervision from the staff nurse.
The MHO and the Chief of Hospital organizes the BEmOC Team. In doing so, the
following are important for them to consider:
1.) Hospital BEmOCs should have 3 teams so that there is 1 team per 8-hour shift.
This arrangement assures mothers and their families of quality care. Duty time per
Team are as follows:
First shift: 7 AM – 3 PM
Second shift: 3 PM – 11 PM
Third shift: 11 PM – 7 AM
a. For District Hospitals with an inadequate staff complement, the following
scheme is suggested:
a) Invite the RHU doctor from a non-BEmOC facility to provide duty time
just like a visiting consultant in the hospital and be a BEmOC service
provider. Invite as well the RHU doctor from a neighboring municipality.
This completes the required number of BEmOC teams.
Please note, that if all the MHOs agree to the proposal and the agreement
is sealed with a MOA between the mayors involved, it is important to
inform the Health Human Resource Development Bureau or National
Center for Disease Prevention and Control of the Department of Health,
for the training needs of all the doctors involved.
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b) Encourage private providers (doctors, nurses, midwives) to apply as
BEmOC service providers in the hospital and provide service to public
health and their private clients.
2.) RHU BEmOCs may have only one (1) team but their working scheme may
be modified as follows:
a) One or 2 midwives should be assigned to go on duty per shift together
with the members of the WHT on duty. The duty time is the same as that
of a hospital BEmOC provider:
First shift: 7 AM - 3 PM
Second shift: 3 PM - 11 AM
Third shift: 11AM -7 PM
The RHU doctor and PHN are BEmOC providers on call.
b) Since the RHU is not a 24-hour facility, those going on “shift” are
required to be physically present at the RHU but should be allowed to
sleep in the facility (the design for RHU BEmOCs provides for adequate
sleeping quarters) at night when there is no patient but with instructions
that the RHU’s lights should be left “on” to indicate that someone at the
RHU is present to render service.
BHSs are satellite facilities of RHUs regardless of whether it is a BEmOC
provider or not. The usual BHS work schedule can be modified for BHS
BEmOCs as follows:
o The BHS may not have a structured three 8-hour shifts, but maternal and
newborn health services should be made available anytime. This means
that the midwife and her team is on “on call” status after the usual 8-hour
clinic time.
o The community should be kept informed of the availability of services
after the 8-hour work schedule (8:00AM – 5:00 PM) together with the
procedure for notifying the midwife and members of the WHT of the
need for their services. This information can be disseminated by posting
a sufficiently prominent notice on the bulletin board of the BHS or the
Barangay Hall.
o If the number of WHT members is sufficient, they may opt to go on three
8-hour shifts with WHT members assigned to go on each shift, observing
the same scheme for that of the RHU BEmOC. The midwife, on the other
hand, shall be on call.
Organizing work is a challenge to health officers. Putting the Teams into operation is
demanding. To make the organization work and service schemes operational, the
following should be done:
1). The PHO and MHO should advocate for the passage of a local policy that provides for –
a) The official working arrangements of the various teams:
o Women’s Health Teams
o BEmOC Teams at Hospital, RHU and BHS
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b) A defined staffing scheme for the BEmOC providers
c) A defined incentive scheme for the Teams:
o Ensure appropriate fund source for additional financial incentives to the teams:
• All BEmOC providers should work for their accreditation to the Maternity
Care Package (MCP) of PhilHealth to ensure a consistent fund source.
• Facility heads should work for the enactment of an LGU ordinance that will
allow the facility to collect user fees for services rendered and for the
revenues generated to be managed by the facility for its operations. Revenues
generated by a BHS shall be managed by the RHU.
o Provide reasonable additional financial incentives to the teams through a share in
the hospital revenues generated: PhilHealth MCP reimbursements, user fees, and
others. The sharing scheme recommended by DOH as well as those being
currently implemented in the provinces of Sorsogon and Surigao Sur are
described in detail in Chapter 12.
2. The CEmOC Teams
Most CEmOC provider facilities are departmentalized, with medical specialties properly
identified and segmented. In this setting, the Teams are configured as follows:
Team Leader can be the Chief of Clinics or head of the Obstetric-Gynecology Department or
an Obstetric-Gynecology Specialist or a General Practitioner (GP) trained on basic and
comprehensive emergency obstetric and newborn care.
The Members are:
• Anesthesiologist or GP trained in anesthesiology (could be in-house staff or visiting
consultant)
• Pediatrician or neonatologist (in-house or visiting consultant)
• Either all operating room nurses or only those assigned to the OB OR, depending on the
operational needs of the hospital
• Medical Technologists
A CEmOC provider hospital is usually the DOH operated tertiary hospital (if there is one in
the province) and the Provincial Hospital, as these are facilities that are usually sufficiently
staffed, equipped and with the required amenities of a departmentalized facility.
Organization of CEmOC teams in these facilities may not be necessary because of their
departmental structure, with an obstetric and gynecology department, a department of
pediatrics and a newborn intensive care unit (NICU), all operating on three 8-hour shifts.
However, the travel time criterion (established to ensure that mothers and newborns have
timely access to emergency care) requires the upgrading of some District Hospitals to
CEmOC provider standards. Thus there are three (3) types of CEmOC provider facilities:
• DOH operated tertiary hospital
• Provincial Hospital
• District Hospital
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The organization of CEmOC Teams in a District Hospital requires the following:
1) Hospital CEmOCs should have 3 teams, 1 team per 8-hour shift:
First shift: 7 AM – 3 PM
Second shift: 3 PM – 11 PM
Third shift: 11 PM – 7 AM
2) For District Hospitals with an inadequate staff complement, the following scheme is
recommended to address the personnel gap:
a) Invite private practicing doctors with the following specialties to act as consultants:
o Obstetric-gynecology
o Anesthesiology
o Pediatrics or neonatology
b) Provide reasonable incentives to consultants providing service to poor public health
clients:
o PhilHealth MCP reimbursement of professional fee amounting to PhP 2,000.00.
o Collection of professional fees from non-poor clients.
3) Train general practitioners on CEmOC skills training.
3. The Itinerant Teams (ITs) are organized to encourage older couples of reproductive age
who have attained their desired family size, to shift to more cost effective, permanent
family planning methods. These teams are based in CEmOC facilities. Each team is
composed of:
1) A doctor trained to perform non-scalpel vasectomy (NSV), bilateral tubal ligation
(BTL) and IUD insertion and
2) Two operating room nurses or an operating room nurse and a surgical midwife.
The main function of the team is to perform, in coordination with local WHTs, outreach
activities on a regular basis in communities within the CEmOC catchment area. The
outreach activity is meant to widen the reach of reproductive health services, particularly
family planning.
4. STI or SHC Teams (STs) are organized in Social Hygiene Clinics or Rural Health Units
with STI control services. The team is tasked to address the health needs of high-risk
groups and to protect the general population from infection. The STs are composed of:
1) A physician,
2) A nurse,
3) Medical technologist and
4) Midwife
5. The Adolescent and Youth Team (AYT) is organized at two levels:
1) The provincial level team is interagency and interdisciplinary and consists of
representatives from the different government agencies concerned with adolescent
and youth welfare. The Provincial Adolescent and Youth Team is composed of:
a. A Provincial Board member responsible for adolescent and youth welfare
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b. Provincial Health Officer
c. Provincial Social Work and Development Officer
d. Department of Education Superintendent of Schools
e. Non-Government Organizations with programs on adolescent and youth welfare
f. Provincial Population Officer
2) The municipal level team is formed in areas where adolescent and youth problems are
prevalent and is tasked to implement interventions that are compatible with the
provincial strategy. As an implementing body, the Municipal Adolescent and
Youth Team is composed of:
a. Municipal Health Officer
b. Municipal Social Worker
c. School Guidance Counselor
d. Municipal Population Officer
e. Sangguniang Kabataan
The Provincial Adolescent and Youth Team (PAYT) assesses the adolescent and
youth situation in the province and crafts an appropriate strategy. The PAYT likewise
assists the Municipal Adolescent and Youth Team (MAYT) in planning and
implementing the interventions suited to the local situation, particularly in building its
capability for peer counseling.
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Chapter 9
TRAINING THE SERVICE DELIVERY TEAMS
The Strategy p 110
The HRTD Mechanism p 111
The Training Packages p 111
The Recommended Teaching and Learning
Process for Women’s Health Teams p 114
Accessing Training Programs p 114
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Chapter 9
TRAINING THE SERVICE DELIVERY TEAMS
THE STRATEGY
Alongside the organization of service delivery teams is the effort to train its members on the
required WHSM competencies. In order to accomplish this, there is a need to enhance the
capacity of the health system to train and develop its human resource to the optimum level of
competence. The appropriate strategy towards this end should be guided by the following:
1. A national policy that calls on health and local government leaders to ensure skilled
professional assisted childbirth within the health system, for all women.
2. A change from separate delivery of key women’s health/reproductive health services
towards an integrated service package that is embodied in the women’s health and safe
motherhood integrated intervention model.
3. Strengthened client focus accompanied by invigorated social support for families and
women in the reproductive age group.
Current training programs provided by the Dr Jose Fabella Memorial Hospital (DJFMH) and
its network of training institutions focus primarily on upgrading and refreshing the skills of
staff (doctors, nurses and midwives) who have completed primary professional training and
who are already practicing their craft. The DOH-Health Human Resource Development
Bureau (HHRDB) plans to adopt the DJFMH program for pre-service training programs in
the entire public health system, to minimize the need for continuous in-service training for
newly graduated health professionals. The scope of the program will, however, be widened
with the inclusion of the pre-service training for the training of members of indigenous
communities, through the stepladder-training program leading to midwifery qualification,
which the HHRDB currently supports.
The new women’s health and safe motherhood policy that emerges from the shift in the
service paradigm requires a rethinking of the human resource training and development
strategy with the objective responding to the challenges brought about by the need to
effectively implement the WHSM service delivery model. Such a rethinking process is driven
by the following service-oriented goals:
1. Upgrading of competence required of the following women’s health and safe motherhood
(WHSM) teams to enable them to effectively perform their assigned tasks:
1.) Women’s Health Teams at the village level,
2.) BEmOC Teams in basic emergency obstetric and newborn care provider facilities,
3.) CEmOC Teams in comprehensive emergency obstetric and newborn care provider
facilities,
4.) Itinerant Teams for outreach services on family planning,
5.) STI control and HIV prevention Teams, and
6.) Adolescent and Youth (AYH) Teams.
2. Making skills available through innovative and pragmatic action in the light of an
ongoing brain drain of skilled health workers (nurses and doctors) from rural and
underserved areas. The Doctors to the Barrios Program and the Volunteer Midwives
Program are among the current initiatives that seek to respond to this challenge.
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3. Re-orienting, upgrading and re-training of key public health providers to enable them to
competently deliver the integrated package, work effectively as part of a team, and
interact in an acceptable manner with clients, families and the community.
4. Ensuring competence in the specific skill mix required to effectively render emergency
obstetric and newborn care, with a focus on the practical aspects of service delivery at the
ground level.
5. Application of competency-based, practical learning, with a high level of responsibility
taken on by the learner, coupled with mentoring and guidance from training providers.
6. Linking training more closely with placement and staffing with the aim of producing and
maintaining functioning service teams and adequate support services.
The strategy discourages past dependence on public sector health workers as trainers.
Training of Trainers (TOT) formats have been shown to limit the availability, motivation, and
effectiveness of the trainers, and have resulted in missed opportunities to make use of other
training resources. The HRTD mechanism described below shows how the shift in training
strategy which involves the nationwide use of the DJFMH training program and its training
network (which shall be expanded further to be able to meet training needs on a nationwide
scale) will serve to satisfy the training needs brought about by the new women’s health and
safe motherhood policy
THE HRTD MECHANISM
To boost the health system’s capacity, the Department of Health has established a more
responsive and effective system for training health providers and support staff. The HRTD
system utilizes a Training Consortium that is headed by the Dr. Jose Fabella Memorial
Hospital (DJFMH) with qualified training institutions strategically located all over the
country as members. Currently, the following training providers are recognized as part of
DJFMH network of training institutions:
1. Bulacan Medical Center, Malolos, Bulacan
2. Baguio Medical Center, Baguio City
3. Quirino Memorial Medical Center, J.P.Rizal St, Project 4, Quezon City
4. Paulino J Garcia Memorial Medical Center, Cabanatuan City, Nueva Ecija
5. Veterans Regional Hospital, Bambang, Nueva Vizcaya
6. St Anthony Hospital in cooperation with Vicente Sotto Memorial Medical Center, Cebu
City
7. Northern Mindanao Training and Teaching Hospital, Cagayan de Oro City
8. Davao Medical Center, Bajada St, Davao City
9. Zamboanga City Medical Center, Zamboanga City
As head of the consortium, DJFMH is also the lead institution for the network of training
providers, with the following responsibilities:
• Managing the training programs,
• Ensuring training quality,
• Periodically supervising, monitoring and evaluating the training institutions within the
network.
• Periodically updating the faculty members
THE TRAINING PACKAGES
Training the WHSMTs is focused on providing each member of the various teams the skills
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that they need to enable them to competently perform their assigned tasks. The following
specialized training courses are designed for each category of health professional working
within a team. These training courses will be continuously developed and updated as those
responsible for curriculum and course design learn from the implementation experience.
The barangay – based Women’s Health Teams, are required to undergo an Orientation
Course that is focused on their functions and includes, among others, topics on:
1. Pregnancy Tracking
2. Birth Planning
3. Organizing Outreach Activities
4. Maternal Death Reporting
As frontline health workers, they will be the main driving force in implementing the
Interpersonal Communication (IPC) strategy that seeks to effect positive behavior change
among the women and men of reproductive age in communities. They will therefore be
trained on IPC as well.
Training courses for the Facility-Based Teams are specially designed for the expertise they
are expected to develop in the course of their professional practice. The training packages
guarantees the Teams’ competence in the delivery of services
1. Basic Emergency Obstetric and Newborn Care for BEmOC and CEmOC Teams
This is an 11-day course where a full team complement is required to attend on the same
schedule. This is to ensure team work, complementation of functions, and camaraderie.
Thus, included in the packages are 3 sub-courses on:
1) Medical management of basic obstetric and newborn emergencies for doctors,
2) Nursing management of basic obstetric and newborn emergencies for nurses,
3) Life saving skills with focus on early identification of signs and symptoms of basic
obstetric and newborn emergencies for midwives,
4) Newborn screening,
5) Updates on prenatal and postnatal protocols,
6) Updates on the maternal death reporting protocol, and
7) Group dynamics session.
In the case of a hospital BEmOC provider, where there are no midwives, the midwives of
the RHU nearest to the hospital should be made part of the team and should be trained
one at a time. Where doctors are not enough to comply with the required 1 doctor per
shift, the doctors of the RHUs nearest to the hospital should also be made part of the team
and trained accordingly.
This course is open to general practitioners in CEmOC provider facilities only. Since
nurses in CemOC provider facilities are expected to be better skilled, the course maybe
taken by this group of professionals assigned in the delivery room as necessary
2. Family Planning courses for BEmOC and Itinerant Teams:
1) Level 1: Basic Knowledge on FP is an orientation course on modern FP methods and
management of side effects. The whole team attends the orientation on FP methods
together, and then will be re-grouped according to profession (e.g., doctors, nurses,
midwives) during the discussion on the management of side effects:
a. Medical management will be for doctors,
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b. Nursing management, counseling and referral for nurses, and
c. Giving practical advice and replenishment of supplies for midwives.
2) Level 2: Comprehensive FP including IUD insertion is open to doctors and nurses.
3) Breast and Cervical Cancer Screening is a training course open to doctors, nurses and
medical technologists.
a. The doctors’ training focuses on:
a) Physical examination of the breast and cervix
b) Medical interpretation of laboratory results: acetic acid wash, papanicolau
smear
c) Making the appropriate diagnosis.
b. The medical technologists will be given updates on cervical cancer screening.
c. The nurses will be re-oriented on taking patients’ medical history and gender
sensitive counseling.
Staff of non-BEmOC facilities are also required to attend the FP courses as appropriate.
Special FP Course for CEmOC provider facility-based Itinerant Teams:
1) Voluntary Surgical Sterilization as necessary since a surgeon is usually assigned to
head the team along with 2 operating room nurses.
3. Courses related to STI Control and HIV Prevention are offered to BemOC Teams as well
as Social Hygiene Clinic Teams (SHC) and RHU based STI Teams:
1) For Doctors:
a. Risk assessment: interpretation of laboratory results
b. Clinical screening and diagnosis
c. Syndromic and clinical management
2) For Nurses:
a. Risk assessment and counseling
b. Syndromic management
3) For Medical Technologists (as needed):
a. Laboratory STI tests
For CEmOC provider facility-based General Practitioner the following special courses are
required:
1) Syndromic and etiologic management of STIs
2) Medical management of complications of STI
Other special training courses are designed to further enhance the quality of the Teams’
ability to provide quality service:
1. Gender and Health
2. Leadership Training and Group Dynamics
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3. Counseling for Nurses and Social Workers as necessary
4. Monitoring, Evaluation, Research and Dissemination for Doctors and Nurses.
THE RECOMMENDED TEACHING AND LEARNING PROCESS FOR WOMEN’S
HEALTH TEAMS
As a teaching and learning methodology, the midwives are trained first. This training is not
only aimed at providing the midwives knowledge on the new protocols developed but also
at providing them with the skills that will enable them to transfer their newly acquired
knowledge to the members of their respective teams.
Adult learners require a different teaching-learning methodology. A classroom type of
instruction does not appeal to experienced adults. Given their vast practical experience and
the operational nature of their tasks, a small group, interactive type of approach delivered
in sessions spanning short time periods could prove more effective. If it is necessary to
divide the modules into several sub-modules, this should be done to allow for ease in
understanding and mastery. For instance, each WHT function may need to be taught singly in
one 30 minute session, with no more than one session scheduled per day to ensure that the
classroom session gets plenty of “on the job” reinforcements for the rest of the day.
For example:
First lesson: Pregnancy Tracking.
Methodology: Discussion and individual instruction on:
o What is Pregnancy Tracking
o Why is Pregnancy Tracking necessary
o What is the Pregnancy Tracking Form
o How is the form filled up
Duration: 1 week
o 30 minutes -1 hour is for interactive instruction
o The rest of the week is for the members to develop their skills on
pregnancy tracking
Evaluation: The midwife as team leader should check on the WHTs task (in this case,
pregnancy tracking) and see if the form is properly filled-up.
A member should not be allowed to advance to the next lesson until the first
lesson is mastered.
The midwife as the teacher can schedule the activity for her Teams at her own pace, e.g.
whenever she visits her catchment barangays. The lesson topics should be guided by the
“Functions of the WHT” as discussed in the WHT Module.
ACCESSING TRAINING PROGRAMS
At the national level, the training program is managed by the following offices:
1. The Health Human Resource and Development Bureau (HHRDB) is in-charge of human
resource management and development. This includes–
1) Recruitment,
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2) Deployment,
3) Career development, and
4) Training.
2. The National Center for Disease Prevention and Control (NCDPC) as the technical arm
for all public health programs, is responsible for providing assistance to the HHRDB in
the
1) Assessment of training needs
2) Over-all design of the training packages, and
3) Maintenance of a data base on the Teams trained on a particular course per facility.
This is to ensure comprehensive training coverage across the country.
3. The DJFMH as the premier maternity hospital in the country is main training arm for
women’s health and safe motherhood. With assistance from NCDPC, its training team is
tasked to:
1) Draft training curricula for the various training packages,
2) Draft and produce training manuals,
3) Conduct or supervise the actual conduct of the training,
4) Conduct post-training evaluation of trainees,
5) Establish networks of training providers across the country,
6) Take charge of training quality assurance, and
7) Monitor the performance of the training providers within the network.
In addition, DJFMH as training center is charged with administrative functions relative to
managing the training program to include such tasks as:
1) Updating training schedules on a yearly basis and informing stakeholders about the
updated course offerings,
2) Determining the number of Teams that it can accommodate for a particular course per
batch,
3) Costing the training package: tuition fee and miscellaneous expenses,
4) Negotiating for the Team’s accommodation while on training,
5) Preparing the training kits, and
6) Assigning faculties for the course.
At the provincial level, the task of making sure that the teams are competent lies with the
Health Human Resource Management Office (HHRMO) of the Provincial Health Office
(PHO). Organizing the training of the Teams will involve the following steps:
Step 1: Assess the Team’s capability to deliver the WHSM – SP, particularly EmOC.
Step 2: Determine the number of Teams that need to be trained.
Step 3: Make a training schedule for the Teams while making sure that each facility is left
with sufficient staff to be able to continue to provide health services while the Teams undergo
training.
Step 4: Inform DOH-HHRDB of the request for training. Be clear on the training packages
needed and number of Teams to be trained. It would help to provide HHRDB with a preferred
training schedule.
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Step 5: Wait for a response from HHRDB which could normally take 2 weeks. As soon as
HHRDB approves the request, it will be endorsed to DJFMH which in turn will send a notice
with the following information:
1.) Confirmation of the training schedule,
2.) Number of Teams to be trained for each batch,
3.) Cost of training that includes tuition fee, accommodation and other miscellaneous
expenses,
4.) Accommodation arrangements, and
5.) Contact person at DJFMH for other administrative details which may include-
a. The training institution where Teams are to be trained and
b. Things that each Team is required to bring, e.g., clinical gowns, masks, etc.
Step 6: Inform the Teams of the approved training schedule.
Step 7: Prepare the training fund. If the training is to be sponsored, by a donor, inform the
donor of the training cost and secure the timely release of funds. If the LGU is funding the
training, inform the chief executive of the schedule and cost.
Step 8: Enroll the Teams.
Step 9: Send the Teams to training according to the schedule.
A. Post-training Activities
The Teams are usually required to submit a post training plan. It would be wise for the PHO
to require the Teams to present their plans and to discuss its implementation. The post
training plan is among those evaluated by the DJFMH in their post-training evaluation where
they do actual visits of their trainees in their posts and observe how well they practice the
skills they have learned. Re-training may be required if the Evaluation Team finds a trainee
still lacking the competence and/or confidence required.
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Chapter 10
DELIVERING THE WHSM
INTEGRATED INTERVENTION MODEL
WHT Service Delivery
Maternal and Newborn Care Service Delivery
Family Planning, STI-HIV Prevention and Control
and Adolescent and Youth Health Service Functions
WHT Tools
Service Delivery by the Facility-Based Teams
BEmOC Teams
CEmOC Teams
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Chapter 10
DELIVERING THE WHSM INTEGRATED INTERVENTION MODEL
This section is addressed to the public health provider tasked to implement the service
delivery model. Thus, it speaks directly to them.
The health system should strive to deliver only the highest quality of service that it can
provide. Saving lives demand that -
We make good decisions,
Towards making reasonable investments, in order to
Provide the best care especially to the poor.
Remember, our patients judge us by the way we talk to them, handle our body language and
facial expression when we are in front of them, touch them. There have been so many
“stories” told on why the public sometimes hold a negative perception of the public health
worker, who usually ends up with a reputation for being insensitive, disrespectful, harsh, and
unkind. It is no wonder that our services are poorly utilized in communities where these
stories are told. Health worker attitude simply drove clients away from the public health
system except perhaps those left with no choice because of poverty. But the poor are the
clients we need to serve well. They recompense us through the taxes they pay and the goods
they buy.
Our Clients Deserve the
BEST…
Be the BEST Health Worker
WHT SERVICE DELIVERY
Since the WHSM intervention model takes an integrated approach to service delivery, as
WHT you are expected to have a skill mix to enable you to perform an array of functions
related to maternal and newborn care, family planning, STI control and HIV prevention and
adolescent health.
Maternal and Newborn Care Service Delivery
1. Pregnancy Tracking
For efficiency, and better organized service delivery -
1.) As midwife and Team Leader, you may assign your
members (BHWs and TBAs) specific cluster(s) or
purok(s) within the barangay that you serve.
2.) Give each member of your Team a copy of the Pregnancy Tracking Form to enable
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them to start implementing the pregnancy tracking and recording procedures you
taught them.
3.) Remind your members to make sure that all pregnant women in their areas of
assignment are recognized and their conditions tracked until 42 days after childbirth.
It may help you as team leader to schedule a regular team meeting for reporting and
updating purposes. This enables your members to gain a wider view of team
operations and in the process, learn from each other’s experience. Such regular
meetings will also minimize instances of double reporting, especially if you keep a
consolidated Pregnancy Tracking Report in every barangay that you handle.
2. Birth Planning
The Birth Plan is a home-based record of a woman’s pregnancy. It details her plan of
action for her pregnancy and childbirth. Important aspects of the Plan are:
1.) Identification of a WHT member assigned in her
area that she could consult for advice.
Reminders:
a. The first time you approach a client, be
courteous and friendly.
b. Introduce yourself.
c. Give her a copy of the Mother and Child Book
that contains the Birth Plan. Advice her to
always bring this Book whenever she visits the health center for check up.
d. Make sure that she writes your name on the space provided for in the Birth Plan.
If she requests for your phone number, write the number where you can easily be
reached below your name. This assures her that you are ready to respond in case
she needs any assistance.
2.) Identification of the BEmOC facility where she will give birth.
Reminders:
a. Familiarize yourself with the facilities nearest the homes of your clients. Know
the services that they offer as well. This way you can advice your client where to
go for prenatal, childbirth and postnatal care.
b. Write the addresses of these facilities in the Birth Plan with clear instructions on
how to get to these facilities. Make sure that the birthing facility is a BEmOC
provider facility.
3.) Identification of a local government unit or individual who will provide a vehicle
when it comes for the mother to be brought to the birthing facility. The information
should include contact persons and their phone numbers.
Reminders:
a. Advice your client of the need for
ready transport service when labor
pains start. Tell her to make
arrangements for this early on in her
pregnancy.
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b. To ensure that the mother has easy access low cost transport, help her ask around
from relatives, friends or neighbors for a vehicle that any of them may be willing
to lend or offer for hire.
c. You should also help the mother explore the option of using accessible
government vehicles, such as the barangay vehicle or vehicles from your
municipal government. If use of the vehicle involves a fee, make sure that the
mother is aware of this.
d. Get the contact person’s name as well as the contact number. Write this in the
Birth Plan.
e. Constantly remind the vehicle contact person about the use of the vehicle on the
third trimester of pregnancy.
4.) Information on how childbirth expenses will be financed.
Reminders:
a. Advice your client that childbirth is not without cost.
b. Inquire if her family is currently enrolled with PhilHealth. If enrolled, ask her to
secure the PhilHealth membership card from her husband and note the card
number in the Birth Plan.
c. Remind her to always bring the PhilHealth Card whenever she utilizes service
from the health center to enable her to enjoy the maternity care benefit package.
d. If her family is not a member of PhilHealth, tell her of the options available:
a) She can pay out-of-pocket for childbirth expenses.
o Inquire about the cost of childbirth from the nearest BEmOC
provider facility.
o Tell her about the cost and advice her to start saving now.
b) Accompany her to talk to the BEmOC Team to verify if she is entitled
to childbirth subsidy under the FBC-PBG.
5.) Appraisal of her health condition.
Reminders:
a. The health center where she goes for prenatal care is supposed to be apprising her
of her over-all condition.
b. Be prepared to give your honest answer when she inquires from you about the
doctor’s or nurse’s notes in her Birth Plan.
c. If you do not know or are not too sure of the answer, DO NOT GUESS. This is
more harmful. Avoid giving false assurance too. Be honest to tell her you do not
know the answer but that you will ask the doctor or nurse about your inquiry and
will be back for the answer as soon as possible.
6.) Prepare checklist of things for herself and her baby.
Reminders:
a. The Birth Plan already contains this Checklist.
b. Monitor the preparation being done by your client by making an update of the
checklist together.
c. Help her prioritize. Identify with her, things that she needs to bring with her when
she goes to the facility to give birth and things that she could ask to be brought to
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her later if needed.
d. For childbirth, help her prepare for the things that she needs to bring to her
chosen Birthing Facility. In a luggage, have the following readied:
a) At least 2 pieces of loose housedress,
b) Enough Underwear,
c) Maternity napkins,
d) Bath towel,
e) Antibacterial soap,
f) Babies clothing, and
g) Diapers.
7.) Information on post-childbirth follow-up.
Reminders:
a. Advice your client that post-childbirth follow-up is as important as prenatal care.
b. Help her comply with the follow-up instructions by reminding her of the
postnatal visit on the scheduled date. Post the schedule of visits in their bedroom.
c. If possible, accompany her when she makes the follow-up visit with her baby.
3. Provide ONLY quality care.
Providing quality care should be the overarching service objective of the WHT. Keep in
mind that YOUR HIGH QUALITY SERVICE is key to making pregnancy safer.
As a general rule, all health care
interventions should be undertaken in a
health facility. However, there are situations
that call for home visits, e.g., following-up
the mother when conditions (e.g., the
weather, the mother’s health) prevent her
from going to the health center. Thus,
prenatal activities such as vital signs taking
and counseling, and post-natal follow-up may be done at home if the conditions dictate.
4. Help your client make accurate recordings.
Accurate recording and reporting is the best way to assure the
quality of the data needed to assess the mother’s health status.
5. Providing counseling services.
Reminders:
1.) When giving information and practical advice, focus on the following:
a. To ensure high quality personal care during pregnancy, childbirth and
immediately after childbirth, remember to give sufficient attention to the things
that are often times taken for granted:
a) Benefits of good personal hygiene,
b) Benefits of early ambulation and exercise after childbirth,
c) Care of the breast before and after breastfeeding, and
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d) Care of the newborn.
b. Importance of newborn screening
Remember to explain the following to your client:
a) Newborn screening is a very simple procedure given to the baby 24 hours
after birth.
b) It is a blood test wherein a blood sample is taken from the heel of the child
and is dropped in a special paper (filter paper). It is then sent by the hospital
to a centralized testing center at the National Institutes of Health, UP Manila.
c) The test checks for five metabolic disorders that could affect the health of the
child within the first few weeks of life. If undetected, these disorders may
cause mental retardation or even death for the child. However, if these
disorders are diagnosed early enough, the child can grow up healthy. Thus
conducting the test within the 24-hour period after birth can spell the
difference between life and death for the newborn.
d) If a baby is shown to be positive for any of the disorders, more tests will be
done to confirm the test. Once properly diagnosed, proper treatment and care
can be given to the baby to correct the disorder; thus, giving the baby a
reasonable chance to lead a normal life.
c. Importance of follow-up visit to the facility after childbirth.
Remember to:
a) Encourage postnatal women to go back to the facility as advised by the
BEmOC or CEmOC team. This is to ensure her health and safety after
childbirth.
b) As member of the WHT, the mother and the newborn will be endorsed to
you. Make frequent follow-up visits to the mother and child until 42 days
after childbirth to:
o Check on the mother and child’s vital signs
o Inspect lochial discharge during the first 7 days after childbirth.
o Provide practical advice on:
personal hygiene,
proper newborn care,
maternal and child nutrition,
breastfeeding,
immunization.
6. Making referrals
Remember to:
1.) Familiarize yourself with the facilities nearest the homes of your client and inquire
about the services they provide. This way referring becomes systematic.
2.) Refer clients appropriately to the following facilities according to their needs:
a. BEmOC provider facilities
b. CEmOC provider facilities
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c. Social Hygiene Clinics
d. Adolescent Centers
e. Rural Health Units
f. Barangay Health Stations
Family Planning, STI-HIV Prevention and Control and Adolescent and Youth Health
Service Functions:
1. Service delivery through outreach activities
Outreach activities are special events that are meant to provide services that are not
normally delivered at the RHU or community level. The WHT as an organization tasked
to provide outreach services to the community shall organize the following activities on a
regular basis or whenever need arises:
1.) Blood Collection Day,
2.) Family Planning Day,
3.) Adolescent and Youth Camp, and
4.) Other similar activities.
1.) For Blood Collection, the WHT shall be asked to mobilize the community for a
blood donation day. You can do this by:
a. Launching an information campaign regarding the blood donation activity
and recruitment of volunteer blood donors.
b. Organizing a health education activity or a community assembly to brief the
community and the blood donors on the benefits of blood donation and how
well they should take care of themselves before the blood collection.
c. In coordination with the Local Blood Council and barangay officials,
selecting an appropriate venue for the activity that is spacious, well ventilated
and well lighted. (e.g. barangay social hall, barangay covered court, school,
etc.).
d. With the assistance of the MHO, coordinate with the BEmOC team and the
Regional Blood Center Team or Provincial Blood Bank team for them to be
at the community on set schedule for the blood donation.
2.) For Family Planning, the WHT shall be asked to organize a visit by the Itinerant
Team (IT) for an outreach activity. The visit is mainly for the team (IT) to provide
service to clients who have decided to undergo voluntary surgical sterilization and
IUD insertion. The organization process shall involve the following:
a. Keep a list of clients who requested for either IUD insertion or surgical
sterilization (either through non-scalpel vasectomy (NSV) or bilateral tubal
ligation (BTL)). This list could be generated from those clients that would
approach you during your home visits either to track pregnancies or help out in
birth planning.
b. Schedule a visit by the IT when you have at least 5 clients in your list. Keep your
clients properly informed of the details of the Itinerant Team visit as to –
a) Date and time
b) Venue of the outreach activity
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c. Coordinate with your RHU, BEmOC or CEmOC facility, depending on the
services that will be provided by the IT. For BTL, an operating room is needed.
Thus, you may need to get the assistance of your MHO to appropriately negotiate
with the nearest CEmOC facility for the use of its operating room.
3.) An Adolescent and Youth Camp is best organized in coordination with the
Municipal Adolescent and Youth Team and the Sangguniang Kabataan. The activity
provides experiences that are suited to teenagers: fun while learning and discussing
adolescent and youth issues.
You are, however, not limited to the suggested outreach activities. Get other sectors
in the community to help you in organizing.
2. Counseling
Remember:
1.) As a midwife, you are probably the only professional that barangay residents get to
see. Be happy that they regard you highly. They come to you for advice. Of course,
you also get tired and stressed out, but your clients (especially the poor) have
probably more problems and are experiencing more stressful lives. So please -
a. Always make yourself available.
b. Be approachable.
c. Be sincere.
2.) As members of your Team, the BHWs and TBAs will be trained on Interpersonal
Communication. This will allow them to develop the skills needed to bring
important messages across to the population and provide practical advice to clients.
This ensures that, community residents will always have someone to consult
whenever you are not around. Your members are indeed added “hands” in the
difficult task of changing client behavior.
3.) Identify women of reproductive age (WRA) with unmet need for FP and STI services.
These are the clients that really need counseling. When you counsel –
a. Provide only the correct information. Try to suppress any tendency to give your
own opinion.
b. If you have some biases regarding contraception, keep these biases to yourself.
Remember, you should help your client make a decision based on correct
information, not on opinions or biases.
3. Service delivery through provision of FP supplies
Remember:
1.) From time to time, as WHT members, you will be asked to deliver a re-supply of pills
or even condoms to the BHS or directly to client users.
a. Don’t ask for fees if you know that these are for free.
b. Don’t use the contraceptives to make vulgar jokes on sex and sexual
behavior. Debasing contraception in this manner may not only embarrass the
client but may also alter the client’s perspective with regards the practice of
contraception.
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WHT Tools
To make your work easy, forms have been developed for your use:
1. Pregnancy Tracking Form
This form is a list of all pregnant women in the area assigned to you. This guides you in
providing the service that each pregnant woman under your care needs until she gives
birth.
As the Team Leader, you should consolidate the different forms accomplished by your
members and summarize their content so that you would have a master list of pregnant
women in the communities assigned to you. This helps in tracking down other vital
indicators such as live births and maternal mortality data.
2. Birth Plan
This Plan is contained in the Mother and Child Book and is a detailed plan of the things a
mother should do to successfully manage her pregnancy, childbirth and the 42 days
following her childbirth. This is a home-based record and the WHT helps the woman
develop and implement the plan.
Every pregnant woman should be given a copy of the “Book”. This serves as her guide
throughout pregnancy and in caring for her newborn.
3. Maternal Mortality Reporting Form
As a member of the WHT, you are also tasked to report the outcome of every pregnancy
in your catchment area. A WHT Maternal Mortality Reporting Form is devised to enable
you to help the health system track maternal death in the community in a timely manner.
The Form is an important tool for tracking and recording maternal death using the public
health system. Such a recording system is envisioned to give a fairly accurate and timely
account of the state of maternal health in the country and therefore allow better public
health programming and budgeting.
This Form is accomplished as soon as you know of the death of a mother under your care.
You are then tasked to submit this to your midwife who, in turn, submits it to the MHO
who validates and registers the death, then submits the form to the PHO for further
review.
SERVICE DELIVERY BY THE FACILITY-BASED TEAMS
BEmOC Teams
1. The Team is tasked to administer the following life saving drugs by parenteral route:
a. Antibiotics,
b. Anticonvulsants, and
c. Oxytocics.
2. The Team is also tasked to perform the following life saving procedures as necessary:
a. Manual removal of placenta
b. Removal of retained products of conception
a. Assisted vaginal delivery (eminent breech delivery)
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CEmOC Teams
1. As experts, the Team is tasked to manage clients with life threatening conditions and is
expected to –
a. Manage complications,
b. Surgically assist in childbirth by performing caesarian section, and
c. Safely administer blood transfusion.
2. The Team is also expected to deal with uncomplicated births, thus should be able to
perform BEmOC procedures.
A. Reminders to the Team
As members of the Team, you are well-educated professionals, appropriately trained to
the competence required by the service model. People come to you because you have
always been a symbol of good health and life.
Deliver ONLY quality service. It is not enough that you are technically competent. People
judge your person by the way you handle yourself when in front of them.
1. Be the best Team that you are.
2. Give your best when delivering service -
a. Be courteous and sensitive when dealing with clients,
b. Be gentle and thorough when performing physical examinations,
c. Explain everything you do to a client in a language she will understand,
d. Give her correct information, and
e. Avoid giving false assurances.
3. As a doctor, you are the team leader. You should therefore lead by example.
4. As a nurse, be conscientious in the performance of your duties. Be a good doctor’s
assistant –
a. Keep track of everything the doctor does in the clinical area,
b. Note the medicines that the doctor prescribes,
c. Don’t hesitate to give your opinion when the situation calls for it. Doctors,
being human, also commit mistakes. You could help save lives by being
meticulous in your nursing care.
d. Always be polite.
5. As a midwife, there are times when you would be delegated a task for which you
have not been trained. As a professional, try to be the best midwife that you can be
but know your limits.
6. Accept referred clients properly.
a. Inform the referring doctor about the status of his or her referral.
b. Acknowledge the referring body as your equal. The WHT at the BHS or the
doctor at the RHU or small community hospital is no different from you. Be
happy that they trust you as their last resort because of your expertise.
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Chapter 11
Making WHSM Facilities Safe and Clean
Health Facility Guidelines
Transport, Treatment and Disposal Guidelines
Monitoring
Localizing the Environmental Safeguards Plan
Enhancing Health Workers Capacity on
Health and Safety
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Chapter 11
MAKING WHSM FACILITIES SAFE AND CLEAN
Safety and cleanliness should be paramount attributes of health facilities as they are essential
elements of quality service. This section lays out procedures and guidelines for facility
personnel in order to ensure the safety and cleanliness of WHSM facilities. In a small
BEmOC provider facilities, BHS, RHU, Community and District Hospitals, the responsibility
of making the facility neat and clean lie on the midwife, MHO, and Chief of Hospital. In
larger CEmOC provider facilities, a team could be organized to take charge of sanitation and
safety. The team is designated the Environmental Management Team.
HEALTH FACILITY GUIDELINES
A. Health Facility Wastes
In general, 80% of the wastes generated by health care establishments, particularly of the
larger facilities consist of general or non-risk health care wastes, similar to household
(HH) waste. This volume is accounted for mostly from administrative- and
housekeeping-related activities of the health facility. Only about 20% are regarded as
truly hazardous waste that may bring about health risks. General wastes can be dealt with
through the municipal waste disposal system.
While there are only a few waste types of concern in the direct delivery of services, the
generation of these will have to be viewed nevertheless in combination with other waste
streams generated from other usual hospital operations.
Health facilities, (based from results of key interviews conducted in the community and district
hospitals) generate as much as 3 to 5 large black bags per day containing an estimated 10
to 25 kgs. of wastes each, representing a mix of general to infectious wastes. Provincial
Hospitals generate an estimated mixed volume of some 10 large bags of waste a day.
Wastewater generation can be gauged from the corresponding metered water usage by
each health facility.
The individual units and departments in community, district and/or provincial hospitals
generate the typical profile of these wastes indicated. RHUs offering laboratory services
will have laboratory associated wastes, as described further below, as well as general
wastes.
a) Medical wards. Consist mostly of general waste with some limited amount of
infectious wastes such as:
o blood-soaked dressings,
o bandages and sticking plaster,
o contaminated gloves,
o contaminated packaging and disposable medical items,
o used or unused hypodermic needles and intravenous sets, and
o certain body fluids.
b) Operating rooms and surgical wards generate-
o general wastes including a great deal of packaging,
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o pathological and anatomical wastes, including tissues, organs, products of
conception and body parts,
o other potentially infectious wastes such as blood-soaked gauze and materials,
contaminated gloves, tubing, some body fluid containers and sharps.
c) Laboratories produce -
o general wastes including packaging and containers,
o pathological wastes including some anatomical wastes, tissue samples,
microbiological cultures and stocks of infectious agents, blood and body
fluids, contaminated gloves, tubing and containers, sharps, possibly some
radioactive materials and a large number of chemicals.
d) Pharmaceutical and chemical storage generate mainly general waste –
o product packaging,
o small quantities of pharmaceutical and chemical wastes, and
o possibly cytotoxic drugs if chemotherapy treatment is prepared in the
pharmacy.
These wastes are usually the result of inappropriate handling and storage and
oftentimes resulting from over acquisition or maintenance of more than average
inventory resulting in expiries.
e) Other units or departments. Mostly general waste with small percentage of
infectious waste (usually sharps).
f) Support units. Mostly general wastes.
B. General Guidelines on Safe Waste Management
1. Personnel assigned to waste management should be properly suited up before
engaging himself in any activity – protective “over-all” clothing and gloves.
2. General wastes should join the waste streams from domestic refuse for disposal.
3. Sharps should all be collected together, regardless of whether these are contaminated
or not, in puncture-proof or rigid containers (metal or high density plastic) and
properly sealed and covered to prevent tampering.
4. Highly infectious wastes should immediately be autoclaved.
5. Small amounts of chemical or pharmaceutical wastes may be collected together with
infectious wastes; the larger quantities of obsolete or expired pharmaceuticals stored
by the pharmacy department for eventual disposal or return to supplier, if possible.
6. Other pharmaceutical wastes (spilled or contaminated drugs or packaging containing
drug residues) should be deposited or collected in the proper container at the point of
generation.
7. Large quantities of chemical wastes should be packed in chemical-resistant containers
and sent to specialized treatment facilities, if available (so far, the only available in-
country capability is for the treatment of used solvents and used oils (except PCB)
and oil sludge. Otherwise, a special and properly marked storage area, away from
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human traffic and potentially incompatible activities, for hazardous wastes should be
available within the health facility.
8. Metal-bearing wastes (usually from breakage of thermometers) in high concentrations
should be collected separately and eventually disposed in specialized disposal or
treatment facilities.
9. Used syringes should never be returned into their original packaging. The packaging
should be disposed of untouched and should go with the general wastes for disposal.
Used syringes should be placed in the yellow rigid container for sharps. This
relieves, in some way, the relative high cost of disposal of hazardous health-care
wastes. Packaging material, classed as general waste that is charged lower for
disposal, adds bulk and weight.
C. Waste Segregation & Collection Guidelines
1. Wastes should be collected daily (or as frequently as necessary) and transported to the
health facility’s designated storage area for wastes until it is time to have these
brought for disposal or treatment;
2. Wastes should be segregated at the point of generation: the general wastes should no
longer allowed to be in contact with potentially infectious or other chemical wastes.
3. General waste receptacles should be marked out separately into: glass, plastic, paper,
metal.
4. Food wastes or leftovers should have separate receptacles.
5. Sharps should be collected in separate puncture-proof containers.
6. Medical personnel should ensure that containers are properly sealed even at 3 / 4 full.
7. Wastes should never be allowed to accumulate at the point of generation. Supply of
the required containers should readily be available for specific waste types at the
designated locations for collection in each of the points of generation.
8. Wastes collected and packaged that are intended for delayed treatment and disposal
should be properly labeled or tagged with permanent ink, indicating therein the chain
in transfer of custody, the date of collection and transfer into storage.
9. The label or tag should have the symbol or the hazard class or category. (The DENR-
EMB has a hazard classification list for this purpose. Otherwise, the widely in use
UN classification can be utilized.)
10. Infectious and other hazardous waste containers should be properly sealed and packed
to avoid spillage or leakage and/or cross-contamination with other materials or media.
C. Storage Guidelines
1. The storage area should be commensurate in size to the volume or quantities of waste
generated as well as the frequency in collection in relation to the length of time it will
take to store the volume of other hazardous wastes without the available immediate
treatment or disposal options.
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2. Chemical reagents and other wastes of small quantities should be properly stored and
inspected on a periodic basis to ensure the integrity of their containers or packaging
conditions.
3. Unless a refrigerated storage room is available, storage times (delay between
production and treatment), particularly for pathological and anatomical wastes,
should not exceed 48 hours during cool months and 24 hours during the hot summer
months.
4. Special waste types usually of limited volume generation like cytotoxic and
radioactive wastes, if ever these are generated, should be stored in a specially
designated and secure location within the waste storage area.
5. Radioactive wastes require specialized containers that should ensure it from being
dispersed and have to be behind lead shielding. It should be stored and labeled with
the type of radionuclide, the date when stored and details of required storage
conditions. RA 6969 provides that while reporting rests with the DENR-EMB, its
eventual disposition is the concern of the Philippine Nuclear Research Institute
(PNRI).
6. Chemical wastes, including pharmaceuticals, should be in specifically designated
areas and separated from the gases.
7. Chemical wastes, consisting of different hazard categories, should not be haphazardly
stored and lumped together in one location. These should be stored according to their
specific hazard class:
a. flammable
b. toxic / poisonous
c. oxidizing or reactive
8. Wastes generated from mop-up of spills or leaks of chemical wastes are to be treated
as hazardous wastes and packed in rigid, non-corroded containers.
9. Any waste type that is entered for storage has to be correspondingly labeled or
marked on its seal or tag the date of acceptance or entry into storage. The log/s of
such acceptance and subsequent transfer or removal should be filed in proper order
(by date and by waste type and by generating department or unit).
10. For purposes of recall and facility in storing, the floor plan and utilization, according
to the designated places for particular wastes, of the storage area should be clearly
marked out and a scaled-down printed version posted conspicuously for immediate
reference.
11. The storage area has to be equipped with good lighting, roofed over and properly
ventilated. The floors should be impermeable, easy to clean and disinfect and
equipped with good drainage.
12. There should be sufficient aisle space in between rows of stored wastes to facilitate
maneuvering of waste carts and trolleys (if these are the means to transfer the wastes
to storage) or pallet trucks (if these are used at all) and for staff to gain easy access in
waste handling.
13. The storage area has to have a specially designated wash section with readily
available supply of water and proper drainage. Disposable protective materials for
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waste handlers should have a designated receptacle or container beside this wash
area. There should also be provision to hang washed or usable protective clothing in
waste handling.
14. A specially sectioned off part, usually allocated space before entry into the main
storage area, should be for the storage of fresh supply of cleaning equipment and
materials, waste bags and containers and protective clothing for waste handlers. This
section should also be equipped with a weighing scale to ascertain the relative
weights of the groups of wastes intended for offsite disposal. Cost proposals from
third party service providers can be provided with the immediate availability of such
figures. This also facilitates in planning for budgetary allocations by the health
facility.
15. The designated location of a storage area within the health facility should be
inaccessible to insects, animals and birds and should not be in the proximity of
storage for food, food preparation and dining areas. It has to be situated in a low
human traffic zone of the health care facility but provided with easy access to park a
vehicle or truck for the eventual transfer of wastes into final disposal.
TRANSPORT, TREATMENT AND DISPOSAL GUIDELINES
A. Onsite transport
1.) Wastes should be transported within the health facility on either trolleys or carts
that should be dedicated for this sole purpose.
2.) The trolleys or carts should have no sharp edges that could puncture or damage
waste bags or containers during loading or unloading.
3.) The trolleys should be cleaned and disinfected daily.
B. Onsite treatment and disposal
1.) Treatment onsite has to be limited to the capability of the health facility and only
on the availability of equipment or technology to undertake this.
2.) Infectious wastes that have gone through the treatment process are technically
downgraded as general wastes are qualified for disposal in a municipal landfill.
Care should be exercised to ensure that the equipment has treated the infectious
wastes.
3.) Sharps should be separated from the treated infectious waste stream. Unless
these have been shredded, treated sharps should not go with the other treated
wastes bound for municipal disposal systems.
4.) In the event of a spill or oil leak occurrence, mop-up activities should
immediately be done as to prevent the material from being transported further.
5.) Residual wastes generated from mopping up (i.e., contaminated rags or cloths and
even soil media) should temporarily be stored until such time that there is an
appropriate reception facility for its proper disposal. Weathering is widely
practiced in dealing with oil-contaminated soils but works effectively to dissipate
the noxious elements in the fuel only if the concentrations are low given a
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particular volume of the contaminated material and given the luxury of time and
space to undertake the activity.
6.) The disposal area should only be accessible to authorized personnel.
7.) The disposal area should be fenced in and for aesthetic purposes, access paths
planted and maintained with ornamental shrubs or low-height vegetation.
8.) The final reception or containment for the wastes within this disposal area should
be lined (bottom and sides) with concrete (thick slab) material to ensure
impermeability. A removable concrete or metal cover with handle bar should be
installed to facilitate the regular entry of wastes and to keep out unwanted
moisture or rainwater to accumulate. The dimension of the cover should
correspond to the maneuverability of tipping in the qualified wastes into the
containment area to avert spillage of the wastes on the surface. The containment
area has to be equipped with an angled exhaust pipe to allow the venting of gases
that will likely accumulate over time in enclosed space.
9.) Access to the site should be concrete and paved.
C. Offsite transport, treatment and disposal
1.) The health facility is responsible in ensuring that the wastes are safely packaged
and labeled or tagged and covered with the authorization or permit for such
offsite disposal. The health facility in charge of waste management activities
should ensure that offsite disposal is only done through truly legitimate, qualified
and capable third party service providers.
2.) The health facility has to ensure that wastes removed from its premises are
properly permitted and manifested and that a destruction/disposal certificate is
issued by the receiving third party facility to remove the accountability of the
HCF over these wastes.
3.) Health facilities have to ensure that hazardous wastes are brought for treatment or
disposal in facilities with approved and permitted technologies. Autoclaving and
microwaving are basically for disinfection.
MONITORING
1. Air Quality
Unless the Health Facility operates any hazardous air-emitting equipment, this specific
operating guideline is optional. The facility will have to monitor for four basic
parameters at the minimum, on a quarterly basis:
1.) Carbon monoxide,
2.) Sulfur Oxide,
3.) Nitrogen Oxide,
4.) TSP
Reports on the results of the quarterly monitoring activity are to be filed with the
Regional EMB office.
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2. Water Quality
Water quality parameters as these apply to health facility activities, are to be undertaken
on a quarterly basis. The minimum quality criteria are four:
1.) Dissolved Oxygen (DO),
2.) Biological Oxygen Demand (BOD),
3.) pH and Coliform Organisms (Total Coliform and E. coli).
4.) Other parameters as indicated in DAO 90-35 (downloadable version available at:
http://www.emb.gov.ph) and subsequent amendments.
Periodic monitoring for bacteriological contamination of the groundwater should be done
in similar frequency as well as for a critical heavy metal – mercury – that has not been
eliminated yet in the country’s health service facilities.
Results of all monitoring activities (air and water) should be filed carefully to track any
changes in time and provide indications on contamination issues that the health facility
may need to address. These files should not be discarded the way that dated patients files
may be disposed of according to the facility’s record storage system.
SAFETY AND SECURITY
Your clients are sick. They deserve to be assured of their safety while confined in your
facility. It is thus recommended to all EmOC provider facilities to have the following
features:
1. Alarm System
The health facility has to be fitted with alarm systems. If at all possible, the emergency
alarm systems should be coded as to differentiate alarms raised for fire, earthquake,
typhoon or flood.
The health facility also has to have immediately available access to fire containment
systems on standby at any given time, particularly those that stock up on fuel
requirements for their generator sets and those that have gas cylinders in storage. The
level in water tanks should always be monitored to ensure that even if fire is a remote
possibility, there always is a contingent provision for such an emergency.
2. Incident command system
To further ensure the safety and security of the health facility and its personnel, patients
and visitors at any given time, an incident command system should immediately be
operable when an emergency arises. The chain of command in this system should be
well defined. The Incident Commander is the head of the facility and/or a trained
designate. The responsibilities of those in the system should be well rehearsed and
known and which will necessitate the undertaking of training and periodic drills to more
than familiarize individual members in the chain of command on their respective tasks.
3. Exit plan during emergencies
Likewise, there always has to be an exit or evacuation plan that displays the exit points
from the health facility in relation to where a person is located. A list of emergency
contact numbers within the facility as well as to other agencies or institutions whose
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help or support may be needed during emergency should likewise be prominently
posted in each and every room and work area.
LOCALIZING THE ENVIRONEMENT SAFEGUARDS PLAN
Strategic Management of Wastes
1. Installation of onsite capability
Identified BEmOC and CEmOC provider facilities are required to have onsite capability
for the disposal of placenta wastes, notwithstanding cultural norm. A low-cost
alternative for their proper treatment / disposition has been demonstrated by the
application of lime to the wastes. This method not only ensures that these wastes do not
emit foul odor but also binds and stabilizes the waste.
Lime is a naturally occurring material– the by-product of mining limestone and found in
nearly all provinces in the country. The application of lime has been demonstrated to be
the most affordable method in the treatment and control of conditions in bio-solids
(sewage sludge) that may support the growth of pathogens. Lime has allowed sewage
sludge to be converted into a usable product, proven through years of study and research
in the U.S., and its use sanctioned by the U.S. Environmental Protection Agency under 40
CFR Part 503.
1.) Infectious wastes sterilization at nearest tertiary referral facility
For easy access, the sterilization capability of Democrito O Plaza Memorial Hospital in
Agusan del Sur can likely serve the requirements of health facilities in Lianga, Barobo,
Hinatuan, Tagbina, Bislig and Lingig municipalities in Surigao del Sur. The relative
distance of these municipalities to Prosperidad, Agusan del Sur, expressed in terms of
commercial travel time, is as short as 30 minutes to as long as 2 hours, even under rough
road conditions (Lianga and Barobo being the nearest to it).
Other provinces should explore the availability of waste sterilization capability of tertiary
facilities nearest their area. Sorsogon should negotiate for the use of infectious waste
sterilization facility of Bicol Regional Training and Teaching Hospital in Legaspi.
While of limited capacity, the existing treatment capability can be replaced with
industrial-type autoclave units that can accommodate bigger capacity.
2.) Toll treatment or subscription to treatment services for infectious wastes
Considering the high cost of investment in installing industrial capacity autoclave or
microwave facility in all health care establishments, it is recommended that the RHUs and
SHCs, send infectious wastes they generate to a tertiary facility nearest their place for toll
treatment or disinfection. Health facilities can opt to subscribe to the service by paying
an annual treatment fee that will require them to deliver their wastes to the tertiary referral
facility in sealed containers.
This arrangement ensures the viability of operating the treatment facility installed in these
tertiary health facilities, if only to help recoup electricity expenses.
3.) Installation of Other Treatment Capability in Tertiary Facilities with Incinerators
Tertiary facilities, being the last referral in the chain of health care establishments and
hosting a full range of services, should, as a matter of priority, be given support in
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acquiring treatment capability. In the absence of this, or in the inability to operate their
incinerators, these facilities should be equipped with alternative treatment capability that
conforms to DOH/DENR standards.
Management of general wastes and downgraded treated infectious wastes
General wastes, including treated infectious wastes (that are now downgraded after treatment
to general wastes) can be brought for disposal to the existing municipal disposal system,
required for conversion into sanitary landfills by 2006 and operational starting 2007, as
required by R. A. 9003. Precaution, though, has to be observed in disposing the sharps to
any of these sites. As the disposal areas of the municipalities are open to scavenging, the
sharps (though these may have been already treated) still present a hazard because of their
inherently blunt tip. On the interim, treated infectious wastes can be brought back within the
health facility compound and contained in a waste vault.
Waste Storage
All hospitals should be required to equip themselves with storage facilities to ensure that
wastes, with no immediate destination yet for treatment or disposal, are contained in a
secure area. All hospitals, in similar manner that they are required to submit a verifiable
waste management plan, should be required to have specifically designated area for waste
storage that can, from to time, be audited by multi-agency inspectors from DENR and DOH
in the interest of public health and safety.
Storage eliminates the possibility of haphazard and indiscriminate waste movement and
disposal. This allows the health establishments time to allocate budgets needed for the
disposal of wastes awaiting a volume viable for disposal.
Materials Acquisition Management
An environment - conscious and friendly acquisitions program can be adopted. This program
is recommended to look into including an accreditation requirement for vendors or suppliers
to provide return-to-supplier support services and arrangements. The health care
establishment can thus be provided a measure of relief from the burden of having to directly
deal with the disposal of damaged, expired or near-to-expiry pharmaceutical products and
even specialty supplies and equipment that have environmental implications.
ENHANCING THE HEALTH WORKERS CAPACITY ON SANITATION AND
SAFETY
Considering the limited exposure, so far, of hospital personnel in waste management,
particularly in implementing the DOH Health Care Waste Management Manual, it is
recommended that training programs or seminar-workshops be held on the following topics:
A. The Regulatory Framework for Environmental Management
This program is targeted for attendance by the head of the facility, together with the
designated Health Facility Environmental Management Officer or Pollution Control
Officer. This is to be held at regional centers and for a whole- to two-day duration. If
for two days, there should be workshops on the permit and reporting requirements to
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familiarize the facility on accountability in running the facility as an environmental
organization, including the set up of Multi-partite Monitoring Teams.
B. The Waste Management Hierarchy Application in the Storage, Treatment and
Disposal Of Health Care Wastes
This is two-day training for attendance and participation of EMO/PCO and/or a senior
level hospital supervisor. This course focuses on the three critical aspects in waste
management and how these apply to hospital operations. This gives the participants
familiarity on:
1.) The waste classes
2.) The hazard categories
3.) The symbols and markings of such hazard categories as a guide in proper waste
marking and segregation for collection (including the use of color codes)
4.) Handling and storage and eventually the choice of the appropriate technology for
their treatment or disposal
5.) It provides the participant a working knowledge on what wastes can be segregated
with recoverable value, and so on.
C. Pollution Control Course (for Hospital Establishments)
Patterned after the regular pollution control training program of the Pollution Control
Association of the Philippines (PCAPI), the course puts the health facilities EMO/PCO
through the paces of:
1. The detailed environmental guidelines and standards to maintaining and safeguarding
air quality and water quality that impact on environmental health.
2. The aspect on the sources of pollution from hospital or health care operations and the
implications of being a pollution control officer for this type of establishment.
3. The reporting arrangements with regulatory authorities.
This is designed as a 24-hour or 3-day course.
D. Health and Safety Training
This is an eight-hour training oriented specifically on health and safety with hands-on
exercises and demonstrations on the appropriate levels of protection. Enhances
consciousness among health care establishment workers to eliminate or reduce the risk of
exposure. Appropriate for attendance even by hospital attendants and ancillary workers.
E. Incident Command
This is a 24-hr training course aimed at providing participants skills in dealing with
emergency situations in their facilities that may potentially lead to an environmental
incident. The discussion focuses on the organization structure of hospital personnel into
operating an action center to deal with an emergency. Teaching and learning
methodology involve role-playing exercises.
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Chapter 12
MAKING THE WHSM FACILITIES
OPERATIONALLY SUSTAINABLE
Facility Sustainability
PhilHealth Reimbursements
Performance Based Grants Towards Universal
PhilHealth of the Poor
User Fees
Establishing a Client Classification Scheme
Sustainability in Essential Drugs and Contraceptives
The P 100 Program
The DOH Contraceptive Self-Reliance and
Social Marketing Programs
WHSMP2 PBG towards Self-Reliance in Essential
Life Saving Drugs and Contraceptives
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Chapter 12
MAKING WHSM FACILITIES OPERATIONALLY SUSTAINABLE
A major objective of the Women’s Health Safe Motherhood Project 2 (WHSMP2) model is to
enable women’s health safe motherhood (WHSM) facilities deliver the integrated WHSM-SP
(service package) in a sustainable manner. This is best achieved if these facilities are
financially sustainable and are not solely reliant on budgetary outlays to fund their
operational needs. Such a goal is attainable especially if advocacy efforts succeed in
convincing women who presently prefer to give birth at home to shift preferences in favor of
facility birth. This section tries to lay out the operational guidelines for the strategy to pursue
the goal of making WHSM facilities sustainable in finances as well as in the supply of
essential drugs and contraceptives.
The basic strategy that we seek to pursue to attain the above goal can be summed up as
follows:
1. Make WHSM facilities financially sustainable by broadening their fund sources beyond
the traditional budget budgetary allocation from the LGU. This could be done by –
a. Enhancing Philhealth reimbursements
b. Allowing facilities to collect user fees from the non-poor, and
c. Allowing the use of the revenue from these sources to augment operational
funds and health worker compensation.
2. Make WHSM facilities sustainable in essential life-saving drugs and contraceptives by
establishing revolving fund schemes:
a. For essential drugs, through the P100 program of DOH and
b. For contraceptives, through the Pop Shop scheme of DKT.
FACILITY SUSTAINABILITY
The financial sustainability of facilities tasked to deliver the WHSM-SP could be significantly
enhanced by putting in place a scheme that would broaden sources of financing to fund
operational needs while making sure that adequate resources are made available for free or
subsidized services for the poor. Two such sources are Philhealth reimbursements and user
fees.
Philhealth Reimbursements
Philhealth reimbursements would be forthcoming only if the client is a Philhealth member
and the facility is Philhealth accredited. The investments in WHSM facilities are designed to
ensure that these facilities have the necessary infrastructure and equipment to comply with
Philhealth accreditation and DOH licensing standards. On the other hand, the Project’s
Performance-based Grant (PBG) seeks to encourage local chief executives (LCEs) to strive
for universal enrollment of the poor. These initiatives are envisioned to eventually make
Philhealth reimbursements a dominant source of financing for facility operations and
the enhancement of provider compensation.
In anticipation of the increase in facility births as result of the behavior change initiatives of
the project and the advocacy work of the WHTs, the PHO should initiate a meeting with the
MHOs, and key staff of the WHSM Teams (nurses and midwives) to decide on a
reimbursement-sharing scheme among the members of the teams that would include the
WHT. This should take into account the fact that the WHT share would come as an
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augmentation to the one thousand peso PBG that the WHT would get for every poor mother
that it refer to give birth in a facility. Such a sharing scheme would apply to the portion of the
reimbursement allotted for providers.
The funds for which a sharing scheme needs to be developed are:
• The 1,000 peso PBG for facility-based childbirths and
• The Maternal Care Package (MCP) of Philhealth.
The PBG mechanism for facility-based childbirths is described later on in this chapter. The
MCP, on the other hand, sets the following conditions for normal spontaneous deliveries
(NSDs):
1. NSD (normal spontaneous delivery) covers normal, uncomplicated vaginal deliveries,
only for the first four deliveries; all other types of deliveries are covered regardless of
order of birth. The NSD is compensable both in hospitals and in non-hospital facilities at
a case rate of P 4,500 for NSDs. For hospitals, this is paid after delivery and covers the
following:
• P2,500 for the hospital and
• P2, 000 for professional fees.
For non-hospitals, reimbursement is made in two tranches:
• First payment of P3,650 for prenatal care, normal delivery, and newborn care; and
• Second payment of P850 for postnatal care` and family planning counseling.
The non-hospital facilities are obliged to give not less than 40 percent of the case payment
to the health care professionals who provided the services. The Newborn Care Package of
P1,000 is filed as a separate claim for hospital births but is included in the NSD package
for births in non-hospital facilities.`
DOH Department Order No. 20007-0098 provides a reference for the LGUs in determining a
sharing scheme that is most equitable and acceptable to health workers. The following sharing
guidelines recommended by DOH maybe modified to suit local situations:
1. For services rendered to indigent non-PhilHealth members, the 1,000 peso PBG shall be
shared as follows:
• For Rural Health Unit (RHU) BEmOC: Ninety five percent (95%) shall be the
share of the WHT. The share of each member shall be determined by the MHO
with technical assistance from the CHD if necessary. Five percent (5%) shall be
the share of the RHU.
• For hospital BEmOC: Eighty percent (80%) shall be the share of the WHT.
The share of each member shall be determined by the MHO with technical
assistance from the CHD or project if necessary. Twenty percent (20%) shall be
the share of the hospital.
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The LGUs in the Project sites made the following modifications to the sharing scheme for
the PBG-FBC:
FOR RHU BEmOC PROVIDERS IN SORSOGON
The 95% WHT share was further pro-rated according to the service rendered as follows:
SERVICE RATE AMOUNT (PhP)
Prenatal care 50 % 475.00
Natal care 30% 285.00
Postnatal care 20% 190.00
TOTAL 100% 950.00
Any service not undertaken by the WHT will be credited to other members of the RHU
BEmOC Team (the doctor and nurse).
The WHT share is also allocated according to health worker category:
CATEGORY RATE AMOUNT (PhP)
Midwife 20 % 190.00
TBA 60 % 570.00
BHW 20% 190.00
TOTAL 100% 950.00
For the HOSPITAL BEmOC PROVIDERS, the 80 % WHT share is also allocated
according to health worker category , with the members receiving the same percentage as
in RHU BEmOCs, above. On the other hand, the 20% share of the hospital staff is
divided as follows:
HOSPITAL STAFF RATE AMOUNT (PhP)
Delivery Room attendants 50 % 100.00
Nursing Service 25 % 50.00
Other staff 25 % 50.00
TOTAL 100% 200.00
In Surigao del Sur, the 80% WHT incentive is pro-rated according to the service provided
by the Team in a Hospital BEmOC provider:
SERVICE RATE AMOUNT (PhP)
Prenatal care 40 % 320.00
Labor watch 20 % 160.00
Assisting in childbirth 20 % 160.00
Postnatal care 20 % 160.00
TOTAL 100 800.00
Fees for services not rendered by the WHT, goes to the Hospital BEmOC Team.
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2. For services rendered to indigent and non-indigent PhilHealth members, the guidelines
issued by PhilHealth on MCP reimbursement apply.
3. To ensure sustainability of providing incentives to WHTs, the professional fees (PF)
provided by the MCP shall be shared among doctors and WHTs as follows:
• Fifty percent (50 %) of the total MCP PF shall be the share of the MHO.
• Forty percent (40%) of the total MCP PF shall be the share of the concerned WHT.
• Ten percent (10%) of the total MCP PF shall be the share of the RHU staff which
should not include the MHO and the midwife.
• The WHT share shall be determined by the MHOs with technical assistance from
the CHD or Project if necessary.
For the Project sites, the following changes/refinements were made to the sharing scheme that
applies to the Maternity Care Package of PhilHealth:
For Sorsogon RHU MCP Accredited Facilitie:
HEALTH WORKER CATEGORY PERCENT SHARE
Municipal Health Officer 50 %
WHT 40 %
o Prorated based on the following:
o Prenatal care - 25 %
o Natal care - 50%
o Postnatal care - 25 %
RHU staff excluding MHO and WHT leader 10 %
TOTAL 100
In Surigao del Sur, since there are 2 types of RHU BEmOC providers, the scheme differ:
RHU BEmOC:
• BEmOC Team (doctor, nurse, midwife leader of the WHT) - 50%.
• WHT (TBAs and BHWs) - 30%
• RHU Staff (excluding the members of the BEmOC Team) - 20%
RHU with Lying-in Clinic as BEmOC Provider such as the Carascal RHU in Surigao del Sur,
the following sharing scheme applies:
• BEmOC Team (doctor, nurse, midwife) - 35%
• Lying –in and RHU staff (excluding the members
of the BEmOC Team) - 35%
• WHT - 30%
4. For services rendered to clients in a hospital BEmOC, the sharing shall be as follows:
• Eighty percent (80%) of the total MCP PF shall be the share of the facility and
shall follow the usual sharing observed in hospitals for PhilHealth members. This
shall be subject to the agreement made by the Chief of Hospital (COH).
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• Twenty percent (20%) of the total MCP PF shall be the share of the WHT. The
share of each member shall be determined by the MHO with technical assistance
from the CHD or Project if necessary.
In Sorsogon, the MCP professional fee provided by PhilHealth is equitably shared
with the Hospital BEmOC Team getting 80% and the WHT getting 20% shared
among its members as follows:
Midwife - 20%
TBA - 60%
BHW - 20%
If the WHT do not have a TBA member, the TBA share is equally divided among the
members.
For walk-in paying clients in both RHU and Hospital BEmOC provider, the sharing
scheme is as follows:
Doctor - 50%
Midwife - 40%
Nurse and other staff - 10%
• Private health professionals who opt to use the facilities of an RHU or hospital
BEmOC, regardless of whether their patients are PhilHealth members or not,
should pay the equivalent twenty percent 20% of their PF as service fee.
• The twenty percent (20%) service fee paid by the private health professional shall
be further subdivided among the health personnel upon approval by the COH.
Performance-Based Grants To Encourage Stakeholder Behavioral Change and
Financial Sustainability
A unique feature of the WHSMP2 design is the offer of performance-based grants to LGUs to
encourage the desired behavioral changes on the part of critical stakeholders. Such behavioral
changes are seen to strengthen efforts towards the attainment of important health and financial
sustainability objectives of the Project. The grant schemes, while focusing on different
stakeholders, are designed to reinforce and complement each other, thereby creating synergies
that strengthen their collective impact towards the desired behavioral changes. This should
increasingly become evident as one progresses through the detailed description of each of the
grant schemes below.
Performance-Based Grant for Facility-Based Childbirth
The Performance-Based Grant to Facility-Based Childbirth (PBG-FBC) is being provided to
enhance the effort of changing behavior of health workers and mothers towards improving the
health of mothers and newborns. The intended behavior change is meant to effect an increase
in skilled attendance at childbirth and is envisioned to demonstrate a measurable impact on
levels of maternal and newborn mortality. Bringing women to deliver at health facilities is an
operational strategy being tested under this project to achieve increases in skilled attended
childbirth. To make this happen, the WHT plays an important role as the community-based
team and is tasked not only to deliver services but also to provide practical advice and
encourage women to improve their health-seeking behavior. It is therefore important to put in
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place a system of incentives that would make WHT members as well as mothers want to
effect such a shift.
Objectives
The PBG to support FBC is an important part of an incentive system to encourage
changes in provider practice at the grassroots level as well as client health seeking
behavior. It is designed to:
1. Ensure that the compensation for birth attendance by the WHT is not diminished
as a result of the shift to facility birth, thereby preempting the possible resistance
of WHT members (particularly the TBAs) to the shift.
2. Support the poor in addressing the cost implications of such a shift, including
indirect costs such as the cost of transport to the facility, care and feeding of other
children while the mother is delivering, etc.
3. Demonstrate to LGUs that enrolling indigents to the PhilHealth-sponsored
program is a cheaper financing alternative to achieving 1 and 2 , above.
4. Utilize WHTs as advocates for the shift from home birth to facility birth as well
as for PhilHealth membership, particularly in the Sponsored Program.
Main Features: Important things to remember about the PBG-FBC
1. The WHT receives P1, 500 (one thousand five hundred pesos) for every delivery
of an indigent mother (whether or not enrolled in PhilHealth) that it refers to
and/or assists in a facility (whether BEmOC or CEmOC).
2. The amount covers –
1.) compensation for members of the WHT, and
2.) child-birth related expenses such as transport to the facility, drugs, supplies,
food during facility stay, etc.
3. As part of the Project’s effort to direct non-complicated pregnancies and
childbirth to BEmOC facilities, no FBC PBG to the WHT or to the mother is
paid for normal spontaneous deliveries (NSDs) in a CEmOC facility unless
the mother lives in the CEmOC catchment area or the case is shown to be an
emergency admission.
4. Of the P1, 500 grant given to the WHT, P1, 000 is contributed by DOH and this
should be appropriately divided among the WHT members, while P500 is
contributed by the municipal LGU to be given to the mother to defray the costs
attendant to her giving birth in a facility.
5. This PBG scheme is covered in the memorandum of agreement signed between
the DOH and the municipal and city government units (MLGUs). The terms of
the agreement applies regardless of whether or not the MLGU owns the BEmOC
provider facility.
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6. Facilities should keep an updated list of accredited WHTs in their respective
catchment areas. Accreditation is done at the end of the training for WHTs. The
list also identifies the member(s) from each WHT who are authorized to collect
the PBG on behalf of the team and specifies the pre-agreed sharing arrangement
for compensation received by the team.
Financial Scheme
1. Funds flow for the Facility-Based Childbirth Performance-Based Grant (FBC-
PBG) shall be from the DOH to the Provincial LGUs then to the City and
Municipal LGUs.
2. The funds flow from the Provincial LGUs is covered by the Program Contract
that specifies the milestones to be achieved (e.g., 50% of targeted FBCs, or
equivalent to 50% of initial payment) and the corresponding tranche payment for
the program.
3. The value of the contract (initial payment) shall be equal to the total expected
payments for FBC-PBGs province-wide for a six-month period at P1, 000.00 per
FBC.
4. Funds to Municipal LGUs shall flow on a replenishment basis subject to annual
financial audits.
Fund Administration
1. Policies and Procedures for FBC Grant Claims:
1.) Claims for FBC-PBG can only be made if a qualified FBC took place in a
BEmOC or CEmOC provider facility.
2.) To make the claim, the WHT leader or a designated member prepares the
following required documents:
a. The Certificate of Eligible Facility-Based Childbirth (CEFBC) should be
accomplished and duly signed by the BEmOC or CEmOC Facility
Manager or a duly authorized senior officer. This form contains the
following information:
a) Referring or attending WHT midwife or doctor
b) Mother’s name
c) Place of residence
d) Confirmation of indigent status by the BEmOC Team
e) If PhilHealth member, PhilHealth identification card number and
confirmation that completed reimbursement request has been
submitted to PhilHealth
f) Obstetrical condition or diagnosis (e.g., normal childbirth, caesarian
section, with or without medical or obstetrical complications)
g) Name, type and address of service facility.
This grant shall apply only to deliveries by mothers listed as poor as a result
of an Identification of the Poor Survey. In the absence of such a survey, the
List of Indigents from DSWD shall used. If no such list is available, the
BEmOC or CEmOC facility manager shall decide on the eligibility issue.
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3.) Payments for this PBG may be released through the following scheme, which
is illustrated in the flow chart and described below:
Procedure for PBG-FBC Grant Claims
a. WHT takes the CEFBC Form to MLGU finance office for processing.
Payment of claims shall be made through a payroll. Beneficiaries shall
be required to sign the payroll as well as an RHU logbook.
b. The P500.00 incentive of the mother can be received by the husband or
any representative authorized by the mother.
c. The WHT leader or a duly authorized member of the WHT shall claim
the P1, 000.00 incentive for referring the mother to a BEmOC or
CEmOC facility. The WHT shall be entitled to this incentive whether or
not the WHT physically accompanied the mother to the facility and/or
assisted in the delivery, provided that the WHT could present proof that
the mother’s pregnancy was tracked using the Pregnancy Tracking Form
and that the WHT assisted the mother in accomplishing and periodically
updating the birth plan.
WHT divides the P 1,000.00 due according to the provisions of the
MLGU Ordinance on compensation sharing.
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In the Municipality of San Miguel, Surigao del Sur, a petty cash is set aside at the
Municipal Health Office (MHO) to advance the payment of PhP 500.000 for every
mother who gives birth at the San Miguel Community Hospital, the designated BEmOC
provider.
o To collect the PhP 500.00 the WHT simply submits the CEFBC form signed by
the BEmOC doctor to the Municipal Health Officer or her designated staff to
release the amount. The WHT then gives the money to the mother before
discharge.
o If there are bills to be paid at the hospital, the mother pays using the grant given
her.
Replenishment of the petty cash is requested by the MHO from the Municipal Treasurer
upon liquidation of at least 50% of total petty cash received.
3. Project Account Replenishment Scheme
The Project requires MLGUs to open an exclusive Project account. The funds for
the PBG-FBC are to be deposited into this account by both the DOH (to cover the
P1, 000 WHT incentive) and the MLGU (to cover the P500 for mother’s expenses).
a. At the end of each month, MLGU:
a) Replenishes the Project Account by an amount equal to P 500 for
every FBC-PBG paid during the month plus all other payments made
out of the Project Account. Note that the account balance plus the
reimbursements due from DOH (i.e. P1, 000.00 for every FBC-PBG)
should equal the initial deposit.
Municipal LGU
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b) Prepares required documents and requests replenishment of P1,000
per qualified FBC through the PPMT (Provincial Project
Management Team).
c) Attach a copy of the latest Bank Statement of the MLGU Project
Account to the Request for Replenishment. This serves as evidence
of satisfactory compliance with the requirement under the Project
Loan Agreement.
4.) At the end of each month, PPMT:
a. Verifies consistency of List of Awardees with Provincial indigent list.
b. Ensures that the MLGU has replenished the Project Account accordingly.
c. Endorses payment of the PBG-FBC to the Provincial treasurer.
5.) Provincial treasure reimburses the MLGU P1, 000 per eligible FBC-PBG
paid.
6.) PLGU requests replenishment from DOH when its account balance falls
below 50% of initial deposit.
FBC-PBG Lead Time for the Release of Funds
s
Relea e
1 Week
DOH PLGU
PLGU 1 Week
m
Replenis h ent
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Sustaining the Shift to Facility Birth
The PBG-FBC is provided by the Project, with a corresponding LGU counterpart. To sustain
the shift to facility birth, it is important to continue providing the incentives even beyond
Project life. However, the LGU budget may not be able to assume the financial burden if the
incentives, as they are currently designed, continue to be given. The local chief executives
may, however, agree to finance a less costly option that could bring more benefits to their
constituents and therefore carry more political weight. One such option is as follows:
1. The same incentives can continue by simply enrolling poor families in the
PhilHealth-Sponsored Program,
2. The LGU premium share in the Sponsored Program is considerably less than the
cost of the Project incentives, and
3. The benefit coverage enjoyed by the family and the potential reimbursement
benefits that LGU facilities receive go way beyond what the Project offers.
For greater impact, the above message is reinforced by the PBG described below.
Performance-Based Grant towards Universal PhilHealth Enrollment of the Poor
The financial sustainability of facilities could be enhanced while providing for a safety net for
the poor by encouraging LGUs to ramp up enrollment of the poor in the Sponsored Program.
It is thus important for health officers to continuously advocate for PhilHealth enrollment of
poor clients to their Mayors and members of the local board. The local lobbying is alongside
the WHSMP2 effort that encourages LGUs to strive for universal coverage levels through a
performance grant mechanism. The grant mechanism seeks to change LCE behavior in
budget allocation towards a preference for supporting health needs of the poor. PhilHealth
coverage is envisioned to have significant impact on the attitude of poor women towards
facility birth since cost is viewed as a major obstacle to choosing the health facility as a birth
venue. The grant mechanism is as follows:
Objective
The PBG is expected to facilitate the access of indigent families to PhilHealth financing by
encouraging MLGU/CLGU to sponsor their enrollment in the PhilHealth Sponsored Program.
PBGs are given based on the attainment of annual MLGU/CLGU enrollment targets.
General Conditions
1. This grant scheme is an annual PBG given to LGUs that either meet or exceed their
respective yearly targets towards universal enrollment of their poor constituents. It is
equivalent to 50% of the LGU’s share of the premium for the target population for that
year. Thus, if the LGU’s annual premium for an indigent is P 120 and the LGU meets its
indigent enrollment target for the year, it is entitled to a rebate amounting to P60 for each
indigent enrolled.
2. The grant amount remains unchanged if the LGU exceeds its target for the year.
3. Only municipalities and cities (MLGUs and CLGUs) are entitled to receive this grant.
4. Funds received by a C/MLGU under this PBG are spent only on WHSM services and
supplies. To ensure this, payments are made directly into the C/MLGU’s Project Account.
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5. Annual Sponsored Program (SP) coverage targets for the duration of the project are set
for each M/CLGU upon initiation of this PBG scheme and are based on the overall
PhilHealth target of 75 percent as universal coverage by year 2010; thus by 2010, the
LGU should have enrolled 75 percent of its poor in the Sponsored Program. The result of
the client classification survey undertaken by the LGU (part of the WHSMP2
requirements) is the basis for determining the number of poor households.
6. Only LGUs that have fully paid for their enrolled indigents are qualified to receive this
grant.
7. LGUs that have attained their annual targets at the end of October of each year are
entitled to receive this grant. LGUs that have reached their annual targets (with premiums
completely paid) before October may request the DOH-CHD to award the grant as soon
as the PhilHealth issues a certification.
8. PhilHealth is responsible for the following:
• Validating the qualifications of the proposed enrollees to its sponsored-program.
• Certifying the LGU’s attainment of its target indigent enrollees.
Administration
1. The PHO and the PhilHealth regional office administer this grant scheme, in accordance
with the WHSMP2 financial management system.
2. The Provincial Project Management Team (PPMT) assists the DOH and PhilHealth in
monitoring the MLGUs attainment of indigent enrollment targets.
Financial Procedures
Requests for PBG payment shall be addressed to DOH and coursed through the PPMT. Upon
submission by the LGU of the request for PBG payment, the PPMT shall:
Request PhilHealth to prepare a list of fully paid indigent enrollees of the MLGU.
Validate the list of enrollees with the Master List of indigents identified through the
Identification of the Poor Survey.
Validate if MLGU has met the eligibility criteria then forward the request to DOH,
endorsing the payment of the PBG to the MLGU.
Funds Flow for Payment and Reimbursement
1. MLGU pays for enrollment directly out of its general funds using Project-endorsed
indigent list.
2. Once MLGU reaches its annual enrollment target, it requests payment from DOH- Bureau
of International Health Cooperation (BIHC) through PPMT.
3. PPMT verifies that:
a. The target has been reached, counting only indigents identified through the
Identification of the Poor Survey.
b. Full payment has been made for all enrollees (validated with PhilHealth)
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4. PPMT endorses payment of PBG to DOH-BIHC.
5. DOH-BIHC transfers PBG to MLGU.
Reporting and Monitoring
1. The M/CLGU PhilHealth sponsored program target is proposed and communicated by the
local chief executive (LCE) at the start of the year to the PPMT, with copies furnished the
PhilHealth regional office and CHD, who, in turn, confirm the accuracy of the target and
communicate the same to the LCE. Although MLGUs set their own targets, it is the task
of the Provincial Governor and the PHO to encourage MLGUs to set targets consistent
with the overall province-wide enrollment targets for the project.
2. Should the MLGU/CLGU fail to spend the PBG as prescribed, the LGU is entitled to use
the grant to enroll indigents for the next four quarters.
This PBG seeks to encourage a shift in LGU priorities towards providing resources to ensure
that its poor constituents have access to basic health services. The scenario leading long-term
behavioral change is envisioned to unfold as follows:
As the LGU ramps up enrollment towards universal coverage, more and more poor
women will enjoy Philhealth coverage and would eventually get used to availing of the
services that it funds. Hopefully, several years of universal insurance coverage for the
poor would make this enough of a political issue such that politicians vying to become
LCEs would inevitably make it a part of their political agenda.
User Fees
Another viable source of facility financing is the collection of user fees. Such fees are usually
collected from non-poor clients using a socialized pricing scheme. However, facilities need
to be authorized to collect such fees by the LGU, preferably through an ordinance
passed by the Sanggunian (local board) to help ensure continuity over time across
political administrations. Such an ordinance should also empower the facility to use the
funds generated from such user fees to finance operations and to augment provider
compensation (in instances where the allocation of Philhealth reimbursements to facilities and
providers is not clearly laid out either in policy or in practice, the said ordinance may have to
cover such allocation issues with regards to Philhealth reimbursements as well).
Pricing schemes are ideally socialized, taking into account the client’s capacity to pay (a
recommended strategy for determining such capacity is discussed below). Price levels
should not be pegged in an ordinance to allow facility managers to respond to changes in
the local situation. Thus, in an economic downturn, facilities may opt to reduce prices or
forego user fees altogether for a larger segment of the population so as not to make
affordability an obstacle to access.
Charging user fees that do not end up as obstacles to access since it requires a pricing scheme
that is sensitive to people’s ability to pay as well as a reliable system for identifying
segments of the population that would need either full or partial subsidies. To arrive at such
a pricing scheme, one has to take into account the difference in financing objectives
between a public health facility and a private facility. While the private health system has
an underlying profit motive in the delivery of health services, the public health system is
established for the primary purpose of providing health services to the community ( in most
cases this is its sole purpose). Generating revenue to either recover cost or to make a profit is
hardly in the equation, if at all. The cost of delivering a service need not be recovered since
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such costs are supposed to be financed out of the budget that the facility receives from the
LGU. However, budget constraints can be quite severe for some LGUs especially small,
remote municipalities with a miniscule tax base. In such cases, service delivery may suffer
severely unless their sources of financing are broadened. Thus, the need to sustainably
deliver health services of acceptable quality drives the effort to recover at least some of
the cost of delivering these services. How much can be recovered would depend on –
• The budget constraint that the facility faces and
• The ability of its client to shoulder some of these costs.
The objective of formulating a pricing scheme that allows the facility to effectively deliver
health services to a wide sector of the population, particularly the poor and marginalized,
while recovering enough of its costs to enable it to deliver such services in a sustainable
manner may be pursued by taking either of two strategies.
First is to use as benchmarks prices charged for the same services by private or NGO
facilities operating at the same level in health care hierarchy (e.g., health center; primary,
secondary or tertiary facility). Apply a discount, taking into account the fact that some of
the fixed costs (and maybe even some of the variable costs) of delivering the service are
unchanging items in the facility budget and will not be affected by the level of facility
operation. Examples of these items are the cost of the building (although one may have to
factor into the fee the cost of building maintenance) and the salaries of support personnel.
Although the salary budget for permanent item holders is fixed and will always be
forthcoming from the LGU, one may want to factor in an incentive scheme for those directly
providing the service and include its cost in the fee calculations. An amount to provide for
the hiring of contractuals when the load becomes heavy or when specialized skills need to be
sourced from the private sector may also be factored into the cost calculus.
A second possible strategy is to follow a cost plus pricing scheme. This involves a tally of
the major cost items involved in the delivery of the service. As in the first strategy above, one
has to take the perspective of a public facility that is seeking to recover those costs that may
not be supported by the budget. Thus, cost items in the said tally may include mostly such
variable costs as the cost of drugs, medicines and supplies, utility costs, incentives for direct
providers, depreciation cost of specialized equipment used, etc.
After baseline prices have been determined for each of the services rendered by the facility, a
socialization factor may be applied to adjust these prices to account for the client’s capacity
to pay. Thus, those clients in the highest income levels may be made to pay the full cost
while those at the lowest income levels may avail of the services for free. Prices may be
graduated for those clients belonging to income levels in between.
Establishing a Client Classification Scheme
The basic principle that underlies the sustainability strategy is to try to generate revenue
while targeting resources to ensuring that the poor and underserved are provided easy access
to quality health services:
• clients who are Philhealth members and
• those who can afford to pay for services
It is therefore important to have a sense of a client’s capacity to pay. For this purpose, it
would be useful to try to segment the population into economic classes. This is a
methodology commonly employed by program planners of subsidized welfare services to
ensure an equitable sharing of resources across beneficiaries.
146
Per capita income would ideally be a segmenting variable of choice. However, per capita
income is difficult to estimate especially in the rural areas where a significant segment of the
population is either self-employed (e.g., farmers and fisher folk) or derives income from the
informal sector where income sources are numerous and often unstable. Furthermore
respondents usually tend to under report income for a myriad of reasons, especially when the
income survey is for the purpose of providing subsidies to the poor.
One could get around this problem by using a proxy measure of household wealth that has
been shown to be closely correlated with income. One such measure is being employed by
the Department of Social Welfare and Development (DSWD) in its implementation of the
Pantawid Pamilyang Pilipino (Conditional Cash Transfer) Program. It consists of a basket of
household attributes which are easily verifiable. Data on the following household attributes is
therefore collected using the DSWD Household Rapid Assessment Survey Form:
• Water and sanitation
o Source of drinking water
o Type of toilet used
• Housing conditions
o Ownership
o Quality of materials used
o Structural condition
o Use of electricity
o Type of cooking fuel
• Household assets
o Land
o Livestock
o Transport
o Appliances and electronic gadgets
• Food security
o Number of meals served
o Adequacy of food
The DOH and the DSWD are in the process of finalizing arrangements for a collaborative
effort to perform client segmentation exercises in WHSMP2 project sites using the above
methodology. The strategy involves the provision of technical assistance by both DOH and
DSWD to guide a survey effort that would be undertaken by LGU counterparts. It is
important for the LGU to take the lead in this exercise for the following reasons:
• An LGU lead survey makes the system of identifying the poor and updating the list of
poor families more sustainable than a nationally or donor-driven initiative.
• LGUs are able to use the data in their annual development and investment plans
since they become the repository of data that they have collected and processed.
Organizing the Survey to Identify the Poor
While DOH and DSWD resource persons shall be on site to provide planning guidance and
training in the use of the survey tool and analysis of the data, the survey exercise is generally
envisioned as an LGU activity, mainly undertaken by LGU-based project stakeholders. The
following outlines the activities that LGUs need to undertake to plan, organize and implement
the survey and data analysis. This should give LGUs a sense of the requirements in terms of
personnel resources and logistics:
147
1) Develop a detailed plan and procedure to carry out a client classification scheme in all the
households of the Province to identify the poor households. The plan should include
procedures for identifying and mobilizing community volunteers (e.g. WHTs) to carry out
the complete enumeration of households in every barangay of every municipality of a
province.
2) Organize survey teams:
• Identify the enumerators at the barangay level,
• Train the enumerators on data collection that should include interview skills, and
• Reproduce data collection instruments.
3) In coordination with the local Social Welfare and Development Office supervise –
• Data collection through complete enumeration of households,
• Data processing,
• Data analysis, and
• Poverty estimation
4) Keep a list of eligible families that have been ranked based on the “poverty index” and
provide the Provincial and Municipal Social Welfare Development Office with this list.
5) Develop a mechanism to keep the list updated.
SUSTAINABILITY IN ESSENTIAL DRUGS AND CONTRACEPTIVES
Drugs and medicines usually constitute a major cost item in most health interventions. Their
cost can significantly affect health seeking behavior and may even serve as an access barrier
to those who are too poor to afford them. The public health budgets of most LGUs are
usually too meager to support the provision of free or subsidized drugs to the poor. Thus,
public health facilities usually provide not much else beyond their supply of donated drugs
and supplies.
The sustainability strategy of WHSMP2 therefore includes helping facilities to become
sustainable in the supply of drugs and to enable them to provide their poor clients with free or
subsidized drugs. The strategy involves building a large enough revolving fund to allow the
sustainable procurement of needed essential drugs, contraceptives and medical supplies. This
strategy shall be pursued by collaborating with two existing DOH programs with similar
objectives:
• The P100 program on essential drugs and
• The Pop Shop initiative of the DOH Social Marketing Project for contraceptives
which is managed by DKT.
The collaborative approach is envisioned to generate synergies between WHSMP2 and the
above programs leading to a strengthened effort towards drug sustainability for LGU health
facilities. A brief description of each of these projects and the WHSMP2 strategy for
collaborating with them are discussed below.
The P100 Program
The program is an initiative of the Secretary of Health and is funded out of the government
budget. The program seeks to increase access to low cost quality drugs, taking into
consideration –
148
• rational drug use,
• economies of scale in procurement and
• a unified pricing scheme (the targeted ceiling for a complete regimen is one hundred
pesos).
DOH and LGU hospitals with functioning Therapeutic Committees and are accredited by
PHIC may participate. LGU participants are encouraged to work for the passage of an LGU
ordinance authorizing them to establish a revolving fund for drugs and medicines.
Participants are required to submit Requisition and Issue Slips to DOH to determine the
quantities to be procured by PITC Pharma, the partner procurement agency. Participants may
retail the drugs with a mark-up so long as the price does not exceed 100 pesos per package.
From the sales revenue, participants are required to remit back to DOH an amount equivalent
to the wholesale cost of the drug. The profit is retained by the facility.
The P100 Program
LGU
Sells at cost + mark-up Sales
Outlet of
Revenue
low-cost R
drugs
PITC
Part retained
for operation R1
P100
R2
Part of the sales
(cost of drugs) are remitted back
to DOH for P100 re-supply
The DOH Contraceptive Self Reliance and Social Marketing Programs
The Family Planning Policy issued by DOH in 2000 recognizes and affirms the need for
Contraceptive Self Reliance (CSR) in response to the phase down of donated contraceptives.
CSR as a national strategy is further defined in Administrative Order Number 58 series of
2004, which provides guidelines on the management of donated commodities as supply levels
are phased down. (A.O. # 58 s.2004 Guidelines on the Management of Donated Commodities
under the Contraceptive Self-Reliance Strategy). The CSR Strategy provides for the
transition from externally donated to domestically provided commodities for family planning.
CSR has two broad goals:
(1) To effect a gradual replacement of externally donated supplies with domestically
provided supplies, and
(2) To expand further the domestic supplies of contraceptives.
149
The first goal seeks to minimize supply disruptions in the public sector as donations decline,
while the second seeks to encourage a wider private sector role in the contraceptive market.
Attainment of these twin goals will not only help ensure that present contraceptive prevalence
rate (CPR) levels are not adversely affected by the withdrawal of contraceptive donations, but
will hopefully also lead to finally ending the country’s reliance on donor support in the
provision of family planning services and commodities.
To effectively pursue the twin CSR objectives above, DOH further strengthened its Social
Marketing Program which for years has been successfully managed by DKT, Philippines.
Under a renewed mandate, DKT focused on helping attain the CSR objectives by launching
the POPSHOP Franchise System. Designed especially to support LGUs maintain a
sustainable supply of contraceptives at the community level, the POPSHOP package offers
products, training and materials needed to help LGUs promote and operate their Family
Planning Programs. Under the system, affordable contraceptives are provided on a
modified consignment arrangement allowing franchisees to recover the initial cost while
they continue to generate funds to sustain their programs. The acceptability of the
scheme to even the poorest remote communities is manifested by the over 200 POPSHOPS
that have been established nationwide from as far north as Luna, Apayao to Bongao, Tawi-
Tawi which is at the southernmost tip of Mindanao, just a few nautical miles from Sabah in
Malaysia (PULSE, November 2007).
The franchise is open to both public and private entities. Its target groups are LGUs, NGOs,
midwives, industrial clinics and cooperatives. Investment costs range from-
• 25,000 pesos for the New Mini-POPSHOP Package which is offered to LGUs
wishing to expand coverage, to
• 92,500 pesos for the Standard Full Package.
The amount covers enrollment and franchise fees and the seed stock. Franchisees are
provided operations training, technical and management assistance, signages, IEC and
promotional materials and client monitoring tools (POPSHOP Briefing Paper)
Sales
Revenue
Part retained
For operation R1
Investment
R2
Part remitted back
to DKT for re-supply
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WHSMP2 Performance-Based Grant towards Self-Reliance in Essential Life-Saving
Drugs and Contraceptives
WHSMP2 offers a performance-based grant to encourage LGUs to participate in the above
programs so that they may avail of the offered seed capital and the technical assistance that
they need to establish and effectively operate revolving fund schemes that would lead them to
sustainable self-reliance in the supply of essential drugs and contraceptives.
The scheme initially requires –
• LGUs to purchase contraceptives to meet the needs of the poor. These contraceptives
are to be given free to poor clients (those in the list of poor clients per the Client
Classification Survey).
• DOH, on the other hand, commits to supply the LGU with an equivalent amount of
essential women’s health and safe motherhood drugs, mainly to help ensure that
BEmOC and CEmOC clients have an adequate and consistent supply of these drugs.
These drugs will be supplied through the P100 program and will be in addition to the
essential drugs supplied by the program in the form of seed stock. Unlike the P100
seed stock, proceeds from the sale of the PBG drugs will not have to be remitted
to DOH but will be retained by the LGU to fund facility operations and to add to
the capitalization of the revolving drug fund (Poor clients will use the 500 peso
subsidy from the LGU that is given as part of the FBC grant to purchase drugs from
P100 outlets).
• As the revolving fund grows, outlets shall be increasingly capable of providing a
steady supply of socially-priced drugs to those who are able to pay and free drugs to
the poor without having to rely on budgetary outlays from the LGU. The process
flow is shown below.
WHSMP2 poor
&
Free WHSMP2
P100 drugs
Drugs
LGU LGU purchases
Non-poor
contraceptives R
C
P100 drugs
sold at cost
RIS & + mark-up
Invoices,
DOH
Receipts matches
From C C Seed
PITC money
buys
drugs cost of drugs remitted
P100 back to P100 for re-
RIS + funds supply
Collaboration between WHSMP2 & P100 Towards
Sustainable Supply of Essential Life Saving Drugs
151
Funds and Process Flow
1. The LGU purchases contraceptives to address the needs of the poor and submits
receipts as evidence of the transaction to the WHSMP2 Provincial Project
Management Team (PPMT) together with RIS for the equivalent amount of
WHSMP2 drugs. The LGU likewise submits to the P100 PMT the RIS for its share
of P100 drugs.
2. The WHSMP2 PPMT endorses the above documents to the DOH-BIHC WHSMP2
PMT after verifying the accuracy of the request.
3. The DOH WHSMP2 PMT submits the RIS for WHSM drugs together with the funds
for their purchase to the P100 PMT.
4. The P100 PMT submits both the RIS for WHSM drugs and the P100 drugs to PITC
Pharma and transfers funds for their purchase.
5. PITC Pharma delivers both the requested WHSM drugs and the P100 drugs to the
LGU.
6. The LGU retails the P100 and the WHSMP2 drugs at prices equivalent to cost plus
mark-up so long as the retail price stays within the 100 peso ceiling (for a full
course). The LGU remits back to the P100 PMT part of the sales revenue equivalent
to the cost of the P100 drugs. The LGU retains the rest of the sales revenue.
To help ease the budgetary burden of providing contraceptives to the poor, PBGs will also be
made available to help LGUs defray the initial cost of setting up POPSHOPs, provided that
they commit to allocate part of the POPSHOP profit to the purchase of contraceptives to be
given free to the poor. As the POPSHOP revolving fund grows, it is envisioned to
increasingly assume the financial burden of providing free contraceptives for the poor until
eventually a budgetary outlay will no longer be necessary. At this point, the LGU shall have
become self-reliant in maintaining a steady supply of socially-priced contraceptives to all
segments of the population.
152
Chapter 13
Tracking and Evaluating Progress
The Monitoring System
Evaluating the Impact of the Project
Dissemination of Results
153
Chapter 13
TRACKING AND EVALUATING PROGRESS
A Monitoring, Evaluation, Research and Dissemination (MERD) system is set up to track the
progress of the implementation of the WHSMP2 through the use of selected output and
outcome indicators.
The importance of monitoring and evaluation of projects in health program intervention
cannot be overemphasized.
• Monitoring is a critical management tool to ensure that activities necessary to deliver
desired outputs to accomplish project objectives and purpose are implemented as
planned and on time.
• Evaluation activities, on the other hand, are essential to measure the desired project
outcomes and impact and be able to attribute such changes to project efforts.
Aside from providing information on project effectiveness, the MERD subcomponent of
WHSMP2 will also be able to provide empirical evidence useful in deciding the Project’s
replication, scaling-up, sustainability and acceptability to key stakeholders such as the donor
agency, health policy makers, program managers, health providers, and direct and indirect
project beneficiaries.
The research component will take the form of special studies and operations research inputs.
The special studies will be conducted to document and examine the effectiveness of
innovative elements of the WHSMP2 that are not adequately captured in the impact
evaluation or monitoring activities. On the other hand, Operations Research techniques will
be used to assist program managers to develop and test new forms of service delivery for
hard-to-reach groups.
The dissemination of results will ensure that the MERD subcomponent complements
management functions by regularly providing information for evidence-based decision
making. It will also substantially strengthen capacity for the reporting of information.
Data on inputs and processes will be collected by the various component projects, which will
be accomplished and submitted monthly, to the PHO (where the WHSM Project Management
Unit is housed). Inputs and processes will not be part of MERD.
Data abstraction forms designed to collect data on output and process indicators from various
data sources are accomplished at the respective offices generating these statistics. This
includes:
o basic health facilities,
o government hospitals and
o Philippine Health Insurance Corporation (PhilHealth)
In general, data abstraction will take the following course:
1. The midwife, nurse or any capable representative from the municipal and provincial
health offices will fill-up the corresponding forms with data abstracted from FHSIS or
other hospital statistics every end of the month.
154
2. If the facilities have electronic communication, these forms will be submitted through
email to the Project Management Team (PMT) of the province not later than 1st
week of next month.
3. On the other hand, a project management staff will collect these forms on the 1st
week of the succeeding month from facilities that do not have Internet connection.
4. At least two weeks will be allotted for collection of data abstraction forms from
the whole province. This is more efficient than waiting for all the facilities to submit
the forms and ensures completeness of data; however, there should be an available
budget for transportation of the PMT staff.
5. While PhilHealth has regional offices, data required for monitoring of WHSMP2 has
to be gathered from the Central Office in Pasig City because its Corporate Planning
Department is the official clearing house for all PhilHealth statistics. Hence, the PMT
at the national level through its MERD coordinator will be responsible for
collection of this data semi-annually or annually. The abstracted PhilHealth data
using the relevant form will be forwarded to the data manager at the provincial PMT.
All forms submitted monthly and semi-annually or annually, respectively, to the data manager
at the provincial PMT are processed immediately. Results are then used for feedback to the
program managers and other stakeholders (i.e. whether or not target indicators are achieved).
The MERD has four (4) major functions:
1. Monitoring the progress of WHSMP2
2. Evaluating the impact of the Project
3. Evaluating the effectiveness of WHSMP2 innovations through research
4. Disseminating the results to support evidence-based decision-making processes
THE MONITORING SYSTEM
Step 1. The midwife, nurse or any capable representative from the municipal health office will
fill-up the monthly monitoring FORM 1 for BEmOCs/ and CEmOCs. The data include:
• Status of BEmOC/CEmOC provider facility with regards to PhilHealth
accreditation for maternity package
• Number of births by place of delivery
• Number of births per type of delivery
• Patient classification
o Referred by WHT (with birth plan)
o Beneficiaries of PhilHealth –SP
o IP status
• Total STI cases by method of diagnosis
• Availability of FP commodities in the facility
• Number of FP acceptors by method
• Number of FP acceptors screened for STI
• Number of maternal deaths by cause
155
Step 2. The data collected using MERD FORM 1 will be submitted electronically to the
Project Management Team of the province not later than 1st week of next month. For
instance reports that are due for submission in January will be collected by the PPMT
on the first week of February. On the other hand, the Project MERD coordinator
based at Central Office will collect these forms on the 1st week of the succeeding
month (March) from facilities that do not have Internet connection by snail mail.
Step 3. The PMT of the province consolidates the data from Step 1 on a semi-annual basis to
monitor the compliance level of municipal LGUs with regard to delivery protocols.
Subsequently, the data obtained is compared with the Project key indicators and
analyzed:
• 80% of births are delivered by skilled attendant, either at health facilities or at
home
• 75% of births are delivered in a health facility
• 75% of deliveries by the poor in BEmOC and CEmOC facilities are financed
through PhilHealth – Sponsored Program
• 25% of deliveries by the poor in BEmOC and CEmOC facilities are financed
through DOH-LGU performance-based grant
• Increase contraceptive prevalence rate by 10 percentage points
• 100% of RHUs have not experienced stock-outs of pills, injectables and IUDs for
the past 6 months
Step 4. Central level MERD coordinator uses the data from Step 1 to evaluate the
effectiveness of advocacy work and referral systems as indicated in the intermediate
results indicators under Component A1 and Component A2 of the results
framework:
Component A.1. Critical Capacities
• 100% of the BEmOCs have PhilHealth accreditation for maternity package
• 50% reduction in the number of normal spontaneous deliveries (NSD) in
CEmOC (referral facility for complicated cases)
• 80% of women who delivered in the past 6 months had birth plans
• 100% of FP users and ante-natal clients screened for STI according to
prescribed protocol
• 70% of women who know the 3 ways (abstain, be faithful, consistent, correct
condom use) of preventing the sexual transmission of HIV
• Increase to 16% from baseline the total proportion of women or their partners
using permanent methods
Component A.2. Sustainable Support Systems
• 70% of non-poor FP clients paying for contraceptives
• Increase LGU enrollment for the PhilHealth Sponsored Program coverage
and sustain to at least 75% of the target poor household at the municipal and
city level
• 100% of BEmOCs share MC revenues with WHT according to guidelines
Step 5. After processing the data collected in Step 1, the PMT of the province feedback the
results to the pogram managers and other stakeholders to check whether target
indicators are achieved. The Central level MERD coordinator provides technical
assistance to the PPMT in ensuring quality of data collection and analysis
156
EVALUATING THE IMPACT OF THE PROJECT
The purpose of evaluating the project is to be able to measure changes (desired and
unintended) that occurred after activity implementation and to be able to attribute these
changes to the WHSM Project activities. To ensure that changes in key output and outcome
indicators can be measured and documented, data collection will be done at three points
during the life of the Project ---
• at baseline,
• at the middle, and
• at the end of the Project.
Accomplishments in the Project sites will be compared with accomplishments in the Non-
Project sites and their differences will be attributed to the observed changes between project
and non-project sites; thus, these will be considered as the Project’s effects.
In general the following types of information will be collected from each data source:
• The population based sample survey measure changes in the knowledge, practices
and health outcomes of women of reproductive age.
• Facility based surveys measure changes in the quality of care in WHSM Project sites.
• Abstracts of facility statistics (using Form 1 for BEmOCs/CEmOC provider facilities)
measure changes in health facility performance.
The population based sample survey and facility based survey are conducted by a local
research agency. The PMT of the province assists in the completion of both surveys. On the
other hand, the MERD staff at the national level oversees the consolidation of project results
framework annually.
EVALUATING THE EFFECTIVENESS OF THE WHSMP2 INNOVATIONS
THROUGH RESEARCH
There are two types of research in the MERD component which will be done by the central
level MERD coordinator with the assistance of the PPMT and the PHO technical staff:
a). Special studies will be conducted to document and examine the effectiveness of
innovative elements of the WHSMP2 that are not adequately captured in the impact
evaluation or monitoring activities.
b). Operations Research techniques will be used to assist program managers to develop and
test new forms of service delivery for hard-to-reach groups.
Special studies for Innovative elements of the WHSMP SP include are best done by the PHO
technical staff with the assistance of the CHD coordinators and the central level MERD
coordinator:
Case studies: Preparation and use of birth plans, maintenance of Women’s Health Teams who
are given referral incentives for facility based childbirth deliveries.
1. Evaluation of the grant scheme for supporting enrollment in PhilHealth
• 50% reimbursement of PhilHealth premium to LGUs who enrolled indigents
157
2. Effectiveness of client classification scheme.
3. Evaluation of province/city-wide drug and contraceptive procurement.
The MERD staff at the national level coordinates with the provincial MERD staff to ensure
consistency and coherence of special studies with project development objectives.
Operations Research studies (pilot studies) include:
1. Appropriate intervention to reduce STI transmission and HIV risk among commercial
sex workers.
2. Establishing a local adolescent and youth health program.
The MERD staff at the national level is responsible for:
• Developing the Terms of Reference (TOR) for the pilot studies and coordinate
with NCDPC, HPDPB for review and approval.
• Supervising the implementation of the pilot studies in coordination with the
MERD staff at the provincial level.
DISSEMINATION OF RESULTS
The dissemination of results will be done at local and central level and will ensure that the
MERD subcomponent complements management functions by regularly providing
information for evidence-based decision making. It will also substantially strengthen capacity
for the reporting of information.
The MERD staff at the national level:
• Assists in the preparation of semi-annual project monitoring reviews for management in
provinces and national offices.
• Assists in the dissemination of Impact Evaluation Results in the form of seminars both in
the Project sites and Manila.
• Organizes quarterly meetings with Inter-Local Health Zone (ILHZ) officials to review
results generated by abstracted data from FHSIS and identify areas for improving data
collection processes and implications for program management.
In the project sites, the overall impact of the inputs and outputs/processes of the WHSMP2
are:
1) to reduce maternal mortality and morbidity,
2) to contribute to the reduction of STI including HIV infection;
3) to contribute to the reduction of the unmet need for family planning.
During the life of the Project, MERD activities are vital to track the progress in the
implementation of the WHSMP2 through the use of selected output and outcome indicators.
158
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