Second Women’s Health and Safe Motherhood Project

INDIGENOUS PEOPLE’S DEVELOPMENT PLAN (IPDP) FOR SORSOGON

October 2004

I. Introduction The WHSMP 2 hopes to demonstrate in selected project sites an affordable model of delivering health services that increases access of vulnerable and disadvantaged women of reproductive age to acceptable, high quality, and cost-effective reproductive health services essential for safely attaining their desired spacing and number of children. Indigenous peoples, youth, poor women, commercial sex workers are among the vulnerable and disadvantaged groups that the project hopes to effectively reach and benefit. WHSMP2 has the following objectives: (i) increase the access (in selected sites) of disadvantaged women (including indigenous people) of reproductive age to high quality and cost-effective reproductive health services; and (ii) develop and implement sustainable and replicable systems, within the framework of the Health Sector Reform Agenda, for the financing and delivery of reproductive health services. The project consists of two parts: a Local Delivery of the Integrated WHSM Service Package (Part A) and a National Capacity to Sustain WHSM Services (Part B). The Province of Sorsogon is among the first batch of Project Sites selected for the project, which will be assisted through the establishment and operation of a network of Women’s Health and Safe Motherhood teams (WHT), provision of assistance in the upgrading of health facilities, development and implementation of cost-effective and sustainable approaches to reach vulnerable and high risk groups. Selected health facilities in the province will be improved and upgraded to increase access of women, particularly the disadvantaged women, to emergency obstetric care. Women’s Health Tams (WHTs) composed of the Rural Health Midwife as Team Leader, Barangay Health Workers (BHWs) and Traditional Birth Attendants (TBAs), shall be organized to help pregnant women develop their respective Birth Plans that would cover prenatal activities, childbirth and postpartum care. They shall also encourage mothers to shift from home to facility births by helping them address identified barriers to such a shift, which include the logistic requirements, transport and temporary shelter arrangements. A social assessment (SA) conducted in the Province revealed the existence of Indigenous Cultural Communities and Indigenous Peoples (ICC/IPs) in six municipalities of Sorsogon where around 12,127 IPs belonging to the agta-cimaron-tabagnon cultural-minority group are known to reside. To obtain a better understanding of the situation of the indigenous peoples in the province, the SA included the conduct of interviews and discussions with IPs in Prieto Diaz in Sorsogon. Subsequent discussions were made by the project preparation team with IP leaders from the different municipalities and the Provincial Health Team. This culminated in an IPDP workshop in August 2 and 3, 2004 where this plan was drafted (Annex A shows the participants to the IPDP workshop).

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This IPDP outlines the measures to be taken to maximize the engagement of indigenous people in the planning and implementation of various project interventions in areas with IP population and come up with culturally-sensitive and appropriate strategies in improving the access of IPs to maternal and child care. It lays out a general workplan to ensure that indigenous peoples (IPs) are informed, meaningfully consulted and mobilized to participate in the various stages of project design and implementation as they are seen as an important stakeholder. The IPDP for Sorsogon described herein aims to ensure compliance with the Philippine Indigenous People’s Rights Act (RA 8371) and the World Bank’s OD 4.20 on Indigenous Peoples, as reflected in the project’s Indigenous People’s Strategy. II. Objectives of the IPDP In line with the overall project objectives, the IPDP aims to increase the access of IP women in Sorsogon of reproductive age to acceptable, high quality and cost-effective reproductive health services and enable them to safely attain their desired spacing and number of children in a manner compatible with their practices and situation. This is envisioned to eventually result in the reduction in both maternal and infant mortality rate in the Province. Related to this, the plan aims to

a) Attain 100% PhilHealth coverage of IP women in the province; b) Double the number of births by IP women in a health facility; c) Have 80% of births by IP women delivered by skilled attendant (health professional),

either in a facility or at home; and d) Improve awareness and acceptance among IP women of reproductive age on birth

planning, and FP services. III. Legal Framework The contents of this IPDP are based on laws and policies of the Government of the Philippines and policies of the World Bank, as follows:

a) The Philippine Constitution of 1987 recognizes the rights of the IPs to their ancestral domains and their power of dominion over their lands and resources, and provides that the rights of IPs to natural resources pertaining to their lands shall be especially safeguarded (ART. XII Section 5). These rights include the right of the IPs to participate in the use, management, and conservation of natural resources;

b) Republic Act 8371, otherwise known as the Indigenous Peoples Rights Act or IPRA,

provides that the IPs have the right to an informed and intelligent participation in the formation and implementation of any project, government or private, that will impact on their ancestral domain, and that the IPs have the right to participate in decision-making, in all matters which may affect their rights, lives and destinies;

c) World Bank Operational Directives on Indigenous Peoples (OD 4.20) requires Bank-

assisted projects to ensure that interventions avoid or minimize detrimental impacts on indigenous peoples and cultural minorities and that measures are made to maximize project benefits on IPs. It likewise requires Bank-assisted projects in areas with IPs to guarantee the informed and meaningful participation of IPs in various stages of project development and implementation. Moreover, this directive expects

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that IPs receive social and economic benefits that are compatible with their cultural practices and tradition.

IV. Baseline Data Of the 14 municipalities and 1 city in Sorsogon, Indigenous Cultural Communities and Indigenous Peoples (ICC/IP) are known to reside in six municipalities. These municipalities are as follows: Municipality with known estimated population Agta sub-tribes IP communities a. Bulusan 755 Agta-Cimaron/Agta-Tabangnon b. Donsol 5,572 Agta-Cimaron/Agta-Tabangnon c. Irosin 1,277 Agta-Cimaron d. Matnog 369 Agta-Cimaron/Agta-Tabangnon e. Pilar 1,190 Agta-Cimaron/Agta-Tabangnon f. Prieto Diaz 2,964 Agta-Tabangnon Most agta households in the province rely on farming, fishing and gathering of forestry products. Households earn an average monthly income of P2,500. However, those in far-flung sitios earn much less than those situated near urban centers. Health status of agta households is generally poor, as is education (intermediate level on the average). Access to health services of women agtas in the barangay is limited to prenatal services. Childbirth support is largely dependent on the support of traditional birth attendant in the community, referred locally as “hilot” or “parabulong”. Hilots charge an average of P300 to P500. Some trained “hilots” charge as much as PhP1, 200 per childbirth, which also makes their services unaffordable to very poor women. As a result, some agta women are not at all assisted by trained and traditional birth attendants, and had to rely on their husbands or other family members for support during child delivery. Most of the agta women interviewed and the tribal chieftains say that many agta women would also want to give birth in a facility, but are unable to do so because of financial constraints and the distance of facilities to their communities. Husbands (majority of whom also assist in child birth) are also in favor of facility-based births, but are concerned of the cost. Although the Provincial records indicate that the Province has already reached 96% PHILHEALTH coverage, tribal chieftains revealed that many of their fellow agtas in the province have not been covered. Moreover, even with the deployment of Barangay Health Workers (BHWs) by the Provincial and Municipal LGUs to cover all the barangays in the Province, far-flung sitios where most agtas reside are yet to be visited by the BHWs. In addition, some agtas tend to avoid or shy away from BHWs and midwives during field visits or medical mission especially when these are not coordinated with their respective chieftains. As a result, a number of agta women are still unable to obtain prenatal care and advise from these trained medical staff. Family Planning is rarely practiced among couples. IPs generally rely on herbal plants than commercial medicines. Agta women tend to marry at a young age (14 to 19 years). Average number of children is 6 to 7. Agta households are organized into tribal communities, each headed by a tribal chieftain and a tribal council. Tribal chieftains then select among themselves a municipal tribal chieftain to

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coordinate with the Municipal LGU on various matters affecting them. There is likewise a Provincial Federation of Tribal Councils of Sorsogon that represents the agtas at the provincial level. These councils are supported by the Provincial Office and Community Service Centers of the NCIP particularly in linking with other government agencies and the LGUs. The NCIP Regional Office has a Medical CVAC unit composed of a doctor, a dentist, a nurse and a midwife which occasionally undertakes medical missions in IP communities in partnership with volunteer associations. The Service Center in Donsol likewise employs a midwife to help address the maternal needs of nearby IP communities. Most IP communities are situated within their respective ancestral domains. There are currently seven ancestral domain claims in the Province. Of these, four are covered by Certificates of Ancestral Domain Claims (CADCs) issued by the DENR between 1996 and 1998. The NCIP Regional and Provincial Offices are taking the lead in the effort for the conversion of these CADCs into Certificates of Ancestral Domain Title (CADTs) as provided for in IPRA. The other three domains are directly being processed for CADT issuance. V. Strategy for IP Participation Engagement of the IPs and integration of IP concerns into the project planning and implementation processes is through the following: a. Orientation of and coordination with the 6 tribal chieftain on the conduct of various project

activities including but not limited to the client classification surveys, impact or perception studies, community visits and missions by the WHTs, design of training modules and protocols and other information dissemination activities;

b. Participation of the municipal tribal chieftain in the monthly BHW municipal meetings for

information dissemination and feedback on project activities; c. Participation of the NCIP Provincial Officer and the President of the Provincial Federation of

Tribal Councils of Sorsogon in the quarterly BHW Officers meetings for information dissemination and feedback and project activities;

d. Inclusion of the NCIP Provincial Officer and the President of the Federation of Tribal

Councils of Sorsogon in the Provincial Project Management Team (PPMT); e. To the extent possible, training of IP midwives through the ladderized training program for

health workers and the training of agta trainers for the associated training modules; and f. To the extent possible, training and inclusion of IP birth attendants into the WHTs to cover

agta areas. VI. Development Activities The IPDP for Sorsogon covers the following inter-related activities: a. Client classification surveys in IP communities – Part of the preparatory activities for the

project is the conduct of client classification survey for the entire Province of Sorsogon. To

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ensure that IPs will be covered by the activity, coordination shall be made by the survey team with the tribal chieftains on the scope and schedule of the interviews. Outcome of the survey will likewise be communicated back to the chieftains for validation. The survey report shall include a separate section on the IP households and women covered to enable the project team to obtain a clearer view of the current situation of the IPs and be able to track progress or changes.

b. PhilHealth Enrollment and Orientation for IPs – Based on the validated listing of indigents in

the Province, the respective municipal local government units shall cause the enrollment of all indigent IP households with the PhilHealth’s Indigent Program. Tribal chieftains will likewise be oriented on basic documentary requirements of PhilHealth e.g. marriage certificates, birth certificates so that these can be disseminated to their constituents. For those lacking the required documentation, the concerned Municipal LGU shall provide the required assistance to obtain such. Both the Municipal Health Offices and the Municipal tribal chieftains shall keep a listing of IPs covered by the PhilHealth and provide timely feedback to the PhilHealth on changes, updates, availment or issues related to this program. In coordination with the respective tribal chieftains, orientations and feedback consultations on PhilHealth shall be conducted by the assigned WHT in all the IP communities. PhilHealth representatives will also join the orientations to provide timely information and decisions.

c. Organizing of Women’s Health Teams and Focal Points for IP communities – A core strategy

of the WHSMP2 is the formation of a WHT for each barangay. The WHT shall be headed by a midwife, and supported by BHWs and traditional birth attendants. All WHTs covering barangays with agta communities, as well as key CEmOC and BEmOC staff, will undergo an orientation on the IP situation and practices relevant to the project in order to improve their cultural sensitivity towards the IPs. IP traditional birth attendants shall be recruited to the WHT especially in far-flung sitios of the Barangay. WHTs shall assist expectant IP mothers in preparing and implementing their respective birth plans, conduct information-education activities and help provide prenatal, childbirth and postnatal assistance. Activities of the WHTs in IP communities shall be coordinated with the respective tribal chieftains in order to improve participation and involvement of the community. Tribal chieftains shall also be invited in the monthly BHW or WHT meetings at the municipal level to obtain feedback and input on the WHT activities in IP areas.

d. Training of IP midwives – Funds shall be sourced for the activation of the ladderized training

for health workers to cover both tuition and miscellaneous expenses of eligible IP scholars to take and complete a degree in midwifery. The scholarship support shall be supplemented by the NCIP Provincial Office through its regular scholarship support. The trained IP midwives would then be recruited as member of the WHT or shall be assisted in obtaining PhilHealth accreditation or right to practice in health facilities.

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e. Organization of IP-WH groups – The Provincial Health Team shall organize IP-WHSM groups that would undertake group activities aimed at developing mechanisms for providing additional support to expectant IP mothers and their households and encourage IPs to save in preparation for childbirth. The Provincial Health Nurse, who has had previous experience in organizing women’s groups under WHSMP, will take the lead in this effort.

f. Health Education in IP communities – Information education on birth planning, health

support services, fertility management, basic preventive health care and related topics shall be extended to IP communities as part of the general BCC activities under the project. Both husbands and wives shall be targeted for the BCC given the strong influence of the husbands on fertility management and key role in encouraging and allowing facility-based delivery. Tribal chieftains and IP-representatives in the WHTs shall be consulted in the design and execution of training and IEC modules and protocols intended for IP audience to improve impact and take into account the cultural applicability and acceptability of such modules and protocols. Impact of these IEC and training activities shall be tracked through the population or client surveys to be conducted throughout the project and feedback from the tribal chieftains during the monthly BHW or WHT meetings.

g. Establishment and identification of Temporary Shelter - To encourage more IP women to

give birth in a facility, the Provincial Project Coordination Committee will explore various options for providing temporary shelter to the expectant mother and her immediate family near the BEmOC or CEmOC. Temporary shelters can be a “dormitory-like” facility in the BEmOC facility where cooking and other household chores can be done, or houses of relatives or fellow tribes situated near the birthing facility that will be identified as part of the birth plans of the expectant mothers.

VII. Implementation Arrangement The implementation arrangement for the IPDP for Sorsogon will follow the overall project management organization of WHSMP2 and build on existing NCIP institutional arrangements and mechanisms in the province and municipalities. The Federation of Tribal Councils of Sorsogon, the municipal tribal chieftain and the tribal leadership shall be mainstreamed into the overall project activities. The DOH Unified Project Management Office (UPMD) shall exercise overall project supervision. The WHSMP Project Management Office organized under the UPMD shall be responsible for the day-to-day administration and monitoring of the project activities, including those that are IPDP-related. The CHD-Bicol shall handle the coordination with the Provincial LGU. At the provincial level, the Provincial Governor assumes general responsibility over project implementation. However, the Provincial Health Officer (PHO) shall be the primary locus of IPDP implementation. Being the overall project coordinator for the project at the provincial level, the PHO shall provide technical direction and administrative facilitation to implementation activities. Under the PHO is the Project Coordination Committee that will help in the day-to-day project administration. The PHO shall also be assisted by the Provincial Project Management Team (PPMT) in the crafting of policies and assist in the general directions for the implementation activities, including those related to the IPDP. The NCIP Provincial Officer and the President of the Provincial Federation of Tribal Councils shall be invited to the PPMT to provide advise and feedback on policies and implementation of activities pertaining to the IPDP.

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At the municipal level, Municipal tribal chieftains shall be invited in both the Municipal Project Coordination Committee meetings and the BHW monthly meetings to provide feedback and advise on IPDP related concerns. In barangays with IP communities, activities of the WHTs shall be coordinated closely with the concerned tribal chieftains to ensure that these are properly communicated to the IP households and are culturally appropriate.

Figure 1 : Institutional Arrangement for IPDP Implementation (Province of Sorsogon)

WHTs WHTs WHTs

NCIP/Federation of IP

Tribal Councils

Mun Mun Tribal Chieftains Tribal

Chieftains DOH Reps Mun

LGUMun LGU

Mun LGU

Project CoordinationCommittee

PHT PUPMT Provincial Health Officer

DOH CHD V

PHIC Regional Field Office

Provincial Governor

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VIII. Implementation Schedule Since the IPDP is integrated into the overall project design, its implementation shall follow the over-all schedule of activities of the project in Sorsogon. MONTH

Activities 1 2 3 4 5 6 7 8 9 10 11 12 Orientation/preparation

Client classification surveys

PhilHealth enrollment and orientation (continuous)

Organizing and orientation of WHTs

Training of IP midwives

Community grant scheme for organized IP-WHSM groups

IEC for IP groups

ID/establishment of temporary shelter

Progress reporting/ monitoring (monthly)

Special studies

Population surveys

IX. Monitoring and Evaluation Monitoring of project impact on the agtas shall be carried out through the following: a) Review by the DOH-CHD Bicol, and DOH-PMO of the IPDP progress as integrated in the

semi-annual progress reports by the Provincial Project Coordination Committee b) Conduct of a population and facility based surveys that will be carried out at various stages of

the project to track implementation progress and effectiveness. The survey shall have IP categories to ensure that responses of IPs covered in the survey are properly reflected in the results. The sampling methodology will include a subset to cover the IP population in the province.

c) Special studies to be conducted during the midterm review of the project to provide further

insight into the impact on the health situation and practices of agta women in the province. d) On a more regular basis, monitoring will be done through the participation of the tribal

chieftains in the BHW monthly meetings, and NCIP’s participation in the PPMT and in the quarterly BHW Officers meetings. Feedbacks and inputs on IP-related concerns shall be properly documented in the minutes of meetings and reports.

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X. Cost Estimates and Financing Plan

Activities Expense Items Amount (PhP)

(per Municipality) Approximate Cost

for 6 Municipalities Orientation/preparation Meetings + transpo 20,000 120,000 Client classification surveys

Meetings (actual survey expenses) + Reporting/feedback

30,000

180,000

PhilHealth enrollment and orientation

Validation/orientation Enrollment expense

25,000 (average for each of the 6 muns. with 12,000 IPs)

150,000

Organizing/orientation of WHTs

Training/orientation 40,000 240,000

Training of IP midwives Training/orientation 60,000 360,000 Community grant scheme for organized IP WHSM groups

Organizing of IP WHSM groups Community subgrant

120,000

200,000

720,000

1,200,000 IEC for IP groups Trainings/seminars 60,000 360,000 ID/establishment of temporary shelters

Accommodations, transport & living assist.

40,000

240,000

Progress reporting/ monitoring

Documentation and research + materials

60,000

360,000

Special studies Meetings, research and transportation

50,000

300,000

Population surveys Meetings, survey, research & transpo.

60,000

360,000

Note: 1. The above cost estimates are cross-referenced with the suggested implementation schedule of this document 2. The 6 municipalities in Sorsogon have varying population sizes, the above cost estimates can be reallocated to optimize the budget

(During the workshop, the following cost estimates were made (considering 6 municipalities):

TEV (transportation) 800+300= 1,100/day (upland and lowland trips) 1,100/day X 20 working days/month= 22,000/month 22,000/month X 6 municipalities= 132,000/month

Other Logistics (training) 7,000 X 6 municipalities= 42,000 Meals/Snacks (per year) 60,000 X 6 municipalities= 360,000 Hiring of Community Organizers 250/day X 24 working days/month= 6,000/month

6,000/month X 4 months work= 24,000/person 24,000 X 6 municipalities= 144,000 144,000 X 5 barangays/municipality= 720,000

Small-grant Scheme 500 (services) 200,000/community proposal X 6 municipalities= 1.2 M

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ANNEX A

WHSMP2 Workshop Participants

August 2-3, 2004 Villa Isabel, Sorsogon City

Name of Participants Position Held Place

Barangay Chieftains/Barangay Council 1. Flaviano Deuna Chieftain Bulawan, Prieto Diaz 2. Milagros Musa Chieftain, Agta-Cimaron Dancalan, Donsol 3. Rebecca Prihago Tribal Organization Secretary-

Agta-Tabangnon Sta. Fe, Pilar

4. Noel delos Santos Barangay Council San Rafael 5. Barbara Chua Barangay Secretary San Rafael 6. Florcita Domo Barangay Council Ulag, Prieto Diaz 7. Ronnie Begardon Youth Leader Agta-

Tabangnon Dancalan, Donsol

• IP Barangay Health Workers/ Barangay Nutrition Scholar 8. Delia Ortico BHW Agta Tabangnon Mabini, Donsol 9. Nimfa Hernandez BHW Agta-Tabangnon Ogod, Donsol 10. Alicia Pura BHW Naburacan Matnog 11. Julie Garelde BHW/BNS Naburacan, Matnog

• Local Government Unit 12. Edgar Garcia Provincial Health Officer Sorsogon 13. Thelma Evita Gillego PHN I PHO Sorsogon 14. Nena Esteves Nurse IV PHO Sorsogon 15. Maria Priscilla Fajardo WHSMP2 Coordinator PHO Sorsogon 16. Ronald Lim Municipal Health Officer IV PHO Sorsogon 17. Ruth Villanueva Nurse I RHU Bulusan

• DOH and WB Representatives 18. Divina Dawal DOH-CHD Bicol Region 19. Raquel Faustino DOH-CHD Bicol Region 20. Tito Nicolas World Bank Operations

Manager

• Other Stakeholders 21. Lourdes Combao Provincial NCIP Sorsogon 22. Silverio Garcia CHO-I Provincial NCIP Sorsogon 23. Aida Teves Provincial OIC- Philhealth Sorsogon