The Family Health Book - UPecon Foundation

The Family Health Book

Aleli D. Kraft, Jhiedon L. Florentino, Rhodora A. Tiongson, and Orville Solon, editors

Aleli D. Kraft, Jhiedon L. Florentino, Rhodora A. Tiongson and Orville Solon, editors


Published by the UPecon-Health Policy Development Program (HPDP), School of Economics, University of the Philippines Diliman, Quezon City, Philippines. Telephone: +632 927-9686 loc 322. E-mail: [email protected]. April 2012.

The mention (if any) of specific companies or of certain manufacturer’s products does not imply that they are endorsed or recommended by the publisher in preference over others of a similar nature. Articles may be reproduced in full or in part for non-profit purposes without prior permission, provided credit is given to HPDP and/or the individual authors for original pieces. A copy of the reprinted or adapted version will be appreciated.

Suggested Citation:

Kraft, A.D., J.L. Florentino, R.A. Tiongson, and O. Solon eds. The Family Health Book. Quezon City, UPecon-Health Policy Development Program, 2012.

This volume was made possible by the support of the American people through the U.S. Agency for International Development (USAID) to the UPecon-Health Policy Development Program under the terms of Cooperative Agreement No. 492-A-00-06-00031. The contents of this volume are the sole responsibility of the authors and do not necessarily reflect the views of the USAID, UPecon Foundation Inc., and the Department of Health (DOH).

Style editing: Wystan de la Peña

Cover design and lay-out: Giselle de la Peña and Judith Camille Rosette

Cover photos courtesy of Maria Gracia Alcantara and the Provincial Health Office of Compostela Valley

Acknowledgements

The UPecon-Health Policy Development Program (HPDP) would like to express its deepest appreciation to the province of Compostela Valley, headed by Governor Arturo Uy, for support in the implementation of the FHB Operations Research.

We would also like to acknowledge the officers and staff of the Compostela Valley Provincial Health Office, DOH-CHD 12, and PhilHealth Regional Office 12 for their invaluable support. The assistance and efforts of Dr. Alexis Cayoca, Dr. January Yabut, and Ms. Cheryl Osorio in running the operations research are also acknowledged.

Table of Contents

LIST OF TABLES 7

LIST OF FIGURES 17

LIST OF ABBREVIATIONS AND ACRONYMS 18

EDITORIAL OVERVIEW 21

1 THE FAMILY HEALTH BOOK OPERATIONS RESEARCH DESIGN 24

Abstract 24

What problems are the FHB trying to solve? 25

What causes can and cannot be affected by FHB interventions? 26

What critical set of services will be promoted by the FHB? 32

What family level barriers to the utilization of critical services can and cannot be influenced by the FHB? 37

What gaps and bottlenecks in the delivery system can and cannot be influenced by the FHB? 39

What are FHB interventions? 48

How will we measure changes due to FHB interventions? 64

How can we validate if observed changes can be attributed to the FHB? 81

What instruments and activities will be conducted to measure observed changes and validate that these changes are due to the FHB?

85

How will the FHB pilot be implemented? 96

How will the FHB pilot be managed? 104

Inter-CA collaboration on FHB 106

References 112

Appendix 1. Log frame of FHB interventions by intermediate outcome 115

Appendix 2. Summary Listing of Forms, Process Flow, and Timing of Collection 141

2 “GIYA SA MAAYONG PANGLAWAS”: THE FAMILY HEALTH BOOK IMPLEMENTATION IN COMPOSTELA VALLEY 144

Abstract 144

Introduction 145

FHB field testing 146

Listing of families 151

Navigator recruitment, training and development 154

Outreach 169

Other complementary and supporting activities 174

References 189

Appendix 1. Counts of Families 191

Appendix 2. Number of Navigators trained per barangay 197

Appendix 3. Family-Navigator Matching, by barangay 200

3 AN ANALYSIS OF THE IMPACTS OF THE FAMILY HEALTH BOOK INTERVENTIONS 204

Abstract 204

Introduction 205

Operations Research Setting 207

Methods 212

Results 222

DIscussion 235

Limitations 242

Conclusions 244

References 246

Appendix 1. Timing of Interventions in FHB municipalities 248

Appendix 2. FHB data collection efforts 250

Appendix 3. Logit runs: MFP 251

Appendix 4. Logit runs: At least one ANC visit 252

Appendix 5. Multinomial logit: SBA at facility 253

Appendix 6. Logit runs: FIC 254

4 BASELINE FAMILY HEALTH BOOK (FHB) SURVEY DOCUMENTATION REPORT 255

Abstract 255

Background 256

Description of the FHB Baseline Survey 258

Highlights of the FHB Household Survey 270

Highlights of Health Provider Survey 298

Highlights of Health Facilities Survey 314

Highlights of Patient Exit Survey 343

ABOUT THE AUTHORS AND EDITORS 372

List of Tables

1The Family Health Book Operations Research Design

Table 1.1 Indicators of Service Use by Wealth Quintile 31

Table 1.2 Number of facilities offering specific services, Compostela Valley

41

Table 1.3 Average score for vignettes, Compostela Valley 43

Table 1.4 Average patient satisfaction, Compostela Valley 44

Table 1.5 Average case load, Compostela Valley 45

Table 1.6 Indicator levels and corresponding health risks 50

Table 1.7 Measures of maternal, infant, and child deaths 64

Table 1.8 Interventions and Barriers Addressed, by Intermediate Outcomes

66

Table 1.9 Measures of intervention inputs received by unintended beneficiaries

71

Table 1.10 Measures and baseline data sources of environmental HH factors outside the control of FHB interventions

74

Table 1.11 Baseline education and income profile of households in Compostela, Mabini, Maco, and Montevista

76

Table 1.12 Measures and data sources of provider factors not covered by the FHB interventions

78

Table 1.13 Measures of other environmental factors not related to the household and providers that are outside the control of the FHB interventions

80

Table 1.14 Schedule of implementation of FHB interventions 83

Table 1.15 Benchmarks and timelines for October 2008-June 2010

100

8

2“Giya sa Maayong Panglawas” The Family Health Book Implementation in Compostela Valley

Table 2.1 Reasons for Family FHB Format 149

Table 2.2 Number of Families Targeted and Given Books 154

Table 2.3 Number of navigators trained 156

Table 2.4 Family-Navigator Matching 157

Table 2.5 Tally of Families by FHB Process 160

Table 2.6 Number of Families and Health Use Plans, as of August to September 2009 tally

161

Table 2.7 Number of Families and Health Use Plans, as of April to June 2010 tally

162

Table 2.8 Number of Families and MFP use 164

Table 2.9 Use of Modern FP of non-pregnant mothers, With RH Plan vs No RH Plan

164

Table 2.10 Number of pregnant mothers who delivered during FHB

165

Table 2.11 Use of Skilled Birth Attendance With Birth Plan vs No Birth Plan

165

Table 2.12 ANC use among mothers who were pregnant during the FHB

166

Table 2.13 With at least one ANC With Birth Plan vs No Birth Plan

166

Table 2.14 FIC among number of infants needing immunization

167

Table 2.15 FIC rates, With and Without Well Baby Plan 167

Table 2.16 Number of families accessing planned services from outreach

173

9

Table 2.17 FHB Developmental Costs 181

Table 2.18 FHB Pilot Implementation Costs 183

Table 2.19 Costs of FHB Operations Research 186

Table 2.20 Total Costs of FHB Implementation 188

Table 2.21 Estimated Unit Costs of Roll-Out 188

3An Analysis of the Impacts of the Family Health Book Interventions

Table 3.1 Descriptive statistics of variables use of any modern family planning method

223

Table 3.2 Marginal effects of regression runs on utilization of any modern FP method (MFP)

224

Table 3.3 Descriptive statistics of variables ANC 227

Table 3.4 Marginal effects of regression runs on utilization of at least one ANC

227

Table 3.5 Descriptive statistics of variables SBA 230

Table 3.6 Marginal effects of FHB interventions on SBA 231

Table 3.7 Descriptive statistics of variables FIC 233

Table 3.8 Marginal effects of regression runs on FIC 233

4Baseline Family Health Book (FHB) Survey Documentation Report

Table 4.1 Sample barangays and number of sample households per municipality

260

Table 4.2 Vignettes and number of respondents for the health provider survey

264

Table 4.3 Sample of facilities and number of patients 267

Table 4.4 General information of households 270

10

Table 4.5 Distribution of households according to wealth index by facility

271

Table 4.6 Distribution of families with PhilHealth membership and type of membership

272

Table 4.7 Average number of times sick, consultations, and hospital admissions

273

Table 4.8 Type of health provider visited 274

Table 4.9 Cost of consultation for all other family members

275

Table 4.10 General characteristics of index women by municipality

276

Table 4.11 Outpatient prenatal care descriptive statistics

277

Table 4.12 Distribution of index women, by facility and municipality

283

Table 4.13 Average prenatal consultation cost, by wealth quintile

283

Table 4.14 Delivery outcome, by facility 284

Table 4.15 Average delivery expense, by PhilHealth coverage

285

Table 4.16 Average delivery expenses, by wealth index 286

Table 4.17 Average delivery expense, by insurance coverage

287

Table 4.18 Average delivery expense, by facility 287

Table 4.19 Average delivery expense, by wealth index quintiles

288

Table 4.20 Fraction of index women who received postpartum care

289

11

Table 4.21a Postpartum expenditure by facility (Public) 289

Table 4.21b Postpartum expenditure by facility (Private) 290

Table 4.22 General information, index child 291

Table 4.23 Average cost of outpatient visit, index child 292

Table 4.24 Outcome of confinement by facility type 296

Table 4.25 Average length of confinement, by facility type 297

Table 4.26 Average length of confinement, by wealth index

297

Table 4.27: Average cost of confinement 298

Table 4.28 Distribution of health service providers across municipalities

299

Table 4.29a Average years of practice, by facility type 300

Table 4.29b Average years of practice, by municipality 300

Table 4.30a PhilHealth accreditation, by facility type 301

Table 4.30b PhilHealth accreditation, by facility type 302

Table 4.31a Average outpatient visits per month, by facility (hospitals)

303

Table 4.31b Average outpatient visits per month, by facility (clinics and RHUs)

303

Table 4.32 Average outpatient cases, by municipality 304

Table 4.33 Average inpatient case by facility type 304

Table 4.34 Average inpatient case load by municipality 306

Table 4.35 Average number of hours allocated by provider, by municipality

308

Table 4.36 Income distribution of health service providers by facility type

309

12

Table 4.37 Income distribution of health service providers by municipality

310

Table 4.38 Average vignette scores, by facility type 311

Table 4.39 Average vignette scores, by municipality 312

Table 4.40 Average vignette scores, by physician type 313

Table 4.41 Distribution of hospitals across Compostela Valley (including Davao Regional Hospital)

314

Table 4.42 PhilHealth accreditation, by facility type 315

Table 4.43 PhilHealth accreditation, by municipality 315

Table 4.44 Average bed capacity, by facility type 316

Table 4.45 Average bed capacity, by municipality 316

Table 4.46 Average number of health care providers present by type of facility

317

Table 4.47 Average outpatient case load and mix 318

Table 4.48 Average inpatient case load and mix 319

Table 4.49 Availability of laboratory services 320

Table 4.50 Average number of equipment present, emergency room

322

Table 4.51 Average number of equipment present, consultation room

322

Table 4.52 Average number of equipment present, delivery room

323

Table 4.53 Average number of equipment present, operating room

324

Table 4.54 Average hospital charge, by facility type 325

Table 4.55 Average hospital charge, by municipality 325

13

Table 4.56 Average hospital expenditures, by facility type

326

Table 4.57 Average hospital expenditures, by municipality

326

Table 4.58 Distribution of clinics across municipalities 327

Table 4.59 Distribution of health providers 328

Table 4.60 Average outpatient case load and mix 329

Table 4.61 Count of available lab services 329

Table 4.62 Equipment present 330

Table 4.63 Facility charge, by type of service 331

Table 4.64 Average facility expenditure, 2007 (in million pesos)

332

Table 4.65 Distribution of medical staff 333

Table 4.66 Bed capacity of birthing homes/lying-in 333

Table 4.67 Distribution of outpatient cases 333

Table 4.68 Distribution of medical equipment 334

Table 4.69 Average service charge, by municipality 336

Table 4.70 Average facility expenditures 337

Table 4.71 PhilHealth Accreditation 338

Table 4.72 Distribution of health providers 338

Table 4.73 Average case load and mix, RHUs 339

Table 4.74 Number of RHUs with laboratory services 339

Table 4.75 Average number of equipment present 340

Table 4.76 Average service charge 341

14

Table 4.77 Average facility expenditure (in million Pesos)

342

Table 4.78 Average facility expenditure, by municipality (in million Pesos)

342

Table 4.79 General characteristics 344

Table 4.80 General characteristics Facility visited for consultation

345

Table 4.81 Distribution of outpatients, by wealth quintiles

345

Table 4.82 Average household expenditures, by municipality

346

Table 4.83 Average household expenditure, by wealth quintile

347

Table 4.84 Patient’s reason for visit 348

Table 4.85 Physician visited by wealth quintile 348

Table 4.86 Average consultation cost by type of facility 350

Table 4.87 Average consultation cost, by municipality 350

Table 4.88 Average consultation costs, by patient type 351

Table 4.89 Average consultation costs, by wealth index 351

Table 4.90 Capacity to pay (average household) 352

Table 4.91 Average capacity to pay, by wealth quintiles 353

Table 4.92 Average patient satisfaction scores, by facility type

354

Table 4.93 Average patient satisfaction scores, by municipality

354

Table 4.94 Average patient satisfaction component scores, by facility type

355

15

Table 4.95 Average patient satisfaction component scores, by municipality

356

Table 4.96 Average patient satisfaction component scores, by patient type.

356

Table 4.97 General characteristics, inpatients 357

Table 4.98 Average length of confinement, by case 359

Table 4.99 Average length of confinement, by facility type

359

Table 4.100 Average length of stay, by municipality 359

Table 4.101 Average length of stay, by wealth quintile 360

Table 4.102 Average household expenditure, by municipality

360

Table 4.103 Average household expenditure, by wealth index

361

Table 4.104 Reason of confinement with attending specialist 361

Table 4.105 Attending specialists, by wealth index quintile 362

Table 4.106 Average miscellaneous costs of confinement, by municipality

363

Table 4.107 Average miscellaneous costs, by type of patient

363

Table 4.108 Average hospital charges, by type of patient 363

Table 4.109 Average hospital charges, by wealth index 364

Table 4.110 Average capacity to pay, by facility setting 365

Table 4.111 Average capacity to pay, by facility type 365

Table 4.112 Average capacity to pay, by wealth index quintiles

366

16

Table 4.113 Outcome of confinement, by facility setting 367

Table 4.114 Outcome of confinement, by facility type 367

Table 4.115 Outcome of confinement, by municipality 367

Table 4.116 Patient satisfaction score, by facility type 369

Table 4.117 Patient satisfaction, by facility 369

Table 4.118 Patient satisfaction, by type of patient 370

Table 4.119 Patient satisfaction component scores, by facility type

370

Table 4.120 Patient satisfaction component scores,by municipality

371

Table 4.121 Patient satisfaction component scores, by type of patient

371

List of Figures


Figure 1.1 Scatterplot for MMR-IMR, Philippines 2007 27

Figure 1.2 FHB Intervention Areas 36

2“Giya sa Maayong Panglawas”: The Family Health Book Implementation in Compostela Valley

Figure 2.1 Stages of Interaction of Families and Navigators 159


Figure 3.1 Predicted probabilities, MFP use 225

Figure 3.2 Predicted probabilities, at least one ANC visit 228

Figure 3.3 Predicted probabilities: SBA 232

Figure 3.4 Predicted probabilities: FIC 234

18

ANC Antenatal care AOP Annual Operational PlanARI Acute Respiratory InfectionBCC Behavior Change Communication BCG Bacillus Calmette-Guerin BHWs Barangay Health Workers BTL Bilateral Tubal LigationBOY Beginning-of-Year CA Cooperating AgencyCA Cooperating Agency CEmONC Comprehensive Emergency Obstetric and Newborn Care CHD Center for Health Development CO Capital OutlayCoNECT Compostela Network of Communications and Transport CPR Contraceptive Prevalence RateCS Cesarean Section CVPH Compostela Valley Provincial Hospital DMPA Depot Medroxyprogesterone AcetateDOH Department of Health DOTS Directly Observed Treatment, Short-Course DPT Diphtheria Pertussis Tetanus EM Emergency Transport and CommunicationEmONC Emergency Obstetric and Neonatal Care EOY End-of-Year FCS Family Call SheetsFGD Focus Group DiscussionFHB Family Health Book FHSIS Field Health Service Information System FIC Fully Immunized Child FP Family Planning FPS Family Planning SurveyGP General PractitionerHH Household HPDP Health Policy Development Program HUP Health Use PlanIEC Information and Education Campaign

List of Abbreviations and Acronyms

19

IMCI Integrated Management of Childhood IllnessesIP Inpatient IRA Internal Revenue Allotments KII Key Informant InterviewsKSFI Kinasang’an Foundation IncorporatedLCEs Local Chief Executives LGU Local Government Unit MCP Maternal Care Package MFP Modern Family PlanningMHO Municipal Health Office/rMNCHN Maternal, Neonatal and Child Health and NutritionMOOE Maintenance and Other Operating ExpensesNSO National Statistics OfficeNDHS National Demographic and Health SurveyOH Office of HealthOB-Gyn Obstetrician-GynecologistOP OutpatientOPB Outpatient Benefit PackageOPV Oral Polio Vaccine OR Operations Research ORS Oral Rehydration Salts PHO Provincial Health Office/rPhP Philippine PesoPHS Philippine Health StatisticsPNC Prenatal CarePPC Postpartum CarePRO PhilHealth Regional OfficePS Personal Services RH Reproductive HealthRHM Rural Health MidwivesSBA Skilled Birth Attendants SDExH Service Delivery for Excellence in HealthTB TuberculosisTBA Traditional Birth AttendantsTEV Travel Expense Voucher

20

TT Tetanus ToxoidTWG Technical Working GroupUNICEF United Nations Children’s FundUSAID United States Agency for International DevelopmentUTI Urinary Tract InfectionWHO World Health Organization

21

EDITORIAL OVERVIEW:


The Family Health Book (FHB) is a behavior change package of interventions which aims to improve utilization of critical services to reduce the risk of maternal and child morbidity and mortality. The FHB was conceived in response to the observation that while the direct causes of maternal and child mortality are clinical in nature, the likelihood of dying from these causes are amplified by the risks of having mistimed and unplanned pregnancies and inadequate antenatal care, of lacking skilled birth attendance during and after delivery, and of low immunization rates among children.

These risks are mitigated through the utilization of critical Maternal, Neonatal and Child Health and Nutrition (MNCHN) services at the pre-pregnancy, pregnancy, delivery, and early childhood phases. FHB interventions thus aim to lessen these risks by addressing at least some family-level barriers to using health services, including the lack of information on what services to access, where and how these services can be accessed, and the means through which these services can be financed, as well as the lack of logistical support to accessing care.

The FHB Operations Research was designed to

(1) establish evidence on whether FHB interventions result in more utilization of MNCHN services and

(2) guide the refinement of specific interventions proven to have positively contributed to increased utilization, before such approaches are recommended for adoption by the Department of Health (DOH) and Centers for Health Development (CHDs).

This volume thus describes the design, implementation, and results of the FHB Operations Research.

22 The Family Health Book

The first article in this volume describes the FHB Operations Research design. It starts with the identification of the barriers that prevent the utilization of critical MNCHN services and details of FHB interventions that seek to address those barriers, to wit:

(1) Provision of information through a “Book” and deployment of “Navigators” to assist families and reinforce information from the book;

(2) Creation of emergency transportation and communication networks; and

(3) Organization of outreach activities which are described in detail.

The article also outlines the methodology for measuring and evaluating the impact of the initiative on key process and intermediate outcome indicators.

The second article in this volume reports on the implementation of the Family Health Book Operations Research (OR) in the province of Compostela Valley. The Family Health Book is known locally as Giya sa Maayong Panglawas. The results of field testing of the book prototype and the family-navigator interaction are described, and revisions on the form of the book, the Navigator’s Kit, and training modules are discussed. Discussion of the highlights of the implementation of each of the interventions, including adjustments made as field operations commenced, follows. Results of monitoring activities, specifically on indicators of input and FHB processes, are then reported, supplemented by results of qualitative assessments.

The third article in this volume presents the methodology for assessing the operations research’s impacts and results. The article begins, by recalling the OR setting and interventions, before detailing data sources and the multivariate models estimated to show the impacts.

The article also reports on the positive impact of FHB interventions on modern family planning (FP) use, antenatal care visits, skilled birth attendance, and immunization of children. For modern family

23

planning (MFP) and skilled birth attendance (SBA), the provision of key information through the Book and the Navigator resulted in increased utilization further amplified by the development of appropriate health use plans (HUPs).

In the case of antenatal care (ANC), the impacts manifested only when appropriate HUPs were developed in response to the information provision. These results suggest that providing key information through a physical medium, supported by personalized guidance and assistance from Navigators that eventually result in families developing plans to address their health risks, are effective in addressing informational barriers to utilization of key MNCHN services.

The Family Health Book Baseline Surveys provided critical information that aided in designing FHB interventions and the operations research, and analyzing its findings. Conducted in Compostela Valley in 2007-2008, the surveys consisted of household, patient exit, and facility surveys that provided baseline information on Compostela Valley residents’ health-seeking behavior and the barriers to care they faced.

The fourth article in this volume describes the surveys’ methodology, the instruments, and summary statistics.

The FHB operations research revealed that provision of information through the Book and Navigators allowed families to understand their health risks and act on them. Subsequently, this informed the development of the DOH Maternal, Neonatal, and Child Health and Nutrition (MNCHN) Strategy Manual of Operations (MOP), and in particular, the definition of the roles and functions of Community Health Teams (CHTs).

CHT navigational functions have been patterned largely after those of the FHB Navigator. In turn, Administrative Order (AO) 2010-0036, “The Aquino Health Agenda: Achieving Universal Health Care for All Filipinos,” provides for the deployment of such CHTs that shall actively assist families in assessing and acting on their health needs. Specific targets for the training and deployment of CHTs are specified in Department Order (DO) 2011-0188, “Kalusugang Pangkalahatan: Execution Plan and Implementation Arrangements.”

24

1 The Family Health Book Operations Research Design

Health Policy Development Program (HPDP)UPecon Foundation Inc. 1

Abstract1

The decline in the maternal and child mortality rates in the Philippines has slowed down over the past few years. While maternal and child mortality can be tied up with direct or clinical causes of death, the likelihood of dying from these causes are amplified by four risks:

1) mistimed and unplanned pregnancies; 2) inadequate antenatal care; 3) lack of skilled birth attendance during and after delivery; and 4) low immunization rates among children.

The Family Health Book (FHB) provides families with information and support mechanisms to access MNCHN services. Information is given through a “Book” and a health “Navigator.”

The Navigator assists families

• on how to use critical information contained in the book, such as health risks and action messages, health emergency contacts, and PhilHealth benefits and availment procedures; and

1 The following contributed to the development of the FHB Operations Research design: Orville Solon, Mary Anne Lansang, Carlo Panelo, Rhodora Tiongson, Jocelyn Ilagan, Aleli D. Kraft, Jhiedon Florentino, Maria Gracia Alcantara, Donabelle de Guzman, Ruth Francisco and Loyd Brendan Norella.


• how to address their health risks through the development of health use plans.

To facilitate physical access of families to these providers, setting up an emergency transport and communication (EM) network is included among the FHB interventions. The conduct of regular and targeted outreach services is one innovative approach to service delivery in far-flung areas with limited or no access to health providers. .

The Family Health Book (FHB) Operations Research intends to establish evidence on the effects of FHB interventions on the use of services deemed critical to reducing maternal and infant deaths–modern family planning (FP) use, antenatal care visits, safe deliveries, and full immunization of children. The province of Compostela Valley was chosen as the operations research site because of its high maternal and infant mortality despite the presence of basic service delivery structures.

This paper discusses the framework, design, and interventions of the FHB operations research and describes the methodology for measuring and evaluating the impact of the initiative on modern family planning use, antenatal care visit, facility-based delivery, and full immunization of children. It also describes the governance and monitoring arrangements for the field-level implementation of the operations research.

What problems are the FHB trying to solve?

In light of the high incidence of maternal and child mortality in the Philippines, FHB interventions are intended to promote and ensure access to life-saving services. In 2006, 162 mothers died per 100,000 live births and 32 children died per 1,000 live births (NSO, 2007). Around three out of four of these under-five deaths are due to infant mortality (24 per 1,000 live births, of which 13 are neonatal deaths). In the 2007 maternal and child death review for Compostela Valley, a total of 24 mothers and 75 under-five deaths were reported. Of these deaths, 27 were infants (36%) and eight (11%) were newborns.


The rate of decline in maternal and infant mortality indicators has also slowed down in the past 10 years, resulting in wide variations in outcomes across income groups and localities in the country (Figure 1.1).

The need to rapidly reduce maternal and child mortality cannot be overstated, as these indicators serve as sensitive indices of performance and equity in any health system. Furthermore, mothers’ and children’s welfare are critical to overall development due to inter-generational impact on human capital development, which in turn is required for families to escape the poverty trap.

What causes can and cannot be affected by FHB interventions?

Direct causes of maternal and child mortality

The direct causes of maternal mortality arise from complications associated with hypertension (28%), postpartum hemorrhage (17%), and complications from abortion (8%) (PHS, 2004). The rest of the direct causes of maternal deaths are due to infection (sepsis) and obstructed labor (DOH, 2005).

Most maternal deaths occur during or within 24 hours after childbirth. In Compostela Valley, most maternal deaths were due to hypertension (33%), followed by hemorrhage (25%) and sepsis (25%). The average age at death of mothers in Compostela Valley was 29 years (range of 15 to 43) (Compostela Valley Provincial Health Office, 2007).


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Leading causes of under-five mortality include pneumonia, accidents, acute gastroenteritis, measles, and congenital anomalies (DOH, 2004). Of the 75 reported child deaths in Compostela Valley, diarrhea accounted for 25%; pneumonia, 21%; and accidents, 13%. The average age at death for under-five children was 1.9 years (Compostela Valley Provincial Health Office, 2007).

On the other hand, common causes of infant death include sepsis, respiratory distress of the newborn, pneumonia, disorders related to prematurity and low birth weight, congenital pneumonia, and congenital malformations (DOH, 2004). Most neonatal deaths occur within the first two days of life (WHO, 2000).

In Compostela Valley province, 48% and 30% of the 27 infant deaths reported were due to diarrhea and pneumonia, respectively. Half of the eight reported neonatal deaths were due to birth asphyxia while another 40% were due to congenital conditions (Compostela Valley Provincial Health Office, 2007).

Risk factors leading to maternal and child mortality

While the direct causes of maternal and child mortality are clinical in nature, the likelihood of dying from these conditions is amplified by four risks:

1. The risk of having a mistimed and unplanned pregnancy. Half of the estimated three million pregnancies that occur each year can be considered mistimed and unplanned. Mothers who have mistimed and unplanned pregnancies are less likely to avail of antenatal services and skilled attendance during delivery (NSO and ORC Macro, 2004). Unwanted and mistimed pregnancies are also more likely to be terminated by induced abortion.


In Compostela Valley, only one out of four women practiced modern family planning and almost one out of three births was said to be mistimed and unplanned -- despite the expressed desired spacing interval of 4.5 years. This highlights the substantial unmet need for family planning and the risk of mortality (HPDP, 2007b).

2. Inadequate and poor quality care. Once pregnant, the woman and her fetus face the risk of inadequate and poor quality care during the course of the pregnancy.

Nearly half of pregnant women suffer from iron deficiency anemia, a fourth are considered undernourished, and a fifth lack vitamin A. On the average, only 70% of mothers would have at least four prenatal visits during the course of the pregnancy (NSO and ORC Macro, 2004).

In Compostela Valley, only 45% of mothers had at least three antenatal care (ANC) visits. There is a large variation in quality of care among providers serving the province (HPDP, 2007a).

3. Delivery without skilled birth attendants (SBA). Home deliveries, attended mostly by traditional birth attendants (TBAs), currently account for 63% of deliveries in the country (NSO and ORC Macro, 2004).

In Compostela Valley, home-based TBA births account for nearly 70% of all deliveries. According to the Compostela Valley Maternal Death Report, all births that led to maternal deaths were initially managed at home by TBAs.


Home-based TBA births are risky because the non-sterile home environment increases the likelihood of infections. In addition, the TBA may not be able to promptly handle and refer complications like excessive bleeding and fetal distress to trained medical practitioners. Delivering mothers in home-based TBA birth settings usually do not have ready access to Comprehensive Emergency Obstetric and Neonatal Care (CEmONC) services in the event of complications.

4. Absence of child survival services. Child survival include promotion of and support for exclusive breastfeeding for at least six months, and immunizations and other services included in the Integrated Management of Childhood Illnesses (IMCI) strategy. In Compostela Valley, the fully-immunized child (FIC) rate was only 83% (DOH, 2007), way below the national target of 95% (HPDP, 2007b).

The magnitude of these risks increases across socio-economic groups and varies with other structural factors. Poor mothers were around three times less likely to avail of SBA services during delivery compared to those in the highest income quintile (Table 1.1). Moreover, children from poor families were less likely to complete their immunization schedule compared to those in the richest quintiles (NSO and ORC Macro, 2004).


Table 1.1: Indicators of Service Use by Wealth Quintile

Wealth Quintiles (in %)

Lowest 2nd 3rd 4th HighestLow/High

2003

Full basic coverage of childhood immunization

55.5 69.3 77.8 72.4 83 0.67

No basic coverage of childhood immunization

15.1 5.9 5 3.9 2.2 6.76

Delivery attendance by a medically trained person

25.1 51.4 72.4 84.4 92.3 0.27

1998

Full basic coverage of childhood immunization

59.8 72.5 76.3 79.6 86.5 0.69

No basic coverage of childhood immunization

16.4 8.7 3.6 2.4 1 16.4

Delivery attendance by a medically trained person

21.2 45.9 72.8 83.9 91.9 0.23

Source: Gwatkin, et al.(2007)

The FHB initiative will help address the direct causes of maternal and child deaths by ensuring that mothers and children get to access critical MNCHN services appropriate at the different stages of the life cycle (i.e., pre-pregnancy, pregnancy, delivery, and early childhood). In particular, FHB interventions aim to mitigate the four risks outlined above, mainly by addressing some family-level barriers to accessing these services.

These barriers include the lack of information on what services to access, where and how these can be accessed, and the means through which the services can be financed, as well as the lack of logistical support to accessing care. The FHB initiative will not address health system barriers that prevent access and utilization of the critical set of MNCHN services, such as insufficient budgets allocated to health care.


What critical set of services will be promoted by the FHB?

FHB interventions seek to improve utilization of a critical set of MNCHN services accessed as a package, reflecting the continuum of care from pre-pregnancy, pregnancy, delivery and postpartum, to neonatal and early childhood. Efforts to increase utilization will focus on a core set of critical services identified to have the greatest impact on maternal and child mortality based on best available evidence and accepted standards of practice (Habana, Mantaring, et al., 2008).

Modern Family Planning

Use of modern family planning methods can prevent mistimed and unplanned pregnancies which contribute to maternal mortality by unnecessarily increasing fertility rates. Fertility reduction has been identified as the most cost-effective intervention in preventing maternal and infant mortality in Bangladesh (NIPORT et al., 2003).

Furthermore, mistimed and unplanned pregnancies also decrease the likelihood of availing of antenatal care services and skilled attendance during deliveries, thus increasing the risk of complications and death. The following modern family planning methods shall be promoted by the FHB:

1. lactational amenorrhea method; 2. temperature or thermometer method; 3. cervical mucus method; 4. sympto-thermal method; 5. standard days method; 6. oral contraceptive pills;7. condom; 8. injectable hormones or DMPA; 9. intrauterine device; 10. bilateral tubal ligation (a permanent

method); and 11. non-scalpel vasectomy (a permanent

method).


Antenatal Care (ANC)

ANC services help avoid missed opportunities in providing a set of services aimed at preventing maternal morbidity and infant mortality. In the course of undertaking at least four ANC visits, the mother needs to at least receive the following interventions:

1) counseling on danger signs;

2) tetanus immunization to prevent maternal and neonatal infections;

3) micronutrient supplementation, such as iron (to prevent anemia) and folate (to prevent congenital malformations in the fetus);

4) screening for complications that will require early referral to specialized care facilities; and

5) planning for SBA during delivery.

While prevailing evidence downplays antenatal care’s role in maternal mortality reduction, it remains distinctly clear that components of prenatal care remain effective in reducing perinatal deaths (Bale et al., 2003).

Safe Delivery and Postpartum Care

Access to SBA during deliveries, including Comprehensive Emergency Obstetric and Newborn Care (CEmONC) services, addresses most direct causes of maternal and infant mortality (Campbell and Graham, 2006).

Delivery by non-skilled attendants hampers early detection of complications, referral to higher facilities, and early treatment of complications, thus increasing the risk of death.


Furthermore, improper postpartum and postnatal care also contribute significantly to increased maternal and neonatal morbidity and mortality. The following interventions crucial to reduce maternal deaths should be part of health providers’ protocols:

1) active management of the third stage of labor using oxytocin and proper cord traction;

2) use of antibiotics in prolonged labor or prolonged rupture of membranes;

3) use of the anticonvulsant magnesium sulfate;

4) use of partographs for monitoring progress of labor;

5) post-abortion care, including removal of retained products of conception, treatment of infection, correction of anemia, and anti-tetanus injections; and

6) administration of steroids for pre-term labor.

Newborn and Early Childhood Care

Reducing neonatal mortality requires the following procedures:

1) neonatal resuscitation;

2) STABLE (sugar, temperature, artificial breathing, blood pressure, laboratory work, and emotional support);

3) delayed cord clamping;

4) early latching on;


5) Routine newborn care (cord care, thermoregulation, weighing of the infant, application of erythromycin eye ointment, administration of vitamin K, hepatitis B vaccination, BCG vaccination); and

6) advanced pediatric life support.

Vaccine-preventable diseases like measles, polio, diphtheria, pertussis, tetanus, tuberculosis, and Hepatitis B can be fatal, but are preventable through vaccination. In countries where fully–immunized child (FIC) rates are low and herd immunity is not achieved, these diseases account for a significant cause of morbidity and mortality, aside from neonatal causes.

Other causes of child mortality, such as acute respiratory infections, benefit from early detection, referral, and antibiotic treatment. Acute gastroenteritis is highly preventable through breastfeeding, proper hygiene, and use of oral rehydration salts (ORS).

Other necessary services will still be implemented subject to the local health systems’ capacity to provide. A critical list of services was disseminated to providers and served as basis for developing the vignettes to assess for quality of care during the facility survey at baseline. Figure 1.2 shows how core FHB interventions relate with the rest of MNCHN and related interventions addressing maternal and child mortality.


Figu

re 1

.2.

FHB

Inte

rven

tion

Are

as


What family level barriers to the utilization of critical services can and cannot be influenced by the FHB?

Barriers to families’ utilization of health services significantly contribute to poor health outcomes. Even where health facilities, services, and supplies are available, many families do not use appropriate services because

• they do not recognize health risks; • they do not know the services they need, • they do not know where these services are available, • they do not know how to finance their access to these services.

Data from Compostela Valley illustrate examples of these barriers.

Lack of knowledge on risks and conse-quences

Information from focus group discussions (FGDs) from Compostela Valley illustrates the importance of cultural factors and the possession of information on the risks and consequences related to providers and services (HPDP and SDRC, 2008; Acuin, 2008).

FGD results show that only about one in every three reproductive-age women practiced modern family planning. More than half of those who did not were afraid of side effects. One out of ten was not aware of family planning. Close to half of pregnant participants did not undergo at least three ANC visits, with 16% of mothers thinking the visits were not necessary (HPDP, 2007b).

Close to eight of ten births were delivered at home under the care of TBAs. Many women preferred delivery with TBAs because it had been the practice in the family. Mothers who depended on TBAs for a long time would pass on this custom to their daughters.


The FGD also revealed that mothers find TBAs convenient since they are easier to summon and are willing to visit them even in the middle of the night. TBAs are also more considerate of expectant mothers’ needs and comfort. Respondents point out that they can scream during delivery without being scolded, and their husbands are allowed to stay by their side during delivery. Home deliveries also provide them with a sense of privacy and comfort, as the woman is not forced to lie on a delivery table with her genitals exposed.

The family does not need to worry about care support for the other children during home-based deliveries, unlike during facility-based deliveries when the father and/or other family members have to leave children at home to take care of the mother and her newborn.

FGD findings also reveal that decisions to seek care from health facilities were often made only when the delivery had become difficult or when complications arose (HPDP and SDRC, 2008). One out of four mothers also believed that delivering with TBAs was safe (HPDP, 2007b).

The FHB will address this barrier through the provision of vital information on health needs and health risks contained in a convenient media. Assigned Navigators can further explain these messages, dispel misconceptions and allay concerns of families.


Inacces-sibility of facilities

While only one out of twenty reported that distance and accessibility of facilities hampered family planning use, four out of ten mothers who did not avail of antenatal care services said going to the facilities was an inconvenience.

Another 15% said the facilities were inaccessible (HPDP, 2007b). Certain areas in Compostela Valley are difficult to reach due to terrain. In areas where public transportation is available, the trips are often long, infrequent, and costly. These barriers affect access patterns for routine and emergency care.

FHB intervention will address this barrier through the establishment of transportation and communication support networks for emergencies, and organization of outreach programs that provide regular public health services. However, the FHB will not intervene in improving transport and road conditions or providing subsidies for transportation costs.

What gaps and bottlenecks in the delivery system can and cannot be influenced by the FHB?

There are also delivery system gaps and bottlenecks that prevent families from accessing services. These include:

1) lack of available services and providers; 2) poor quality of services provided; 3) inadequate supply of health goods and commodities; 4) high user fees; 5) lack of access to emergency transport and communications; 6) insufficient health budgets; 7) unstable peace and order conditions;


8) geographic isolation; and 9) environmental hazards.

Lack of availability of services and providers

Access to services was largely contingent on the availability of services and qualified providers in the area. A survey of Compostela Valley services and facilities shows wide variations in accessibility of specific types of services across municipalities (see Table 1.2).

Of the 79 physicians practicing in the province, there were nine obstetrician-gynecologists, seven surgeons, five pediatricians, three internists, and one anesthesiologist. The remaining 54 physicians were generalists.

At the time of the survey, Cesarean section deliveries and blood banking services were usually done at the Davao Regional Hospital in Tagum City (HPDP and SDRC, 2008). Furthermore, the ability of PhilHealth members to avail of their privileges depended in part on the availability of accredited facilities.

Of the 38 health facilities in Compostela Valley, only 17 had PhilHealth accreditation. None of the 14 private clinics were PhilHealth-accredited or had Sentrong Sigla certification. Although all 11 RHUs had Sentrong Sigla certifications, 4 RHUs were not PhilHealth Outpatient Benefit (OPB)-accredited.

Only 33% of physicians and 14% of midwives had PhilHealth accreditation (HPDP, 2007a). During the provider orientations, one hospital was found to be operating without a license and was dropped from the FHB list of providers.


FHB interventions do not aim to increase the number of available providers in the province but will facilitate access by providing FHB holders with lists of available providers for specific services and information about these providers’ PhilHealth accreditation.

Table 1.2: Number of facilities offering specific services, Compostela Valley

Municipality2007

PopulationPrenatal

CareNormal delivery

Immuni-zation

Primary Care

Modern FP Counseling

Compostela 69,849 6 4 3 4 6

Laak 66,607 1 2 1 2 2

Mabini 35,308 1 0 1 1 1

Maco 70,906 3 1 2 2 2

Maragusan 51,547 2 1 2 2 1

Mawab 34,656 2 1 1 3 2

Monkayo 90,971 3 1 5 3 2

Montevista 35,192 3 2 2 1 3

Nabunturan 67,365 6 5 5 6 3

New Bataan 45,309 2 1 2 2 1

Pantukan 69,656 2 1 2 2 1

Compostela Valley 637,366 31 19 26 28 24Source: HPDP-FHB Baseline Household Survey, 2008

Poor quality of care

Even if services are available, their quality affects consumer decisions to utilize care.

The quality of facilities can be measured along different dimensions. One dimension is physician knowledge of treatment protocols, which was measured using clinical vignettes.


Data from the Compostela Valley baseline indicated that the providers on the average scored less than 30% for pregnancy-related vignettes and less than 50% for general pediatrics. Both fell short of the 55% cut-off score set at baseline (Table 1.3).

Another dimension of quality is the level of patient satisfaction for services rendered. Table 1.4 indicates that in general, close to three out of every four patients were satisfied with services they received. While patient satisfaction did not differ much across public and private facilities, private lying-in clinics registered higher satisfaction levels.

The facility’s patient load was also used as an indicator of quality of services. Table 1.5, which indicates the average case load of Compostela Valley providers, shows that public facilities had relatively higher patient load than private facilities.

The FHB can partly mitigate this barrier by facilitating access to resources needed to upgrade selected facilities. In particular, the focus of support will be the Compostela Valley Provincial Hospital (CVPH) to enable it to better provide CEmONC services. However, FHB will not do this for all facilities in the province.

Inadequate supplies and commodities

In the FGDs, many families reported not going to facilities because either services or supplies were not available. While service and supply inventory indicators such as drug stock out rates are not routinely collected, a proxy index of the lack of supplies could be that 88% of Compostela Valley residents resort to self-medication when ill (HPDP, 2007b). FHB interventions will not purchase nor supplement the commodities in the facilities.


Table 1.3: Average score for vignettes, Compostela Valley

Facility TypePregnancy

CareLabor and

Delivery CareNewborn

CareGeneral

Pediatrics

Public Hospital 0.32 0.39 0.31 0.48

Private Hospital 0.28 0.29 0.26 0.42

RHUs 0.32 0.13 0.19 0.48

Private Clinics 0.23 0.33 0.23 0.41

Private Lying-in Clinics 0.27 0.27 0.27 na

ComVal Health Facilities 0.28 0.24 0.23 0.44

Davao Regional Hospital 0.49 0.57 0.44 0.59

“na” – Vignettes on general pediatrics were not administered to the health professional of lying-in clinics.Source: HPDP-FHB Baseline Provider Survey, 2007

High user fees

High user fees for services has been commonly cited as a barrier to accessing care. Survey data shows that the cost of TBA-assisted births (P 1,414) was a bit lower compared to those done with a skilled birth attendant (P 2,233). In the provinces, the difference of around P 800 amonted to a minimum wage worker’s four days of work.

The FHB will address this barrier by encouraging PhilHealth enrolment of residents through the LGU. However, the FHB will not specify exact amounts of the budget to be spent for premium subsidies.


Tabl

e 1.

4: A

vera

ge p

atie

nt s

atis

fact

ion,

Com

post

ela

Valle

y

Faci

lity

Typ

ePu

blic

H

ospi

tal

Priv

ate

Hos

pita

lR

HU

sPr

ivat

e C

lini

cs

Priv

ate

Lyin

g-in

Cl

inic

s

Com

Val

Hea

lth

Faci

liti

es

Dav

ao

Regi

onal

H

ospi

tal

Gen

eral

Sat

isfa

ctio

n72

.577

.676

.773

.986

.775

.676

.7

Tech

nica

l Qua

lity

75.9

79.5

79.3

75.0

85.0

77.6

80.0

Inte

rper

sona

l Man

ner

80.0

78.8

84.6

80.0

91.7

81.1

62.2

Com

mun

icat

ion

80.8

81.8

80.4

81.3

90.0

81.4

71.1

Fina

ncia

l Asp

ects

74.0

68.4

74.6

87.1

85.0

76.7

47.8

Tim

e Sp

ent w

ith

Doc

tors

74.0

70.4

76.7

71.6

90.0

73.5

71.9

Acce

ssib

ility

& C

onve

nien

ce74

.476

.674

.167

.186

.773

.281

.9

Ove

rall

pati

ent s

atis

fact

ion

75.9

76.2

78.0

76.6

87.9

77.0

77.4


Tabl

e 1.

5: A

vera

ge c

ase

load

, Com

post

ela

Valle

y

Faci

lity

Typ

eO

utpa

tien

t lo

ad fo

r th

e pa

st m

onth

Inpa

tien

tloa

d fo

r th

e pa

st

mon

th

Out

pati

ents

pe

r M

DIn

pati

ents

per

M

DO

utpa

tien

ts

per

Mid

wif

eIn

pati

ents

per

M

idw

ife

Publ

ic H

ospi

tal

3,99

91,

604

167

6723

594

Priv

ate

Hos

pita

l1,

286

555

5423

257

111

RHU

s4,

510

034

70

550

Priv

ate

Clin

ics

3,70

60

195

092

70

Priv

ate

Lyin

g-in

Clin

ics

122

3441

11

Com

Val H

ealt

h Fa

cilit

ies

13,6

232,

193

170

2712

320

Dav

ao R

egio

nal H

ospi

tal

5,31

92,

457

6329


Lack of access to emergency transporta-tion and communi-cation

Compostela Valley residents usually resort to private means of transportation and communication -- if ever these are available -- during emergencies. While there were at least six government ambulances and an undetermined number of private vehicles with informal arrangements with communities, these were not organized as a formal network to serve the needs of the province.

Neither did households know how to access emergency transport. Emergency communications was mainly done through a radio network connecting the four public hospitals. While cellular phone access has increased over the past few years, only about one in three households had access to cellular phones in some areas. The peculiarity of single-side band radio system and cellular phones’ private nature limit household access to communication facilities to connect with the rest of the health system, especially during emergencies.

FHB interventions will address these barriers, not through the provision of vehicles and communication equipment, but through the establishment of a transport and communications network using local resources and initiatives.

Local health budget levels and allocations

The 2007 province-wide health budgets amounted to P 135.7 million, or 11% of total internal revenue allotments (IRA). Most of these monies (61%), was spent on personal services (PS) followed by maintenance and other operating expenses (MOOE) (30%) and capital outlay (CO) (2%). Around 7% was spent on programs.


Close to 60% of the IRA allocation is spent on the four hospitals, leaving very little for public health functions. Of these amounts, 54% goes to PS, 43% to MOOE, and only 3% to CO. The FHB will be able to generate estimates of service demands, which can guide LGUs on how to allocate these budgets, given fiscal constraints. The FHB, however, will not intervene in terms of increasing LGU budgets for health.

Peace and order

Implementation of FHB interventions depends largely on the peace and order situation in the area. Family access to Navigators, health emergency networks, health facilities, and outreach activities hinges on the feasibility and safety of operations in the area and the continuing support of the local government as well as other stakeholders. No FHB intervention was identified to address the special needs of internally displaced persons or people in conflict with the law.

Geographic and envi-ronmental hazards

Transport and communication providers, as well as Navigators and health facilities, may not venture in far-flung or hard-to-reach areas for logistical and practical reasons. This puts families in these locations in a disadvantaged position since they cannot use services they are entitled to receive nor fully tap the assistance Navigators should routinely provide. Despite FHB interventions, accessibility factors resulting from beneficiaries’ geographical locations and the environmental hazards these bring effectively limit their utilization of health care services.


What are the FHB interventions?

The FHB initiative is a package of interventions directed at addressing health care use barriers. This package provides essential health information backed by a supportive environment that enables target families to initiate and sustain the targeted behavior, i.e., the utilization of critical maternal and child health care services. Thus, FHB interventions include the linking of families to emergency transportation and communication services and mitigating the effects of geographic isolation and cost of transportation for routine health care.

FHB interventions are designed to inform and guide families in understanding health risks, in knowing and deciding on what services to access, in planning for and using these services, in knowing where to access transport and communication networks for emergency care services, and in identifying facilities where they can avail of essential family planning and MNCHN services.

In addition, the FHB initiative has complementary activities designed to address the lack of quality providers for safe deliveries, postpartum and neonatal care, and the lack of social health insurance that would effectively reduce out-of-pocket expenses. The FHB will accomplish this through three complementary interventions:

1) providing information through a book and deploying Navigators to assist families and reinforce information from the book;

2) establishing emergency transportation and communication networks; and

3) organizing outreach activities.


Providing vital information through the Family Health Book and Navigators

The FHB provides information to families in a way that allows them to understand and recognize health risks resulting from mistimed and unplanned pregnancies; inadequate or lack of prenatal and postpartum care; deliveries not attended by SBAs; unimmunized children and poor infant and childcare. Such information will guide families in determining the essential health services they need and identifying the health providers available in their area (i.e.,licensed and accredited providers, fee schedule, location, and their contact numbers) to address such risks and plan for the eventual utilization and financing of such services. Providing this information to families allows them to take effective responsibility for their own health.

This intervention proposes to use Navigators to reinforce the information contained in the book. The Surveys and FGD findings have validated the idea of engaging families to assist them and reinforce information they receive.

Both the HealthGov survey and baseline survey results point to barangay health workers (BHWs) and health volunteers as likely candidates for this navigation role, being the traditional and preferred conduits of information. Mothers in one Family Planning FGD expressed preference for face-to-face interaction when relaying family planning information (Acuin, 2008). The combined use of information and a health worker to complement the intervention has been proven effective in a pilot implemented in Davao del Norte and Compostela Valley (Costello et al., 2001).

Book

The Book is organized into sections which allow the families, with the help of their Navigator and providers, to go through the following FHB cycle:

1) orientation; 2) needs assessment; 3) health use planning; and 4) adherence to developed health use plans.


The FHB has the following sections:

1. Health messages. The messages talk about modern family planning methods; the importance of prenatal care; danger signs during pregnancy and after delivery; need for skilled birth attendance during deliveries; newborn danger signs and prevention of common child illnesses such as diarrhea, cough, colds, and pneumonia; and male partner participation in family health concerns.

The health action messages are based on best available evidence, accepted practice guidelines, and expert opinion (see Table 1.6).

Table 1.6: Indicator levels and corresponding health risks and action messages

Indicator Health risks Health Action Messages

Use of Modern FP

Unplanned and mistimed pregnancies; lack of adequate spacing between births

Practice modern family planning; short or long term methods for spacing; permanent methods for limiting births

ANC Inadequate antenatal care; lack of nutritional support for mother and fetus

Have at least four antenatal care visits; first antenatal care visit preferably during first trimester; inquire about supplements from providers

SBA Lack of skilled attendance during delivery and postpartum / postnatal

Deliver with skilled attendance, preferably in accredited facilities; prepare birth plan including identifying means for emergency transportation

FIC Lack of immunity from vaccine preventable diseases; other common infectious diseases of childhood such as diarrhea and pneumonia

Have children vaccinated fully and on schedule; additional messages on breastfeeding, hand washing, ORS


To allow customization of the various health messages to individual families and help determine what services are needed, the families, guided by their respective Navigators, need to assess their health status and anticipated health risks.

This can be done with the Health Risk and Needs Assessment tool in the Navigator’s kit. This tool allows the family, with the assistance from their Navigator, to better understand what health risks threaten their family, to identify critical health needs, and more importantly, to prompt them for action based on the applicable health messages. A summary report on the assessment will be given to the family. It will also be shown to a health provider for the development of a health use plan. The use of a health needs assessment form builds on the experience on the use of self-assessment tools such as growth charts that prompt users to act on specific findings.

The development of the health assessment tool builds on the experience with similar diagnostic checklists that ask questions from users based on characteristics or symptom patterns, including the triage or systematic screening checklists used by clinic staff (FHI, 2003) and a combination of patient education booklets and symptom checklist forms for TB patients (Datta and Nichter, 2003).

2. Health Use Plan. This will help families, assisted by the Navigator and in consultation with their provider, determine the steps necessary to act on identified health risks and needs.

The health use plan serves as a guide and reminder for families and providers in achieving desired goals. These health use plans will help the Navigator remind families and monitor their adherence to these plans.

Health use plans are an expanded application of birth plans -- drawn up by mothers in preparation for delivery -- being promoted by the DOH. The FHB contains separate health use plans for reproductive health and family planning needs, birth and delivery, sick child consultations, well-baby visits, and health emergency situations. A guide on how to avail of PhilHealth benefits will be integrated into the health use plan so that families, their Navigator, and their health providers can plan ahead and prepare specific requirements to access PhilHealth benefits.


3. Providers’ list. This includes information on locally-available providers, their location, contact numbers, fees, DOH licensing and PhilHealth/Sentrong Sigla accreditation status and available services.

This section addresses survey data and FGD findings that point to the lack of awareness on where services are being provided, who the licensed and accredited providers are and what services are being offered as important obstacles to health care utilization.

4. PhilHealth information. Significant gains could be generated from providing adequate PhilHealth information considering that a third of members are not aware of PhilHealth benefits and that half of mothers were not able to file claims. Inserts of PhilHealth information materials are included in the FHB. Reminders to PhilHealth members for them to seek care in accredited facilities and prepare documents required to file for claims are also mentioned in applicable health use plans the families will develop.

5. Contact information of the emergency transport and communication network. This information will provide families with the name of the person to contact during emergencies. These persons either operate the vehicle itself, or have authority to deploy transport. In some cases, these same persons listed may be the designated communication “hub” in isolated localities where cell phone access is limited.

To come up with the book, the following tasks and activities need to be undertaken:

• identify families who would most benefit from the information to be provided;

• develop the appropriate content and the form to ensure usefulness and acceptability to families;

• reproduce the book;

• distribute copies of the book to targeted beneficiaries; and

• regularly update the book’s contents to ensure continuing relevance.


In the identification of families, analysis of FHB Baseline Survey data undertaken with support from HPDP indicated that families which would benefit from use of the book are those with mothers who did not finish high school and those which satisfy the following criteria:

1) pregnant;

2) below 25 years old and with at least one child below five years old; and

3) 25 years old and above with at least two children below five years old.

Mothers belonging to low-income families or those with less than high school education are to be given priority since they are vulnerable to adverse health conditions, being unable to afford minimum basic needs for food, health, and other social amenities. National Statistics Office (NSO) data show that the poor spent more on food, fuel, and utilities in 2006, which took away 66% of the family budget. Given the worsening food and energy crisis in the last two years, we expect the poor to dig deeper into their pockets to cover food essentials, leaving very little for education and health.

The FHB Navigators

Navigators are expected to orient families and assist them in determining their health risks and assessing their health needs. They are also expected to guide families, together with the health providers, in developing health use plans, and do follow-up visits to monitor adherence to those plans. The Navigator links the families to providers and the emergency transport and communication network. In addition, Navigators also report families’ needs to the midwife and municipal health officer and help coordinate and organize FHB outreach activities.

Interaction between the families and the Navigators will allow families to become comfortable about discussing further any health risks and needs, and about choosing providers and


actually going to the identified provider. Constant reminders by Navigators will also increase families’ adherence to health use plans, hence, increasing the utilization of appropriate services.

Critical activities for the deployment of Navigators include the following:

1) selection and recruitment of Navigators;

2) matching of families with Navigators;

3) Navigator training including the development of instruction materials;

4) provision of continuous capacity building activities for Navigators;

5) provision of logistical support and incentives including support to their PhilHealth enrolment; and

6) monitoring and supervision of Navigators.

Selection and recruitment of Navigators

As a source of information for the family, recruited Navigators should be credible and be able to provide sufficient attention to the families they are managing.

Each Navigator will be assigned around 20 families in the community, which is consistent with the DOH standard. Simple application of this ratio identifies the minimum number of Navigators to be trained to cover the identified families. However, this number can be increased to ensure coverage of all FHB families in all puroks. The distribution of Navigators is to be based on the number of FHB families identified per barangay.


The initial 40 Navigators recruited for the FHB were chosen using the following criteria:

1) with at least two years of health-related activities in the community;

2) able to work with local officials;

3) with at least two years of high school education;

4) able and willing to regularly visit the households covered;

5) with good interpersonal communication skills and highly motivated; and

6) respected in the community.

The criteria were later relaxed due to a very limited number of Navigators who met the educational criteria. Those who finished elementary education were considered qualified provided that they had more than two years of health-related experience. HPDP assisted in identifying, recruiting, and training 40 Navigators. Out of these, 12 (three per municipality) were trained and tapped to participate in the FHB field testing. Results of the field assessment suggested limiting the number of families to be managed by Navigators (hence the need to recruit more Navigators) or delegating some of the Navigator tasks to other families.


Matching of families with Navigators

Careful matching of Navigators and families is crucial to the smooth implementation of the FHB initiative.

The process should take due consideration on the cultural context of a particular group or community (e.g., indigenous population, religious groups, etc.).

Navigator training

This entails the development of the following:

1) a training module (facilitator’s guide) for the core trainers who will be training the rest of the Navigators;

2) training modules for Navigators; and

3) the Navigator’s kit or instruction manual for the Navigators.

The core set of trainers came from the DOH, selected municipal health officers (MHOs), nurses, midwives, and other trainers, including from among Navigators themselves. The trainers are expected to provide mentoring support to the Navigators.

The module for Navigators shall consist of:

1) an overview of the health situation in the province;

2) the FHB Initiative and its components,

3) an orientation on FHB concepts including family planning and maternal and child health;


4) steps in engaging the families to participate in the FHB Initiative;

5) training for enhancing communication

and health teaching skills;

6) an orientation on PhilHealth benefits availment; and

7) training on the development and monitoring of related forms.

Navigators should have relational skills development in their training. Improvement in Navigators’ presentation, facilitation, and relational and negotiation skills using both non-verbal and verbal approaches will enable them to better explain health messages and health use plans in the FHB.

The Navigator’s Kit serves as an instructional manual for effectively engaging families, monitoring their compliance to health use plans and coordinating with midwife supervisors for technical and operational guidance (HPDP, 2008). The first part of the kit gives an FHB backgrounder while the second part shows how to engage families.

The key processes described in the second part include orienting families, assessing and determining health risks and needs, assisting families in developing their health use plans, encouraging families to access appropriate services, and following up on families.


Navigators should follow an appropriate communications strategy in talking to the families to help them better understand and act on key health messages. This strategy is discussed in the Navigator’s Kit, which gives concrete guidelines on how to maximize attention, like suggested scripts and scenarios. Navigators can employ these guidelines to contextualize messages to the families’ particular situation, and reinforce messages.

Provision of continuous and sustained capacity-building

The Navigator’s work requires continuous and sustained capability building on maternal and child health.

LGUs and concerned cooperating agencies (CA) should conduct re-orientation and refresher training on these essential public health programs on a staggered or modular basis to constantly update and build the knowledge among Navigators on MNCHN concepts and standards.

These capability-building activities are expected to help Navigators guide FHB families in health needs assessment, health planning, and accessing of health services.

Logistical support and incentives

As local issuances are critical to sustain Navigator community activities, LGU should make budgetary appropriations for these activities.

Local advocacies, policies, and resolutions to strengthen LGU-private partnerships (e.g., private sponsors supporting FHB Navigators) are essential to generate additional support for Navigators. In addition, incentives such as enroling Navigators in PhilHealth and giving them performance awards have been instituted to sustain Navigator support to the Initiative.


Navigator monitoring and supervision

To ensure that FHB Navigators are properly supervised and assisted, monitoring tools are needed.

The monitoring plan should come with adequate logistical support (e.g., travel expense vouchers or TEV) to ensure the regular conduct of monitoring activities.

Establishing emergency transport and communication networks

Unavailability and unaffordability of transport services explain families’ inability to reach facilities and utilize their services on time during emergencies. An emergency transport and communication (EM) network promotes rapid response to health emergencies and facilitates referrals and transfers to appropriate facilities. As barangays make arrangements for their constituents for these contingencies, the FHB initiative attempts to build on these community initiatives and facilitate broader coordination between communities and health facilities.

This intervention seeks to promote and expedite access of families to MNCHN services by providing them with the names and contact numbers of barangay officials, health workers, and other transport providers, as well as companies in their areas which allow use of their vehicles during emergency referrals. The FHB initiative seeks to make such a network functional in selected municipalities.

To establish a functional health emergency transport and communication network, the province must:

1) assess any current emergency system and network;

2) secure commitments of emergency contacts and different stakeholders to be involved in the FHB initiative;


3) work out arrangements on use, cost, repairs, maintenance and schedule of emergency vehicles with local officials, health and transport providers;

4) regularly update list of health emergency contacts;

5) continue to provide funds, mobilize support for emergency vehicles’ maintenance and repairs, and coordinate actively with health providers, transport groups, and the private sector to ensure availability of emergency vehicles 24 hours a day, seven days a week.

The overall responsiveness of the different pilot municipalities to health emergencies helps determine the right approach for the establishment of a functional health emergency transport and communication network in the area. To jumpstart this, HPDP conducted a survey to help the Provincial Health Office (PHO) to

• assess the accessibility of the nearest CEmONC facility from the different barangays;

• determine transport and communications costs in the different municipalities;

• identify the common response of different barangays to health emergencies; and

• map out all existing transport and communications providers in the area.

In an initial survey conducted in December 2008 on emergency arrangements in Compostela Valley, barangay captains reported that they were most often called for emergencies. Hence, they are more likely to be in charge of the emergency transport and communication network in each barangay. Part of the FHB/Giya sa Maayong Panglawas (GMP, or “Guide to Good Health”) kit is a booklet with a list of emergency contact persons (most are barangay captains) and their respective contact numbers.


Earlier, HPDP assisted the province in listing available health emergency contacts in selected barangays of the four pilot sites. This work was expanded to cover all barangays and to validate and update existing FHB health emergency directories. Intensive advocacy and collaboration with local health staff, community leaders, transport groups and private sector partners should be done to secure commitments for transport and communication arrangements in the municipality where the EM intervention is to be done.

Organizing outreach services

Geographic isolation, constraints of transportation systems and road networks, and transportation costs as barriers to accessing care will be addressed through periodic outreach services that provide critical services to FHB holders and their communities. The Municipal Health Office (MHO) shall coordinate and organize outreach activities based on needs identified by Navigators during the risk identification and health needs assessment and in the families’ health use plans developed for their reproductive health requirements, sick child care, and well-baby care.

The specific needs identified shall determine the kind of services and commodities to be delivered, the timing of the activity, and targeted beneficiaries (men and women of reproductive age, pregnant mothers, postpartum mothers, newborn infants and under-5 children). Outreach services, to be done on a quarterly basis, should be so scheduled to not interfere with major activities during the planting, harvesting and fiesta seasons, and important weekday or weekend activities. Regular outreach services to be conducted as part of the FHB initiative will target hard-to-reach and highly-mobile communities. Since these groups are most likely not frequently reached by Navigators, outreach activities are expected to bring the needed services closer to these FHB holders, increasing their adherence to health use plans, such as the reproductive health plan, well child plan, and sick child plan.

This intervention intends to increase the number of families utilizing antenatal care (ANC), family planning, and immunization services. Once the most vulnerable, high-risk and hard-to-reach


communities with very low access to and utilization of MNCHN services are mapped and identified, the outreach services are to be conducted in selected barangays or puroks. These barangays or puroks should

1) be located no more than two hours of time hours from the RHU or hospital using the most common mode of transportation;

2) have as patients at least 30% of the total number of FHB/GMP holders in the barangay;

3) be accessible by a motorcycle;

4) pose no security concerns for the medical teams;

5) have barangay officials committed to the outreach activities.

Moreover, the medical team involved should be willing and capable of rendering needed services and there should be available funds for the outreach activities.

Outreach services may include health navigational support, health education and promotion services, family planning counseling and distribution of prenatal care commodities, Vitamin A and iron folate supplements, immunizations and child health and nutrition counseling, and ancillary services like PhilHealth orientation and birth registration.

Outreach activities shall be organized only whenever there are enough attending families and there is an ample mix of cases that will require the services of a multi-function health team. The Navigators, together with the midwives, will review the summary call sheets to determine the number of FHB families and the corresponding services they need.


Key activities include the following:

1) Identifying hard-to- reach and highly-mobile communities;

2) Summarizing and analyzing families’ health use plans;

3) Planning the scope of services to be provided and the ideal mix of health providers during outreach activities, preparing health commodities needed by patients, and identifying units (PHO/RHU/others) and sponsors for a particular outreach activity;

4) Identifying coordination arrangements among the PHO, CHD, providers, local officials and other stakeholders in the conduct of the activity; and

5) Providing or soliciting resources for the conduct of such outreach activities.

HPDP provided technical assistance to the province to guide the conduct of outreach programs during the FHB pilot in Compostela Valley. The assistance includes a review of the design and conduct of existing health-related outreach services in the different municipalities to determine best practices from different models; the development of community outreach protocol to be organized for the FHB pilot; and creation of criteria for selecting families and communities to be targeted by the outreach activities. This protocol will also guide Compostela Valley in organizing, managing, and monitoring its outreach services.

There is ongoing technical assistance seeking potential local and private sector sponsorships for the different outreach services. Assistance can also be provided for advocacy for resources from both provincial and municipal governments as well as from private sponsors.


How will we measure changes due to FHB interventions?

FHB interventions aim to improve health outcomes, in particular the reduction of maternal, neonatal, infant, and child mortality rates. Effects on health outcomes can only be validated after implementing interventions after quite some time.

In the meantime, initial impact will still be measured by monitoring the actual counts of maternal, neonatal, infant, and child deaths in Compostela Valley, particularly in the municipalities where FHB interventions are implemented (see Table 1.7).

Table 1.7: Measures of maternal, infant, and child deaths

Outcome Baseline Data Sources

Number of MaternalDeaths

Compostela 9 PHO FHSIS Records; EOY Assessment ReportsMabini 0

Maco 2

Montevista 2

4 Pilot Sites 13

Number of Infant Deaths


Maco 39

Montevista 12

4 Pilot Sites 112

Number of Child Deaths


Source: Compostela Valley PHO, 2007 FHSIS


Intermediate outcomes

Parallel to the goal of improving health outcomes is the utilization of critical MNCHN services measured in terms of intermediate outcomes. The FHB initiative focuses on these four intermediate outcomes:

• Modern Family Planning (MFP) Method use;• Fully-Immunized Children (FIC);• Antenatal care (ANC); and • Skilled-Birth Attendance (SBA).

These will be monitored by the following intermediate outcome indicators:

• MFP: Number of users who continued to use family planning (FP), number of new acceptors of modern FP methods, and shifters from traditional to modern FP methods;

• FIC: Number of children fully immunized, and with immunization being on-schedule;

• ANC: Number of pregnant women with at least four antenatal visits, number of pregnant women with first antenatal visit during the first trimester, and number of women who received iron and folate supplementation; and

• SBA: Number of mothers who were assisted by skilled birth attendants.

However, there are barriers to utilization of MNCHN services, which eventually contribute to poor health outcomes. The three FHB interventions aim to address these barriers by providing information and supplementing it with a supportive environment that enables families to exhibit targeted behavior.


The Book+Navigator intervention seeks to provide information and correct misconceptions. These are summarized in the health risks and health action messages in Table 1.6.

As there are messages contained in the Book for pregnancy and child health, the Book+Navigator intervention is expected to impact on all four intermediate outcomes. The interventions and the specific health care use barriers being addressed by each intermediate outcome are listed in Table 1.8.

Table 1.8: Interventions and Barriers Addressed, By Intermediate Outcomes

InterventionMFP Use

FIC ANC SBA

Book+Navigator Lack of knowledge and misconception on the risks and consequences faced by families due to particular actions (e.g., mistimed and unplanned pregnancy, delayed detection of diseases)

Outreach Distance, time, and inaccessibility of facilities and services

EM Network Inaccessibility of facilities and services

Inaccessibility of facilities and services

Outreach interventions seek to bring essential services closer to the families, addressing barriers related to distance, time, and inaccessibility of facilities. FHB services are envisioned to be regularly conducted, scheduled according to requirements of FHB families in the remote areas, and expected to serve a critical number of beneficiaries. Since the exact date of delivery is largely unpredictable, the outreach intervention cannot be counted on to provide skilled birth attendance.

The establishment of an emergency transport and communication network is expected to impact on the utilization of urgently-needed services. This intervention is primarily expected to influence skilled birth attendance and emergency care for sick


children. Support to access to CEmONC facility is expected to influence utilization of services related to births, in particular skilled birth attendance.

FHB intermediate results /outputs

The processes and activities for each intervention are expected to attain FHB outputs (see Appendix 1 for the detailed logframe and indicators). The major outputs of FHB interventions are

• the number of completed health use plans; and

• the number of adhered-to health use plans.

Families that have been oriented by Navigators and informed of their health risks and consequences, and thus have identified their family health needs, are expected to develop health use plans corresponding to their identified health needs.

Health use plans serve as concrete manifestations of families’ intentions to use the identified critical MNCHN services. Depending on health needs, beneficiaries should have one or more health use plans (i.e., reproductive health, birth plan and emergency plan, and well baby and sick child plan).

Families who intend to limit or space pregnancy, for instance, should have a reproductive health (RH) health use plan, which will indicate the desired method of choice. Meanwhile, families with a pregnant mother should have a birth plan which will indicate when and where the pregnant mother should complete at least four ANC visits and other necessary maternal care services, the intended place of delivery and type of delivery assistance needed, and other details that are important, especially in case of emergency.


Families with infants should have a well-baby plan that includes three doses of the Diphtheria Pertussis Tetanus (DPT) vaccine, three doses of Oral Polio Vaccine (OPV), measles vaccines, and a Bacillus Calmette-Guerin (BCG) vaccine shot before the infants turn 12 months old. The health use plan will also serve as an important guide for Navigators when to remind and conduct a follow-up visit to the family to promote adherence to the health use plan.

Since FHB interventions are also intended to address barriers to utilization of services aside from the lack of information, families are expected to adhere to developed health use plans, utilizing identified services from the provider identified in the plan and during the specified time.

For instance, FHB families in remote barangays can still comply with antenatal care visits and immunization schedules, and utilize family planning services provided through outreach services. Those who identified a specific birth attendant to be consulted should be able to do so, as the contact numbers of emergency transport and communication networks are provided and a functional network is established in a selected municipality.

FHB intervention inputs and processes

The success of the FHB interventions can further be measured in terms of its objectives regarding

• the level of expended input; and

• the quantity and quality of FHB intervention processes and activities.


For example, the Book+Navigator intervention includes various inputs like health messages, a PhilHealth brochure, a list of health providers, and trained Navigators. Quantity and quality indicators at these levels can be used to gauge the interventions’ operational aspect and the potential effect on both intermediate and final outcomes.

FHB intervention inputs are indicators of the level of effort exerted in implementation. Different measures of inputs are assigned for each of the FHB interventions.

For the Book+Navigator intervention, books will be produced and distributed to households identified and validated based on criteria. The 300-plus Navigators will each receive a Navigator’s Kit and will have to orient all of these households. All barangays shall have a list of emergency transportation and communication networks, and these lists will be made available to all FHB holders.

Functional networks shall be established in selected areas. Outreach missions shall be systematically organized and targeted, and resources and sponsors for outreach services and commodities tapped.

The quantity and the quality of these processes/activities are to be assessed using process indicators. For example, the level of effort exerted on recruiting and developing the Navigators can be measured by the number of Navigators recruited, the number of Navigators who are trained and who passed post-training evaluation, and the number of Navigators who quit. Once Navigators are on-board, the next activity is the actual matching between families and Navigators and eventual family-Navigator contacts.


Process indicators that assess the inputs and activity’s quantity and quality include the number of Navigators who visited all the assigned families at least once a month, the ratio of FHB beneficiaries who agreed to be assessed to the number of families who agreed to be oriented, and the number of Navigator re-assignments.

Measuring these process indicators per activity gauges the operational performance of the interventions and the related activities. At the same time, the quality and quantity of inputs and activities greatly affect how inputs are translated into intermediate outputs.

For example, the number of Navigator visits might not be enough for a family to complete and adhere to a health plan if the Navigator has not communicated with the family well. For the FHB intervention, the level and quality of engagement between the family and the assigned Navigator can be measured by the number of re-assignments of a Navigator.

The design, provision, and monitoring of quality and responsiveness of services are the relevant processes/activities for outreach and emergency interventions. Aside from the counts of services provided, client satisfaction is also important.

Measuring spillover effects

Non-FHB families, especially those residing in pilot municipalities, cannot be excluded from availing of benefits included in FHB interventions, such as access to the emergency transportation and communications network, access to outreach services, and access to the upgraded facility.


Thus, there is the possibility of benefit spillovers and increased utilization of services of non-FHB beneficiaries. To account for the extent of these spillovers, the number of FHB and non-FHB beneficiaries that used the emergency transport and communication networks and availed of of outreach services are compared (Table 1.9).

Table 1.9: Measures of intervention inputs received by unintended beneficiaries

InterventionMeasure of Spillovers

Numerator Denominator

FH Book Number of non-FHB eligibles which received the book

Number of FHB books distributed

Navigator Number of non-FHB holders followed up by Navigators

Number of FHB holdersfollowed up by Navigators

Number of non-FHB holders followed up by Navigators

Number of persons followed up by Navigators

Emergency transport and communication

Number of non-FHB holders using emergency transportation and communication networks

Number of FHB holders

Number of non-FHB holders using emergencytransportation and communication networks

Number of persons using emergency transportationand communication networks

Outreach Number of non-FHB beneficiaries served by anoutreach group

Number of persons served by an outreach group

Number of FHB beneficiaries without developed healthuse plans and served by an outreach group

Number of FHB beneficiariesserved by an outreach group


In addition, FHB interventions may have effects on FHB families’ utilization of other health care services, such as dental care, TB, and minor surgery. This is possible because FHB families are more closely linked to providers through the Navigators. For instance, families are not limited to PhilHealth MNCHN service benefits. They can avail of other services during the intervention and their utilization is tracked.

Change in confounding / environ-mental factors

Confounding or environmental factors will also be measured even if the FHB has no direct interventions to address these concerns. Confounding factors are grouped into the following:

• household factors such as income and education;

• provider factors such as quality, resources, accreditation etc.;

• local delivery and financing systems;

• PhilHealth accreditation policy changes and enrolment campaigns;

• DOH and LGU regulations;

• peace and order conditions; and

• exposure to natural phenomena, like landslides.

A summary of the measures and baseline data sources is given in Table 1.10. Baseline profiles of education and income measures for the four pilot sites are shown in Table 1.11. A year into the implementation, these profiles will be compared with profiles of FHB beneficiaries at the end of the intervention to detect any significant changes in their income and education profiles, which, other than the influence of FHB interventions, may affect family planning and MNCHN service use.


Since FHB beneficiaries were chosen on the basis of the mother’s educational attainment unlike the baseline sample, comparisons of income and employment status changes would have to be made for the same levels of educational attainment.

Assessment of provider factors will entail collecting measures of quality, resource availability and capacity, attitudes, prices and fees, and accreditation status of health facilities in Compostela Valley and the Davao Regional Hospital in Tagum City. Changes in these provider factors will be detected by comparing health provider profiles from the HPDP-FHB facility patient exit surveys, FHB baseline vignettes, and the profiles of Compostela Valley health facilities and providers, and the Davao Regional Hospital with post-intervention facility surveys, vignettes, and information from key informant interviews (KII) and focus group discussions (FGDs).

Measures on other environmental factors can be obtained from LGU records, PhilHealth records, project reports, key informant interviews, and news reports. They will be compared with gathered information on these environmental factors between beginning-of-year 2009 and post-intervention 2009 (see Tables 1.12 and 1.13).


Tabl

e 1.

10: M

easu

res

and

base

line

data

sou

rces

of e

nvir

onm

enta

l HH

fact

ors

outs

ide

the

cont

rol o

f FH

B in

terv

entio

ns

Det

erm

inan

ts /

Fa

ctor

sM

easu

reBa

seli

ne

(gen

eral

po

pula

tion

)

Begi

nnin

g 20

09

(6,0

00 F

HB

hold

ers)

End

2009

(6

,000

FH

B ho

lder

s)

Dat

a So

urce

Educ

atio

nAv

erag

e nu

mbe

r of y

ears

of e

duca

tion

(see

Tabl

e 1.

11)

FHB

Base

line

Hou

seho

ld S

urve

y;

Profi

le o

f 6,0

00

FHB

bene

ficia

ries

at

beg

inni

ng-2

009

Profi

le o

f 6,0

00FH

B be

nefic

iari

es

at e

nd-2

009

Dis

trib

utio

n of

hou

seho

ld b

y hi

ghes

t ed

ucat

iona

l lev

el c

ompl

eted

(%)

Inco

me

Mea

n an

nual

hou

seho

ld in

com

e (in

pes

os)

FHB

Base

line

Hou

seho

ld S

urve

y;

Profi

le o

f 6,0

00

FHB

bene

ficia

ries

at

beg

inni

ng-2

009

Profi

le o

f 6,0

00FH

B be

nefic

iari

es

at e

nd-2

009

Dis

trib

utio

n of

hou

seho

lds

by

inco

me

quin

tile

(%)


Det

erm

inan

ts /

Fa

ctor

sM

easu

reBa

seli

ne

(gen

eral

po

pula

tion

)

Begi

nnin

g 20

09

(6,0

00 F

HB

hold

ers)

End

2009

(6

,000

FH

B ho

lder

s)

Dat

a So

urce

Hou

seho

ld S

ize

Aver

age

num

ber o

f hou

seho

ld m

embe

rsFH

B Ba

selin

e H

ouse

hold

Sur

vey;

Profi

le o

f 6,0

00

FHB

bene

ficia

ries

at

beg

inni

ng-2

009

Profi

le o

f 6,0

00FH

B be

nefic

iari

es

at e

nd-2

009

Dep

ende

ncy

rati

o

Num

ber

of c

hild

ren

unde

r 5 y

ears

old

Empl

oym

ent

Stat

us%

of h

ouse

hold

wit

h a

curr

entl

y-em

ploy

ed h

ouse

hold

hea

dFH

B Ba

selin

e H

ouse

hold

Sur

vey;

Profi

le o

f 6,0

00

FHB

bene

ficia

ries

at

beg

inni

ng-2

009

Profi

le o

f 6,0

00FH

B be

nefic

iari

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at e

nd-2

009

% o

f wom

en c

urre

ntly

em

ploy

ed

Dis

trib

utio

n of

mot

hers

by

empl

oym

ent s

tatu

s


Tabl

e 1.

11: B

asel

ine

educ

atio

n an

d in

com

e pr

ofile

of h

ouse

hold

s in

Com

post

ela,

Mab

ini,

Mac

o, a

nd M

onte

vist

a

Hou

seho

ld fa

ctor

sCo

mpo

stel

aM

abin

iM

aco

Mon

tevi

sta

4 pi

lot s

ites

Educ

atio

n m

easu

res

Aver

age

num

ber o

f yea

rs o

f sc

hool

ing

(yea

rs)

98

87

8

Hig

hest

Edu

cati

onal

Lev

el

Com

plet

ed (%

)

No

educ

atio

n0

00

20

Elem

enta

ry u

nder

grad

uate

1941

2937

30

Elem

enta

ry11

713

1011

Hig

h sc

hool

und

ergr

adua

te30

2526

2727

Hig

h sc

hool

gra

duat

e19

1322

1518

Colle

ge u

nder

grad

uate

136

56

8

Colle

ge g

radu

ate

89

54

6


Inco

me

Mea

sure

s

Mea

n an

nual

HH

inco

me

(in P

hP)

75,0

7172

,646

64,1

4173

,086

70,7

69

Inco

me

Qui

ntile

s (%

)

Inco

me

Qui

ntile

1 (p

oore

st)

2929

3125

29

Inco

me

Qui

ntile

218

138

2014

Inco

me

Qui

ntile

322

1817

2020

Inco

me

Qui

ntile

421

2231

2826

Inco

me

Qui

ntile

5 (r

iche

st)

1017

137

11

Hou

seho

ld S

ize

Aver

age

num

ber o

f hou

seho

ld

mem

bers

5.4

5.0

5.3

5.7

5.4

Dep

ende

ncy

rati

o (%

)53

5253

5653

Num

ber

of c

hild

ren

unde

r 5

year

s ol

d1.

61.

51.

31.

61.

5

Curr

entl

y em

ploy

ed m

othe

r (%

)11

.112

.813

.914

.112

.9

Empl

oym

ent s

tatu

s of

mot

her

Empl

oyed

in th

e pu

blic

sec

tor

36.1

28.7

8.3

10.5

19.5

Empl

oyed

in th

e pr

ivat

e se

ctor

22.3

42.8

10.9

5.2

18.1

Self

-em

ploy

ed41

.728

.680

.884

.362

.4So

urce

: FH

B-Ba

selin

e H

ouse

hold

Sur

vey


Table 1.12: Measures and data sources of provider factors not covered by the FHB interventions

Factors Measure Data Sources

Quality Average Vignette Scores FHB Baseline Vignettes; EOY 2009 Key Informant Interview (KII) and EOY 2009 Vignettes

Personnel/Staff by facility

Number of doctors FHB Baseline Facility Surveys; EOY 2009 Facility Surveys and/or KII

Number of registered nurses

Number of registered midwives

Number of BHWs PHO Records

Availability of drugs & medicines by facility

Number of stock-outs on Hepa B vaccines for the past year

FHB Baseline Facility Surveys; EOY 2009 Facility Surveys and/or KII

Number of stock-outs on OPV vaccines during the past year

Number of stock-outs on measles vaccines during the past year

Number of stock-outs on BCG vaccines during the past year

Number of stock-outs on DPT vaccines during the past year

Number of stock-outs on TT vaccines during the past year

Number of stock-outs on Vitamin A supplements during the past year

Number of stock-outs on iron and folate supplements during the past year

Number of stock-outs on condoms during the past year

Number of stock-outs on IUD during the past year

Availability of supplies



Factors Measure Data Sources

Availability of equipment


Annual budget Amount of budget for the past year FHB Baseline Facility Surveys; PHO Records on Public facilities, EOY 2009 Facility Surveys and/or KII

Attitudes Overall patient satisfaction FHB Baseline Facility Surveys; Focus Group Discussions

General satisfaction

Technical quality

Interpersonal manner

Communication

Financial aspects

Time spent with doctors

Accessibility and convenience

Prices and Fees Charges for room & board FHB Baseline Facility Surveys; EOY 2009 Facility Surveys and/or KII

Consultation fees

Procedure fees

Charges for laboratory services

Accreditation PhilHealth accredited facilities FHB Baseline Facility Surveys; EOY 2009 Facility Surveys and/or KII, PhilHealth Records

Facilities offering PhilHealth maternity outpatient package

Facilities offering PhilHealth maternity benefit package

Facilities offering PhilHealth TB- DOTS benefits

Sentrong Sigla certified facilities

PhilHealth accredited doctors

PhilHealth accredited midwives


Table 1.13: Measures of other environmental factors not related to the household and providers and outside the control of FHB interventions

Factors Data Sources

PhilHealth

Existence of an enrolment campaign

Subsidy rates PhilHealth Circular

Accreditation policy PhilHealth Circular

Regulation on the private sector LGU Records

Peace and Order Index News Reports

Landslide News Reports

Typhoons News Reports

Floods News Reports

Management and operations

Management systems and processes will be assessed using LGU records, project reports, key informant interviews, and FGDs.

The assessments will involve measuring the variance between intended frequencies of meetings, supervisory visits, and report submissions with actual performance.


How can we validate if observed changes can be attributed to the FHB initiative?

Five comparisons are to be used to determine the incremental impact of FHB interventions:

1. Comparison of the utilization of families from the baseline survey with that of FHB families.

• Utilization rates of households with the same characteristics as FHB holders will be generated using the FHB household baseline survey. These will be compared with the actual use rates of FHB households.

2. Analysis of the utilization of FHB households, controlling for household characteristics and health risks.

• This requires an analysis of individual characteristics of FHB families’ patterns against actual adherence to health use plans. A critical factor here is the drawing up of a health profile of recipient families during orientation.

3. Post-intervention examination of changes in the status of FHB holders and the status of the comparable population in the same municipalities.

• This involves comparing non-FHB holders with FHB families in the same municipalities using a post-intervention household survey. This comparison will assume that non-FHB holders’ pre-intervention status is to be obtained in the baseline survey, while FHB holders’ baseline status is to be established at the beginning of the intervention (later than the baseline).

• Secondly, the comparison will have to account for contaminations or leaks of the interventions into the non-FHB population in the same municipalities. The second issue is particularly important for the use of emergency transport and communication, enrolment, and outreach. The FHB initiative will not deny non-FHB families access to these services.


4. Examination of changes in the status of families from both FHB and non-FHB municipalities.

• The non-FHB municipality serves as a control municipality that would allow the isolation of temporal and spillover effects. This will mean the conduct of a post-intervention survey of a sample of families from a non-FHB municipality. The results will be compared with those of the baseline survey for that municipality (as the pre-intervention status).

• A non-FHB municipality with relatively accessible health facilities should be chosen to ensure no overstating of the observed FHB effect. As resources permit, the post-intervention survey may be extended to cover more than one non-FHB municipality.

5. Comparison of changes in factors outside the control of the FHB such as health budgets, provider quality levels, and other confounding factors need to be compared.

• How such changes affect the observed incremental FHB effect need to be determined. This comparison will contribute to the proper attribution of impacts.

In undertaking any of the five comparisons, the analysis should take on a difference-in-difference approach even when doing qualitative assessment of possible FHB effects. The difference in difference approach compares the changes in outcomes over time between the FHB families (the ones receiving the interventions) and the non-FHB families (the comparison group). This would allow us to take into account any differences in the FHB families and non-FHB families that are constant over time.

A key concern with any operations research that tries to implement a package of interventions is the determination of each intervention’s incremental contribution. The FHB faces the same challenge. Ideally, different combinations of the interventions should be randomly assigned among the study sites. However, LGU commitments and support as well as operational bottlenecks prevent the FHB from being implemented like a randomized experiment.


Emergency transport and communication and the outreach programs should be implemented in selected municipalities at a time. There should be a specific schedule to allow comparisons of the impact of individual interventions, while also considering what feasible interventions to organize and implement in a short period of time.

These are informed by results from preparatory work, indicating that the establishment of a functional emergency transport and communication network, as well as the systematic organization and frequent conduct of outreach services, would take some time and effort to mount. This schedule is summarized in Table 1.14.

Table 1.14: Schedule of implementation of FHB interventions

1st Quarter 2nd Quarter 3rd Quarter 4th Quarter

COM

POST

ELA

Book+Navigator

EMERGENCY TRANSPORT AND COMMUNICATION

MA

BIN

I

Book+Navigator

MA

CO Book+Navigator

MO

NTE

VIS

TA Book+Navigator

OUTREACH

NA

BUN

TUR

AN


The selective implementation of the interventions described in Table 1.14 allows for the following specific comparisons to be made:

1) The effect of the Book+Navigator – comparison of outcomes in Mabini and Maco with those in Nabunturan (as the non-FHB municipality).

2) The joint effect of the Book+Navigator and the functional emergency transport and communication network – comparison of the outcomes in Compostela with those in Nabunturan.

3) The joint effect of the Book+Navigator and outreach services – comparison of outcomes in Montevista with those in Nabunturan.

4) The effect of a functional emergency transport and communication network – comparison of outcomes in Compostela with those in Mabini and Maco.

5) The effect of outreach services – comparison of outcomes in Montevista with those in Mabini and Maco.

There is a possibility that in the current design, the effects of the outreach and emergency interventions may be completely confounded with the effects of unobserved factors specific to the municipalities where these interventions are implemented. A suggested adjustment to partly mitigate this is the utilization of the barangay as an alternative unit for implementing interventions.

For instance, emergency interventions are suggested for selected barangays in Maco, Mabini, and Montevista, and outreach interventions for selected barangays in Maco, Mabini and Compostela. The impact of these interventions can also be assessed by looking at the outcomes in these barangays.


These suggestions are under review, as they entail additional resource requirements. The political ramifications are also being considered, since it may be hard to convince local chief executives to limit implementation to the selected barangays.

To partly address the confounding factor, comparison of utilization patterns of non-FHB families with those of FHB families in these municipalities is suggested. The difference in the outcomes is expected to isolate the impact of the interventions from the impact of unobserved factors.

What instruments and activities will be conducted to measure observed changes and validate that these changes are due to the FHB?

In order to monitor the implementation of FHB interventions and evaluate their effects, several instruments and activities are proposed. These include:

1) Baseline and post-intervention surveys;

2) Forms accomplished by families and Navigators as part of the Book+Navigator intervention;

3) Profile forms for families and Navigators;

4) Intervention- and activity-specific forms to gather information on process indicators and the conduct of the interventions;

5) Focus group discussions; and

6) Meetings that form part of the management and governance of the FHB, like meetings of the FHB Technical Working Group (TWG) and the Steering Committee.


Surveys

Baseline surveys

Baseline surveys were conducted to generate information that will guide project planning and design, and provide basis for setting targets.

The following FHB baseline surveys were conducted with households, physicians, midwives, health facilities, and pharmacies across the 11 Compostela Valley municipalities:

1) Household survey and preliminary mapping of health facilities in Compostela Valley. This entailed a province-wide survey of sample households and a preliminary mapping of location of health facilities and other providers of health services where the sample households usually go to access maternal, neonatal, and child health services, as well as family planning counseling and commodities.

Sample barangays were randomly chosen and the survey focused only among index families with either a pregnant woman or a child below 12 months of age (called the index child). Eligible index families are further limited to families whose primary decision-maker is either the husband of the pregnant woman/father of the index child or his spouse.

This survey generates information like socio-economic characteristics, demographic characteristics and the household’s general health utilization pattern, health status of both the woman-respondent and the index child, and utilization of maternal, neonatal and childcare, nutrition, and family planning services.

The household survey was conducted from January 2007 to February 2008, with the preceding month as the reference period for utilization. A total of 2021 households were covered, distributed as follows: Compostela (203), Mabini (109), Maco (219), Montevista (110), and Nabunturan (216).


Data generated by the baseline household survey will also be useful in isolating the incremental contribution of each intervention and will be the main source of information for

• the health status and utilization patterns of families with the same characteristics as FHB beneficiaries, i.e., the expected use rates that would be utilized for the comparison with the actual use rates of FHB beneficiaries;

• the pre-intervention status and utilization patterns of households with the same characteristics as non-FHB and FHB families in the four pilot municipalities; and

• the pre-intervention status and utilization patterns of households with the same characteristics as non-FHB and FHB families in the control municipality of Nabunturan.

2) Physician and midwife survey and quality-of-care (QOC) assessment using vignettes. The survey aims to map health care professionals in Compostela Valley and measure quality of their maternal and child health care services. This survey provided information on the characteristics, income sources, and clinical and non-clinical practices of health professionals in their delivery of family planning, maternal, and child health services in Compostela Valley.

A total of 85 health professionals -- physicians (general practitioners and specialists), midwives, and nurses -- were randomly selected to answer vignettes and a provider survey. Thirty health professionals from the four FHB municipalities and 11 health professionals from Nabunturan participated. A total of 400 vignettes were administered.

VIGNETTES

Vignettes were administered among physicians, midwives and nurses to measure quality-of-care across family health providers. While these had five common cases, those vignettes for doctors had two additional ones. The cases which the vignettes touched on were

• Antenatal care;• UTI in pregnancy;• Uncomplicated birth delivery; • Postpartum hemorrhage; and• Newborn resuscitation.

Physician vignettes also covered neonatal sepsis and diarrhea (with mild/severe dehydration), two cases not found in the version for midwives and nurses.


3) Survey of patients, health facilities, and other health care providers in Compostela Valley. Patient exit interviews were conducted in public and private hospitals, RHUs, and lying-in and private clinics. This survey collects information on patients’ socio-economic and demographic characteristics, and contains a description of the confinement/consultation, services received, and expenditures. It also has results of a records review, information on patients’ health status, and satisfaction of maternal and pediatric patients.

Surveys were also conducted in public and private hospitals, RHUs, lying-in and private clinics, free-standing diagnostic facilities, and pharmacies. These surveys intend to map out health facilities, in terms of availability, affordability and quality of health services, and proximity and accessibility particularly to poor households. This mapping aims at forming an integrated network of facilities and professionals who will provide FHB services.

Patients from 13 inpatient facilities, which included public and private hospitals and lying-in/birthing homes, were included in the exit survey. Of the 61 inpatient respondents 16 were from FHB municipalities while nine came from Nabunturan.

From the 40 outpatient facilities, 155 outpatients were included in the patient exit survey. Of these outpatients, 29 were from FHB municipalities while 18 were from Nabunturan.

This baseline provider-side information would be utilized to measure pre-intervention levels of quality of care, most especially for the Compostela Valley Provincial Hospital and the other providers in the four FHB municipalities.


Post-intervention surveys

Ideally, the post-intervention survey should be conducted after a reasonable amount of time has elapsed following the start of implementation of the interventions. A year would be sufficient to assess the impact of, say, the full cycle of pregnancy and birth.

For the FHB initiative, post-intervention impact assessment surveys were conducted at around the ninth month (February 2010) after the start of the interventions. This was due more to practical and political realities. As general elections were scheduled in May, survey firms were expected to be fully occupied by March and April.

A household survey of families from the four FHB municipalities and Nabunturan was the major post-intervention survey conducted. A second set of surveys would be conducted on facilities and providers.

1) Post-intervention household survey. Unlike the province-wide baseline household survey, the proposed coverage of the post-intervention household survey was limited to the four FHB municipalities, one non-intervention site, the current control municipality (Nabunturan), and an additional municipality.

Resource limitations, including the need to finish the survey in a short time, constrained the coverage. Restricting the number of municipalities to be covered allowed for increasing the sample number of families in each site.

The post-intervention survey is to follow the sampling scheme used in the baseline household survey -- families with currently pregnant women (or were pregnant within the last year as of the reference period) or families with children under a year (or were one year old as of the reference period) -- to allow for direct comparison with baseline households.


This sampling scheme allowed previously-listed comparisons, since it could capture households that were

1) FHB beneficiaries;

2) Non-FHB beneficiaries;

3) Households with similar characteristics as the FHB and non-FHB beneficiaries in the control municipality; and

4) Households that may have received Navigator-less books or participated in FHB activities and interventions.

However, some FHB-eligible families may not qualify (i.e., those with children under 5 years but over a year old and the wife is not currently pregnant) and would not be sampled under this scheme.

The analysis for the outcomes of these families would just be a comparison of their status before and after the FHB initiative, as reflected in the forms filled out as part of the interventions.

The sampling scheme and sample size should also allow sufficient numbers of observations assessing the impact of the FHB interventions. The final sample size is still to be determined based on appropriate power calculations. As resources permit, oversampling of FHB families may be considered.

The post-intervention household survey would be:

a) a source of information for the health status and actual use rates of FHB beneficiaries for the first comparison;

b) the main source of information on the post-intervention status and utilization patterns of non-FHB households in the four FHB municipalities for the third comparison; and

c) the main source of information on the post-intervention status and utilization patterns of households in the control municipality of Nabunturan for the fourth comparison.


These information would also be utilized in analyzing the incremental impact of specific interventions. The post-intervention survey is also the backup information source should the collection of the Book+Navigator forms be hampered by non-functioning of the Navigators or the breakdown of the family-Navigator relationship.

The survey instrument to be used in the post-intervention household survey would be longer than the one used in the baseline survey. Two major additional sections would be included to measure spill-over effects of the interventions on non-FHB households in the FHB municipalities and in the control municipality, and to measure adherence to health use plans and some process indicators on the interventions (e.g., Navigator visits) for sampled FHB families.

2. Post-intervention facility survey and patient exits, provider vignettes. These surveys would be the main source of information for tracking changes in provider quality levels and other provider factors (changes in prices and presence of facilities and staff that could affect utilization of facilities by FHB and non-FHB families). Like the post-intervention household survey, the post-intervention facility survey would be limited to those providers identified in the baseline as being utilized by the households in the four FHB municipalities and in Nabunturan. A limited set of questionnaires and instruments sufficient to give indications on provider quality levels and factors would be administered.

Book+Navigator Forms

Forms that are required to be accomplished in the course of implementing the Book+Navigator intervention are also sources of information on utilization and other process indicators. These forms include:

1) the family health risk assessment form;2) the family journal;3) the family call sheet (FCS); 4) the health use plans; and5) GMP Navigator reporting form (see Appendix 2 for a summary

listing, the process flow and the timing of their collection).


These accomplished forms are the main sources of information for comparison of the status of FHB families before and after the intervention. These forms (or their photocopies) are to be collected at specified periods and encoded.

The family health risk assessment form

The Navigator uses this to assess the family’s health needs and risks and thus enables the Navigator to identify necessary services that the family should utilize.

The information it captures is useful for monitoring and evaluation purposes.

This form is to be collected at the beginning of the intervention period since it is a baseline indicator of FHB beneficiaries’ health needs. For additional health needs like pregnancy, the Navigators will have to make special reports.

The family journal

This is a monthly record of the Navigator’s visits with the family, recording activities undertaken during those visits, and other services accessed by the family during a current month.

This would show if Navigators visited at least once a month, and show what other services, aside from MNCHN-related ones, were accessed by the FHB families.

The health use plan form

This is accomplshed by the family, the Navigator, and the provider. It details the services that need to be accessed, the services actually accessed, when these were accessed, and identifies the provider of services. It records the family’s actual utilization of services.

Unlike the health risk assessment form, the health use plan would indicate whether FHB families actually obtained needed services as indicated by the risk assessment.


Since these serve as guides for the families and are accomplished in the course of accessing services, they cannot be collected from the families at the beginning or mid-term. These plans are only collected towards the end of the intervention period, near or at the time of the post-intervention survey.

To monitor intermediate-term service utilization of families based on their health use plans, family call sheets accomplished by the Navigators would be collected and used.

The information in the family call sheets are obtained from the health use plans and provide a family-level summary of services needed in a month, when and where these were obtained, what problems were encountered in accessing these services, and what were the adjustments carried out by the families and Navigators.

Navigators are to provide extra copies of these forms and these copies would be collected towards the middle of the intervention year. This is an alternative source of information available before the collection of health use plans.

GMP Navigator reporting form

This is another monitoring tool for process indicators.

It is a monthly reporting form that Navigators submit to their supervisor midwives, who in turn detail the summary tallies of the number of families who were given orientations, developed health use plans, utilized services, and claimed from PhilHealth.

Information from these reporting forms will be collected quarterly, although Navigators accomplish the forms monthly.


Profile forms for families and Navigators

In order to assess the impact of FHB interventions on utilization, socio-economic factors that could possibly influence utilization need to be controlled. Information on the socio-economic characteristics of FHB families can be seen in the socio-economic survey (SES), which elicits basic information on respondents’ educational and employment status, housing characteristics, assets, and household roster.

The form was patterned after the socio-economic part of the baseline household survey form. These are accomplished during the first meeting of Navigators and families. The information from these forms would be used to compare the status of FHB families at the beginning and at the end of the interventions. They would also be partly utilized in comparing utilization patterns of FHB holders with that of non-FHB holders from the baseline household survey.

Observed differences in utilization patterns of FHB families can be largely influenced by the performance of the Navigators, which in turn may be related to their skill levels, experience, and the possible incentives they expect to receive.

To control for these factors in the assessment, a similar socio-economic profile of Navigators is obtained through the Navigator profile form, which includes basic information on educational attainment, years of experience, as well as information on incentives and compensation they receive from the LGUs. The results of post-training assessment of the Navigators, which were composed of a post-training skills score and an assessment of family-Navigator interaction and skills in accomplishing forms conducted on a sample of Navigators, would also be integrated into the Navigator database.

Interventions and activity specific forms

Some of the services needed by families in far-flung areas are expected to be provided through outreach services interventions. To monitor how outreach activities effectively deliver the required services, an outreach monitoring form would be developed and administered during outreach activities.


The form would resemble a “patient chart” detailing services actually delivered and patients’ satisfaction with the services. It would have additional questions, specifically for FHB families, to obtain information needed to link with other family-level based data. This form would be an important source of spillovers of FHB services to non-FHB families.

A similar monitoring form will be developed for emergency services. The form would have to be accomplished by all those utilizing the emergency services, including non-FHB families.

Focus group discussions

Conducting focus group discussions (FGDs) to obtain qualitative information on the conduct of the interventions including feedback from families, is being planned. Select FHB families and Navigators would constitute the FGD participants. FGD topics would include operational concerns, families’ feedback on Navigators, outreach services conducted in Montevista, and emergency services in Compostela. The FGDs are proposed to be conducted a quarter after the interventions are implemented.

Maternal death reviews, specifically for FHB mothers who died during the intervention period, are also being considered.

Meetings that form part of the FHB governance structure

The FHB pilot has two working groups, the FHB Steering Committee and the FHB Technical Working Group (TWG). The FHB TWG is to meet monthly, while the FHB Steering Committee is to meet quarterly to discuss FHB concerns. Minutes and discussion notes from these meetings are envisioned to document important decisions and field level circumstances that may have an impact on the conduct of the interventions. Information in the forms submitted as part of the Book and Navigator interventions, particularly the GMP Navigator reporting form, are important inputs to these meetings.


How will the FHB pilot be implemented?

The FHB needs to be piloted to provide evidence on the FHB’s impact on health care use and on MNCHN outcomes. Specific evidence has to be generated to determine which features of the initiative contribute significantly to achievement of FHB outcomes. Moreover, necessary management and operational arrangements for FHB implementation cannot be effectively designed without field experience acquired from the pilot. Those arrangements are to guide the development of operational guidelines for future FHB implementation and roll-out.

Site selection

The provinces of Bulacan, Davao del Norte, Bukidnon, and Compostela Valley were originally considered for FHB piloting because of their commitment to health programs and the presence of DOH and USAID support. Compostela Valley was chosen because of its high maternal and infant mortality and low rates for contraceptive prevalence (CPR), antenatal care (ANC), skilled birth attendance (SBA), and fully immunized children (FIC) despite the presence of basic service delivery infrastructures.

The municipalities of Montevista, Maco, Compostela, and Mabini in Compostela Valley were selected for the distribution of the FHBs on the basis of their high maternal and infant mortality and low utilization rates of the health services, despite access to a full network of services including tertiary services.


Phases of the FHB pilot

The FHB pilot in Compostela Valley will be implemented in four phases:

1) preparation and baseline setting;

2) FHB design and validation;

3) implementation and measurement of effectiveness of the FHB on health care utilization; and

4) roll-out throughout the rest of the province.

Phase 1: Preparation and baseline setting

During the first phase, buy-in from DOH, Center for Health Development (CHD) XI, Compostela Valley, and partners will be secured. Baseline surveys and FGDs will be conducted to provide preliminary analyses relevant to FHB design and interventions. Providers will be oriented on their roles and expectations from them, especially concerning quality of care.

A steering committee headed by Governor Uy will be established. The Steering Committee, to be composed of the CHD, PhilHealth, mayors, and other local officials, is responsible for managing FHB pilot’s implementation.

A TWG composed of provincial and municipal health staff will assist the Steering Committee. The consultations and findings from surveys and FGDs done in the first phase will inform the FHB’s specific design in Compostela Valley.


Phase 2: FHB design and validation

Phase 2, which will run through February 2009, includes an assessment of the book’s prototype on the following areas:

1) effectiveness of the FHB form (carrier versus book); 2) effectiveness of content and form, including ease of use; 3) language; and 4) effectiveness of initial Navigator recruitment and training.

Initially, 24 families will be given books/carriers; and 12 Navigators will be trained to assist them. Assessment will be conducted in late November through December through FGDs and KIIs. Results of the assessment will be used in the FH Book’s revision, which is to be submitted to the Office of Health (OH).

Phase 3: Implementation and measurement of effectiveness of FHB on health care utilization

In Phase 3, many Navigators will be recruited, trained, and assigned to the initial 6,000 FHB recipients to maintain a 1:20 Navigator-family ratio. Navigators will be recruited from the pool of barangay health workers and other community-based volunteers, including mothers. They will be trained on how to orient families in using the FHB, how to assess family health needs, and how to support the development and accomplishment of family health use plans. The Rural Health Midwives (RHM) will supervise and monitor Navigators.

Phase 4 – Roll-out to the rest of the province

Roll-out throughout Compostela Valley depends on accomplishing FHB targets. Monitoring and evaluation schemes should thus be integrated in FHB operations. While the province, the municipalities, the CHD Davao Region, and USAID-cooperating agencies led by HPDP are to share the cost of implementing the initial FHBs in pilot municipalities, the cost of rolling out the FHB throughout the province is expected to be largely financed by commitments from local authorities, the CHD, and local sponsors.


Benchmarks and timelines for the FHB pilot’s implementation are shown on Table 1.15.

Expected lessons from the FHB pilot

The pilot is expected to draw out lessons from the various phases of the initiative and to recommend appropriate sequence and strategies for implementing various FHB interventions.

Specifically, it aims to:

1) determine strategic ways of securing local buy-in from national and local officials and stakeholders;

2) draw out lessons on how to establish and sustain local FHB management structure and operations;

3) determine each intervention’s contribution to the initiative’s desired outcomes;

4) improve each intervention’s design or develop a more appropriate one to local needs and conditions;

5) identify areas for improvement in the FHB implementation; and

6) guide the finalization of the FHB design for future roll-out to the rest of the province.

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How will the FHB pilot be managed?

Compostela Valley

• Sustaining governance structures for FHB. The FHB Steering Committee, headed by the governor, will exercise oversight function in FHB implementation. Every quarter, the Technical Working Group (TWG) tasked with managing the pilot, will provide reports to the Steering Committee regarding the following:

1) status of FHB distribution;

2) status of Navigator deployment;

3) feedback on Navigator performance;

4) status of process and output indicators (i.e., families oriented, family health needs assessed, health use plans made and completed); and

5) issues/difficulties encountered by families and Navigators in developing and adhering to health use plans.

To generate this report, the TWG, headed by the PHO, shall meet at least once a month and consolidate findings into a quarterly report after convening the quarterly meeting of Navigators.

• Managing and sustaining FHB interventions. The province will be responsible for implementing the various FHB interventions, including updating and printing of the Book, recruitment and training of Navigators, maintaining and sustaining the health emergency transport and communication network, conducting periodic outreach services, building the CEmONC capacities of the Compostela Valley Provincial Hospital (CVPH), enroling FHB families in PhilHealth, and assisting critical facilities to comply with PhilHealth accreditation standards.


• Matching demand with the corresponding supply of needed FHB services and commodities. Navigators shall consolidate monthly the family call sheets which record the family’s health needs. They will submit a summary call sheet to the supervising rural health midwife, who will summarize all the health commodity and service requirements of families through the resource inventory sheet which is to be submitted to the MHO. This instrument guides the MHO in estimating the service and commodity requirements for a particular period. Should the expected requirements exceed local capacity to provide, the MHO may request assistance from the PHO or from CHD Davao Region for augmentation of its budget on specific MNCHN concerns.

CHD-Davao Region

CHD-Davao Region will assist in capacitating Navigators and in monitoring compliance of facilities with DOH licensing standards. It will also provide technical leadership on matters related to maternal, newborn and child health, and guiding FHB implementation towards the achievement of desired MNCHN outcomes.

PhilHealth

PhilHealth Region XI will support FHB intervention on PhilHealth enrolment with campaigns for universal health insurance coverage and the conduct of orientation sessions on PhilHealth benefits. The agency will become a strategic partner in facilitating accreditation of facilities for PhilHealth OPB, TB-DOTS and maternal and child packages (MCP).


Inter-CA collaboration on FHB

HPDP As the lead agency for the initiative, HPDP shall provide overall support to the management and operations, as well as the monitoring of the FHB in Compostela Valley.

It has assisted the province in getting baseline information needed for identifying the type and design of interventions needed in the province. This guided the selection of appropriate sites and beneficiaries, as well as the setup of structures and systems needed for the implementation of various FHB interventions (such as the Book and Navigator, the health emergency transport and communication network, regular outreach services, access to CEmONC facility, and support to PhilHealth accreditation and enrolment).

In line with its policy development thrust, HPDP jointly developed the core maternal and neonatal standards with the DOH. These now serve as the gold standard for the delivery of MNCHN services in Compostela Valley. Orientations were made with CHD XI and the PHO to update public and private health providers on these standards.

For the pre-implementation phase, HPDP is assisting the province in recruiting and training Navigators, selecting families, designing and printing the books, establishing a functional health emergency transport and communication network, designing the outreach activity, linking CVPH to funding sources, facilitating PhilHealth accreditation and renewal, and seeking sponsorships for various FHB activities.


To track the progress of the various interventions and immediately address impending operational problems, HPDP will conduct quarterly monitoring as well as mid-year and end-of year program evaluations. This entails conduct of surveys as well as FGDs with families, Navigators, midwives and other stakeholders in the initiative. Results of the surveys shall guide HPDP in making the necessary program adjustments and design improvement.

HPDP shall continue to monitor and evaluate the impact of FHB interventions in the four pilot municipalities until 2011.

HPDP will be the principal source of support during the first year of FHB implementation. Assistance from other CAs will come mostly in the roll-out phase.

HealthGov Assistance to FHB pilot sites. To sustain HPDP support for PhilHealth accreditation of critical facilities in the four pilot sites, HealthGov will provide the province with technical assistance on fund management.

Consultations will be made with the governor, mayors, and service providers in developing arrangements for managing PhilHealth capitation funds and reimbursements in a way that will sustain desired health outcomes. For instance, a local resolution may be issued enjoining health providers to share part of their reimbursements and capitation funds with the health emergency transport providers who brought the patient to the facility, and the TBAs who made the referrals. HealthGov can help organize sessions on this and can guide the province in drafting such issuance.


As part of its resource mobilization support, HealthGov will assist the province in generating funds for sustaining FHB interventions. It shall provide technical assistance to the province in developing grant applications and establishing resource generation schemes such as introduction of user’s fees in a public health facility.

Support can also be given in terms of identifying sources of FHB funds within the local budget and allocating portions of the 20% development fund, local taxes, and other similar coffers for the initiative.

Additionally, HealthGov will assist the Compostela MHO in securing a supplemental budget for setting up and maintaining its health emergency transport and communication network, and the Montevista MHO for the conduct of periodic outreach services.

Consultations with the mayors and barangay captains of the four pilot municipalities will likewise be made to leverage their share in the PhP 1.5 million family planning grant given to Compostela Valley for increased budgetary support for Navigator/BHW transport and training allowances and incentives as well as for procurement of MNCHN-related commodities.

HealthGov shall ensure that activities and investment requirements for Navigators, health emergency transport and communication network, outreach services, CVPH upgrades, and PhilHealth enrolment and accreditation are integrated in their 2010 Annual Investment Plan (AIP) and Province-wide Investment Plan for Health (PIPH) Annual Operational Plan (AOP).


To enhance the CVPH’s CEmONC capacity, HealthGov, at the province’s request, will roll out the Service Delivery for Excellence in Health (SDExH) to encourage a positive attitude towards patients among health personnel and to improve the quality of service delivery in the pilot sites.

This activity aims not only to help providers analyze the gap in their performance, but also to update them on clinical and service delivery standards and offer coaching and mentoring sessions in between workshops. The SDExH initially targeted the CVPH OB-Gynecology and Surgery personnel.

However, with the implementation of HealthGov’s Quality Assurance Partnership Committee (QAPC) initiative starting in April 2009, this initiative would be integrated with the FHB initiative in Compostela Valley. The QAPC is a governance mechanism that brings together local government officials, health service providers, members of civil society, and community representatives to address issues on accessibility, availability, and quality of MNCHN-related services in local health facilities.

Unlike other quality assurance programs where only service providers assess the quality of services, the QAPC intervention not only provides a venue for civil society to give feedback on health service delivery and quality, but also holds local officials and providers accountable to their communities for services delivered.


The QAPC is envisioned to provide oversight and problem-solving actions to improve MNCHN services in the facility. In Compostela Valley, a QAPC is proposed to be organized in the CVPH. In line with this, the QAPC orientation workshops will include an orientation on the SDExHH program. There are proposals to integrate into the QAPC the core maternal standards developed under the FHB.

Assistance to roll-out areas. For roll-out areas, HealthGov will coordinate with PhilHealth Regional Office (PRO) XI and the PHO in organizing sessions to orient heath service providers and LCEs on how they can benefit from PhilHealth by maximizing reimbursements. This is to encourage them to apply for or renew PhilHealth accreditation of their facilities and fast track PhilHealth enrolment of families to ensure optimal PhilHealth reimbursements.

HealthGov will also support municipalities in lobbying for supplemental budget for investments needed for MCP accreditation. Through SDExHH, support will also be provided for workshops and coaching/mentoring sessions aimed at improving the quality of services provided by RHUs.

HealthPRO To promote an environment conducive to the behavior change expected to result from the FHB interventions, HealthPRO will assist in a number of behavior change communication (BCC) on sensitive areas and issues.

Local champions and influential persons are keys to the promotion of healthy behaviors of target beneficiaries. Hence, the FHB initiative intends to engage them to endorse and promote the use of FHB and to help forge good relationships between families and the Navigators.


Arming these local champions and opinion leaders with appropriate health messages and information materials, and improved presentation and relational skills, will help families better understand the value of FHB interventions.

HealthPRO, through their Gabay, Damay, at Hawak Kamay programs which focus on developing and enhancing the network or areas of contact points, will help identify and develop local champions and opinion leaders. Through these programs, HealthPRO will also assist in the promotion and popularization through strategic brand development of the planned “FHB hour”–envisioned to be a “tag” or “brand” for all activities related to FHB implementation.

HealthPRO’s Gabay, Damay, at Hawak Kamay programs will also boost the planned promotion of CVPH and its services as a Center for Health and Wellness.

While the FHB remains a very good source of health messages and information on good health behavior and various health use plans, it remains a reading material without the Navigator. HPDP thus made the FHB+Navigator one package of behavior change intervention.

These necessary skills and interventions will be made possible through HealthPRO’s special assistance to the FHB initiative. Specifically, it will help in developing modules aimed at improving health service providers’ basic relational skills and in motivating them to value their work and role in the community.


References

Acuin, C. 2008. Conduct of Focus Group Discussions (FGDs) on Family Planning Behaviors among Men and Women in Selected Municipalities of Compostela Valley Province. Report submitted to the Health Policy Development Program, Quezon City, Philippines.

Bale, J., Stoll, B., and Lucas, O. (eds.) 2003. Improving Birth Outcomes: Meeting the Challenges in the Developing World. Washington, DC: National Academy of Sciences and Institute of Medicine.

Campbell, O.M. and Graham, W.J. 2006. “Strategies for reducing maternal mortality: getting on with what works.” The Lancet, 368 (9543): 1284-1299.

Compostela Valley Provincial Health Office. 2007. Maternal and Child Death Report. Manila, Philippines: Field Health Service Information System.

Costello, M., Lacuesta, M., RamaRao, S. and Jain, A. 2001. ”A Client-Centered Approach to Family Planning: The Davao Project.” Studies in Family Planning, 32: 302–314. Retrieved from http://www.jstor.org/pss/2696318.

Datta, M. and Nichter, M. 2003. Introducing Culturally Sensitive Tuberculosis Education and Context Specific Patient Screening. 1-30. Retrieved from http://www.tnmmu.ac.in/edu.pdf.

Department of Health (DOH). 2000. Philippine Health Statistics. Manila, Philippines: DOH.

____________________. 2004. Philippine Health Statistics. Manila, Philippines: DOH.

____________________. 2005. The National Objectives for Health 2005-2010. Manila, Phillipines: DOH.

____________________. 2007. Field Health Service Information System 2007. Manila, Philippines: DOH.


Family Health International Institute for HIV/AIDS (FHI). 2003). Baseline Assessment Tools for Preventing Mother to Child Transmission of HIV. Arlington, VA: Family Health International. Retrieved from http://www.fhi.org/en/hivaids/pub/guide/baseline+assessment+tools+for+pmtct.htm.

Gwatkin, D., Rutstein, S., Johnson, K., Suliman, E., Wagstaff, A., and Amouzou, A. 2007. Socio- economic Differences in Health, Nutrition and Population in the Philippines. Washington, DC: World Bank.

Habana, M., Mantaring, J. et al. 2008. The Family Health Book: Maternal, Neonatal and Child Health Care Packages and Standards for Practice and Facilities. Manila, Philippines: Foundation for the Advancement of Clinical Epidemiology, Inc. and Health Policy Development Program.

Health Policy Development Program (HPDP). 2007a. Family Health Book Baseline Facility Survey. Quezon City, Philippines: UPecon Foundation, Inc.-Health Policy Development Program..

____________________. 2007b. Family Health Book Baseline Household Survey. Quezon City, Philippines: UPecon Foundation, Inc.-Health Policy Development Program.

____________________. 2008. The Family Health Book Navigator’s Kit. Quezon City, Philippines: UPecon Foundation, Inc.-Health Policy Development Program.

Health Policy Development Program (HPDP) and Social Development Research Center (SDRC). 2008. Focus Group Discussion Report. Quezon City, Philippines: UPecon Foundation, Inc.-Health Policy Development Program.

National Institute of Population Research and Training (NIPORT), ORC Macro, Johns Hopkins University and ICDDR, B. (2003). Bangladesh Maternal Health Services and Maternal Mortality Survey 2001. Dhaka, Bangladesh and Calverton, Maryland: NIPORT, ORC Macro, Johns Hopkins University, and ICDDR, B. Retrieved from http://www.measuredhs.com/pubs/pub_details.cfm?ID=456.


National Statistics Office (NSO). 2006. Family Income and Expenditure Survey. Manila, Philippines. Retrieved from http://www.census.gov.ph/data/pressrelease/2008/ie06frtx.html.

____________________. 2007. Family Planning Survey 2006. Metro Manila: NSO.

National Statistics Office (NSO) and ORC Macro. 2004. National Demographic and Health Survey 2003. Calverton, Maryland: NSO and ORC Macro. World Health Organization (WHO). 2000. Core Health Indicators for Philippines. Washington, DC: World Health Organization. Retrieved from http://www.who.int/whosis/indicators.


App

endi

x 1:

Log

fra

me

of F

HB

inte

rven

tion

s by

inte

rmed

iate

out

com

e

Use

of M

oder

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mil

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ng M

etho

d

Inte

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iate

Out

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e In

dica

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A

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ivit

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ons

• N

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s w

ho

cont

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acce

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mod

ern

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etho

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uenc

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d un

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nanc

ies

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ors

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dis

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ed

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a so

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ide

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mon

thly

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rt, N

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ata

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ce:

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onth

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• N

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r of N

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sour

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thly

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rts)

• N

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ors

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ed (

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of

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th

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user

s w

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to u

se fa

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d ac

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ty

of fa

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ies

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ting

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r FP

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mpl

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n •

Adhe

renc

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each

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se p

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tio

of w

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d w

ith

FP

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g to

the

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al n

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wom

en n

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ng F

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of s

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C, F

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ew

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ptor

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m

oder

n FP

m

etho

ds•

Shift

ers

from

tr

aditi

onal

to

mod

ern

FP

• N

umbe

r of n

on-

FHB

fam

ilies

pr

ovid

ed w

ith

RH

serv

ices

dur

ing

outr

each

• M

ix o

f ser

vice

s•

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et re

cipi

ents

’ sc

hedu

le

• Ra

tio

of

wom

en

prov

ided

w

ith

pills

to th

e to

tal n

umbe

r of w

omen

ne

edin

g pi

lls b

ased

on

the

RH H

UP

• Ra

tio o

f wom

en w

ho re

ceiv

ed D

MPA

to

th

e to

tal

num

ber

of

wom

en

need

ing

DM

PA b

ased

on

the

RH H

UP

• Ra

tio

of f

amily

rec

ipie

nts

of F

P co

mm

odit

ies

(con

dom

s, p

ills,

IUD

, D

MPA

) to

th

e to

tal

num

ber

of

fam

ilies

nee

ding

FP

com

mod

itie

s ba

sed

on th

e RH

HU

P

Freq

uenc

y•

Out

reac

h sc

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le


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rmed

iate

Out

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e In

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Barr

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ddre

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iate

Resu

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puts

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ivit

ies

Proc

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Indi

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terv

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ons

• Ra

tio

of w

omen

who

und

erw

ent

BTL

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ring

out

reac

h to

the

tot

al

num

ber

of w

omen

nee

ding

BTL

ba

sed

on th

e RH

HU

P•

Rati

o of

m

en

who

un

derw

ent

vase

ctor

my

duri

ng

outr

each

to

th

e to

tal n

umbe

r of m

en n

eedi

ng

vase

ctom

y ba

sed

on th

e RH

HU

P•

Num

ber

of

hard

-to-

reac

h FH

B be

nefic

iari

es

serv

ed

by

an

outr

each

gro

up

(Dat

a So

urce

s:

FHB

TWG

m

onth

ly

repo

rts;

Nav

igat

or C

all

Shee

ts,

FHB

Book

, Out

reac

h M

onito

ring

For

ms)

Prom

otio

n of

ou

trea

ch s

ervi

ces

• N

umbe

r of a

nnou

ncem

ents

, sch

edul

e of

out

reac

h se

rvic

es d

istri

bute

d (D

ata

Sour

ce: F

HB

TWG

mon

thly

repo

rts)

Cond

uct o

f out

reac

h•

Tota

l num

ber o

f clie

nts

serv

ed•

Num

ber o

f FH

B fa

mili

es s

erve

d•

Num

ber o

f non

-FH

B Fa

mili

es S

erve

d


term

edia

teO

utco

me

Indi

cato

rs

Barr

iers

A

ddre

ssed

Inte

rmed

iate

Resu

lts/

Out

puts

Proc

ess/

Act

ivit

ies

Proc

ess

Indi

cato

rsIn

terv

enti

ons

• Ra

tio

of

actu

al

num

ber

of

outr

each

se

rvic

es

to

plan

ned

num

ber o

f out

reac

h se

rvic

es•

Freq

uenc

y of

out

reac

h se

rvic

es in

a

quar

ter

(Dat

a So

urce

s: F

HB

TWG

mon

thly

re

port

s, N

avig

ator

cal

l sh

eets

, FH

B Bo

ok,

Out

reac

h m

onit

orin

g fo

rms,

C

lient

sat

isfa

ctio

n fo

rm)

Qua

lity

Mon

itor

ing

• N

umbe

r of

cl

ient

s co

mpl

aini

ng

abou

t sto

ck-o

uts o

f FP

com

mod

ities

(p

ills,

con

dom

s)•

Num

ber

of f

amili

es c

ompl

aini

ng

on a

bsen

ce o

f FP

coun

selo

rs•

Num

ber

of f

amili

es c

ompl

aini

ng

on a

bsen

ce o

f FP

prov

ider

s•

Num

ber

of

clie

nts

com

plai

ning

on

sc

hedu

le

(e.g

. Ta

rdin

ess)

of

ou

trea

ch

(Dat

a So

urce

s: F

HB

TWG

mon

thly

re

port

s, N

avig

ator

cal

l sh

eets

, FH

B Bo

ok,

Out

reac

h m

onit

orin

g fo

rms,

C

lient

sat

isfa

ctio

n fo

rm)


Skil

led

Birt

h At

tend

ant

Inte

rmed

iate

Out

com

e In

dica

tors

Barr

iers

A

ddre

ssed

Inte

rmed

iate

Resu

lts/

Out

puts

Proc

ess/

Act

ivit

ies

Proc

ess

Indi

cato

rsIn

terv

enti

ons

• N

umbe

r of

mot

hers

as

sist

ed b

y sk

illed

birt

h at

tend

ants

Misc

once

ptio

ns

rega

rdin

g fa

cilit

y-ba

sed

deliv

ery

• Bi

rth

heal

th u

se

plan

com

plet

ed•

Birt

h he

alth

use

pl

an a

dher

ed to

Book

Dev

elop

men

t•

Cont

ent

deve

lopm

ent

• Fo

rm

deve

lopm

ent

• Fi

nal p

roto

type

app

rove

d by

U

SAID

-OH

Book

+Nav

igat

or•

Mes

sage

s•

Form

s•

Know

ledg

e•

List

of h

ealth

pro

vide

rs•

Trai

ned

Nav

igat

ors

Book

dis

trib

utio

n•

Tota

l nu

mbe

r of

fam

ilies

ide

ntifi

ed

(Dat

a so

urce

: FH

B TW

G m

onth

ly re

port)

• To

tal

num

ber

of f

amili

es i

dent

ified

fr

om m

aste

rlist

(D

ata

sour

ce:

FHB

TWG

mon

thly

repo

rt )

• N

umbe

r of

fam

ilies

ide

ntifi

ed b

y co

-FH

B be

nefic

iarie

s (D

ata

sour

ce:

FHB

TWG

mon

thly

repo

rt, N

avig

ator

repo

rts)

• N

umbe

r of

fam

ilies

ide

ntifi

ed b

y N

avig

ator

s (D

ata

sour

ce: F

HB

TWG

m

onth

ly re

port

, Nav

igat

or re

port

s)•

Num

ber

of

fam

ilies

gi

ven

book

s (D

ata

sour

ce:

FHB

TWG

m

onth

ly

repo

rt, N

avig

ator

repo

rts)


term

edia

teO

utco

me

Indi

cato

rs

Barr

iers

A

ddre

ssed

Inte

rmed

iate

Resu

lts/

Out

puts

Proc

ess/

Act

ivit

ies

Proc

ess

Indi

cato

rsIn

terv

enti

ons

Recr

uitm

ent,

sele

ctio

n, a

nd

train

ing

of N

avig

ator

s•

Recr

uitm

ent

• D

evel

opm

ent o

f tr

aini

ng m

anua

ls•

Nav

igat

or’s

Kit

• N

umbe

r of N

avig

ator

s rec

ruite

d (D

ata

sour

ce: F

HB

TWG

mon

thly

repo

rts)

• N

umbe

r of

Nav

igat

ors

train

ed (

Dat

a so

urce

: FH

B TW

G m

onth

ly re

ports

)•

Num

ber

of N

avig

ator

s w

ho p

asse

d po

st-tr

aini

ng e

valu

atio

n (D

ata

sour

ce:

FHB

TWG

mon

thly

repo

rts)

• N

umbe

r of N

avig

ator

s w

ho q

uit (

Dat

a so

urce

: FH

B TW

G m

onth

ly re

ports

)

Fam

ily-N

avig

ator

m

atch

ing

• N

umbe

r of f

amili

es w

ith

assi

gned

N

avig

ator

s (D

ata

sour

ce: F

HB

TWG

m

onth

ly re

port

)•

Dis

trib

utio

n of

Nav

igat

ors

by ra

tio

of

Nav

igat

ors

to

fam

ilies

(D

ata

sour

ce: F

HB

TWG

mon

thly

repo

rt)

Fam

ily-N

avig

ator

Co

ntac

ts•

Vis

its

• FH

B ho

ur•

Ori

enta

tion

• Ra

tio

of

the

num

ber

of

FHB

bene

ficia

ries

w

ho

agre

ed

to

orie

ntat

ion

to

the

num

ber

of

FHB

bene

ficia

ries

(D

ata

sour

ce:

Fam

ily c

all s

heet

s)•

Num

ber o

f Nav

igat

ors

who

vis

ited

al

l ass

igne

d fa

mili

es a

t le

ast

once

a

mon

th (

Dat

a so

urce

: Su

mm

ary

call

shee

ts, N

avig

ator

jour

nal)


Inte

rmed

iate

Out

com

e In

dica

tors

Barr

iers

A

ddre

ssed

Inte

rmed

iate

Resu

lts/

Out

puts

Proc

ess/

Act

ivit

ies

Proc

ess

Indi

cato

rsIn

terv

enti

ons

Inte

ract

ion

wit

h ot

her k

ey fa

mily

m

embe

rs

• Pr

esen

ce

of

nego

tiat

ed

and

regu

lar

FHB

hour

(D

ata

sour

ce:

Nav

igat

or jo

urna

l, FH

Boo

k)•

Rati

o of

th

e nu

mbe

r of

F H

B be

nefic

iari

es

whi

ch

agre

ed

to

be

asse

ssed

to

th

e nu

mbe

r of

fa

mili

es

whi

ch

agre

ed

to

be

orie

nted

(D

ata

sour

ce:

Sum

mar

y ca

ll sh

eets

, Nav

igat

or jo

urna

l)•

Num

ber

of

visi

ts

whe

re

both

m

othe

r an

d fa

ther

w

ere

key

info

rman

ts

(Dat

a so

urce

: N

avig

ator

jour

nal)

Birt

h he

alth

use

pl

an d

evel

opm

ent

• Pr

ovid

er

orie

ntat

ion

• Pr

ovid

er fa

mily

co

ntac

ts

• N

umbe

r of

pro

vide

rs o

rien

ted

on

the

FHB

(Dat

a so

urce

: FH

B TW

G

mon

thly

rep

ort)

• Ra

tio

of n

umbe

r of p

rovi

ders

who

fil

led

out

Birt

h H

UP

to n

umbe

r of

pro

vide

rs v

isit

ed b

y fa

mili

es

(Dat

a so

urce

: Fa

mily

cal

l sh

eet,

Fam

ily jo

urna

l)


term

edia

teO

utco

me

Indi

cato

rs

Barr

iers

A

ddre

ssed

Inte

rmed

iate

Resu

lts/

Out

puts

Proc

ess/

Act

ivit

ies

Proc

ess

Indi

cato

rsIn

terv

enti

ons

• Ra

tio

of

the

num

ber

of

FHB

bene

ficia

ries

w

ho

agre

ed

to

deve

lop

a Bi

rth

heal

th u

se p

lan

to

the

tota

l nu

mbe

r of

FH

B be

nefic

iari

es a

sses

sed

to h

ave

the

need

for

a B

irth

hea

lth

use

Plan

(D

ata

sour

ce:

Fam

ily c

all

shee

t, Fa

mily

jour

nal)

• N

umbe

r of

mot

hers

as

sist

ed b

y sk

illed

birt

h at

tend

ants

Inac

cess

ibili

ty

of fa

cilit

ies

• Bi

rth

heal

th u

se

plan

com

plet

ed•

Birt

h he

alth

use

pl

an a

dher

ed to

Emer

genc

y Tr

ansp

ort a

nd

Com

mun

icat

ion

Net

wor

k•

List

of c

onta

ct

num

bers

• Fu

ncti

onal

EM

ne

twor

k

• N

umbe

r of

ca

lls

rece

ived

fr

om

FHB

fam

ilies

due

to d

eliv

ery

• N

umbe

r of

ca

lls

rece

ived

fr

om

non-

FHB

fam

ilies

due

to d

eliv

ery

(Dat

a so

urce

s: E

M p

rovi

der

log,

FH

B TW

G

quar

terl

y re

port

s,

Nav

igat

or

call

shee

ts)

Emer

genc

y Tr

ansp

ort

and

Com

mun

icat

ion

Net

wor

k•

List

of c

onta

ct

num

bers

• Fu

ncti

onal

EM

ne

twor

k

Mon

itor

ing

of

resp

onsi

vene

ss

of E

M n

etw

ork

• N

umbe

r of

em

erge

ncy

calls

re

spon

ded

to b

y th

e ne

twor

k (D

ata

sour

ces:

EM

pro

vide

r log

, FH

B TW

G

quar

terl

y re

port

s,

Nav

igat

or

call

shee

ts)


Full

y Im

mun

ized

Chi

ld

Inte

rmed

iate

Out

com

e In

dica

tors

Barr

iers

A

ddre

ssed

Inte

rmed

iate

Resu

lts/

Out

puts

Proc

ess/

Act

ivit

ies

Proc

ess

Indi

cato

rsIn

terv

enti

ons

• N

umbe

r of

child

ren

fully

im

mun

ized

an

d on

sc

hedu

le

Lack

of

know

ledg

e on

risk

s an

d co

nseq

uenc

es

of n

ot h

avin

g ch

ildre

n va

cci-

nate

d, d

elay

ed

dete

ctio

n of

dis

ease

s,

impr

oper

hy

gien

e, a

nd

inad

equa

te

nutr

ition

• W

ell b

aby

heal

th

use

plan

com

plet

ed•

Wel

l bab

y he

alth

us

e pl

an a

dher

ed to

• Si

ck c

hild

hea

lth

use

plan

com

plet

ed•

Sick

chi

ld h

ealth

us

e pl

an a

dher

ed to

Book

Dev

elop

men

t•

Cont

ent

deve

lopm

ent

• Fo

rm

deve

lopm

ent

• Fi

nal p

roto

type

app

rove

d by

U

SAID

-OH

Book

+Nav

igat

or•

Mes

sage

s•

Form

s•

Know

ledg

e•

List

of h

ealth

pro

vide

rs•

Trai

ned

Nav

igat

ors

Book

dis

trib

utio

n•

Tota

l nu

mbe

r of

fam

ilies

ide

ntifi

ed

(Dat

a so

urce

: FH

B TW

G m

onth

ly re

port)

• To

tal

num

ber

of f

amili

es i

dent

ified

fr

om m

aste

rlist

(D

ata

sour

ce:

FHB

TWG

mon

thly

repo

rt)

• N

umbe

r of

fam

ilies

ide

ntifi

ed b

y co

-FH

B be

nefic

iarie

s (D

ata

sour

ce:

FHB

TWG

mon

thly

repo

rt, N

avig

ator

repo

rts)

• N

umbe

r of

fam

ilies

ide

ntifi

ed b

y N

avig

ator

s (D

ata

sour

ce: F

HB

TWG

m

onth

ly re

port

, Nav

igat

or re

port

s)•

Num

ber

of

fam

ilies

gi

ven

book

s (D

ata

sour

ce:

FHB

TWG

m

onth

ly

repo

rt, N

avig

ator

repo

rts)


term

edia

teO

utco

me

Indi

cato

rs

Barr

iers

A

ddre

ssed

Inte

rmed

iate

Resu

lts/

Out

puts

Proc

ess/

Act

ivit

ies

Proc

ess

Indi

cato

rsIn

terv

enti

ons

Recr

uitm

ent,

sele

ctio

n an

d tra

inin

g of

Nav

igat

ors

• Re

crui

tmen

t•

Dev

elop

men

t of

trai

ning

man

uals

• N

avig

ator

’s K

it

• N

umbe

r of N

avig

ator

s rec

ruite

d (D

ata

sour

ce: F

HB

TWG

mon

thly

repo

rts)

• N

umbe

r of

Nav

igat

ors

train

ed (

Dat

a so

urce

: FH

B TW

G m

onth

ly re

ports

)•

Num

ber

of N

avig

ator

s w

ho p

asse

d po

st-tr

aini

ng e

valu

atio

n (D

ata

sour

ce:

FHB

TWG

mon

thly

repo

rts)

• N

umbe

r of N

avig

ator

s w

ho q

uit (

Dat

a so

urce

: FH

B TW

G m

onth

ly re

ports

)

Fam

ily-N

avig

ator

m

atch

ing

• N

umbe

r of

fam

ilies

wit

h as

sign

ed

Nav

igat

ors

(Dat

a so

urce

: FH

B TW

G

mon

thly

repo

rt)

• D

istr

ibut

ion

of N

avig

ator

s by

rati

o of

N

avig

ator

s to

fa

mili

es

(Dat

a so

urce

: FH

B TW

G m

onth

ly re

port

)

Fam

ily-N

avig

ator

Co

ntac

ts•

Vis

its

• FH

B ho

ur•

Ori

enta

tion

• In

tera

ctio

n w

ith

othe

r key

fam

ily

mem

bers

• Ra

tio

of

the

num

ber

of

FHB

bene

ficia

ries

w

ho

agre

ed

to

be o

rien

ted

to n

umbe

r of

FH

B be

nefic

iari

es (D

ata

sour

ce: F

amily

ca

ll sh

eets

)•

Num

ber o

f Nav

igat

ors

who

vis

ited

al

l ass

igne

d fa

mili

es a

t le

ast

once

a

mon

th (

Dat

a so

urce

: Su

mm

ary

call

shee

ts, N

avig

ator

jour

nal)


Inte

rmed

iate

Out

com

e In

dica

tors

Barr

iers

A

ddre

ssed

Inte

rmed

iate

Resu

lts/

Out

puts

Proc

ess/

Act

ivit

ies

Proc

ess

Indi

cato

rsIn

terv

enti

ons

• Pr

esen

ce

of

nego

tiat

ed

and

regu

lar

FHB

hour

(D

ata

sour

ce:

Nav

igat

or jo

urna

l, FH

Boo

k)•

Ratio

of

th

e nu

mbe

r of

FH

B be

nefic

iarie

s w

ho

agre

ed

to

be

asse

ssed

to th

e nu

mbe

r of f

amili

es

whi

ch a

gree

d to

be

orie

nted

(Dat

a so

urce

: Su

mm

ary

call

shee

ts,

Nav

igat

or jo

urna

l)•

Num

ber o

f vis

its w

here

bot

h m

othe

r an

d fa

ther

are

key

info

rman

ts (D

ata

sour

ce: N

avig

ator

jour

nal)

• N

umbe

r of N

avig

ator

reas

sign

men

ts

(Dat

a so

urce

: FH

B TW

G m

onth

ly

mee

tings

)

Wel

l bab

y/si

ck

child

hea

lth

use

plan

dev

elop

men

t•

Prov

ider

or

ient

atio

n•

Prov

ider

fam

ily

cont

acts

• N

umbe

r of

pro

vide

rs o

rien

ted

on

the

FHB

(Dat

a so

urce

: FH

B TW

G

mon

thly

repo

rt)

• Ra

tio

of n

umbe

r of

pro

vide

rs w

ho

fille

d ou

t wel

l bab

y/si

ck c

hild

HU

P to

num

ber

of p

rovi

ders

vis

ited

by

fam

ilies

(D

ata

sour

ce: F

amily

cal

l sh

eet,

Fam

ily jo

urna

l)


term

edia

teO

utco

me

Indi

cato

rs

Barr

iers

A

ddre

ssed

Inte

rmed

iate

Resu

lts/

Out

puts

Proc

ess/

Act

ivit

ies

Proc

ess

Indi

cato

rsIn

terv

enti

ons

• Ra

tio

of

the

num

ber

of

FHB

bene

ficia

ries

w

ho

agre

ed

to

deve

lop

a w

ell

baby

/sic

k ch

ild

heal

th

use

plan

to

th

e to

tal

num

ber

of

FHB

bene

ficia

ries

as

sess

ed a

s ha

ving

to

have

the

ne

ed f

or a

wel

l ba

by/s

ick

child

he

alth

use

pla

n

• N

umbe

r of

sick

chi

ldre

n at

tend

ed

Inac

cess

ibili

ty

of fa

cilit

ies

• Si

ck c

hild

hea

lth u

se

plan

adh

ered

toEm

erge

ncy

Tran

spor

t and

Co

mm

unic

atio

n N

etw

ork

• Li

st o

f con

tact

nu

mbe

rs•

Func

tion

al E

M

netw

ork

• N

umbe

r of

ca

lls

rece

ived

fr

om

FHB

fam

ilies

due

to a

sic

k ch

ild•

Num

ber o

f cal

ls re

ceiv

ed fr

om n

on-

FHB

fam

ilies

due

to a

sic

k ch

ild

• N

umbe

r of

FH

B fa

mili

es

who

ac

cess

ed E

M fo

r a s

ick

child

Emer

genc

y Tr

ansp

ort

and

Com

mun

icat

ion

Net

wor

k•

List

of c

onta

ct

num

bers

• Fu

ncti

onal

EM

ne

twor

k

Mon

itor

ing

of

resp

onsi

vene

ss

of E

M n

etw

ork

• N

umbe

r of

em

erge

ncy

calls

re

spon

ded

to b

y th

e ne

twor

k (D

ata

sour

ces:

EM

pro

vide

r log

, FH

B TW

G

quar

terl

y re

port

s,

Nav

igat

or

call

shee

ts)


Inte

rmed

iate

Out

com

e In

dica

tors

Barr

iers

A

ddre

ssed

Inte

rmed

iate

Resu

lts/

Out

puts

Proc

ess/

Act

ivit

ies

Proc

ess

Indi

cato

rsIn

terv

enti

ons

• N

umbe

r of

child

ren

fully

im

mun

ized

an

d on

sc

hedu

le

Inac

cess

ibili

ty

of fa

cilit

ies

• W

ell b

aby

heal

th

use

plan

com

plet

ed•

Wel

l bab

y he

alth

us

e pl

an a

dher

ed to

• Si

ck c

hild

hea

lth u

se

plan

com

plet

ed•

Sick

chi

ld h

ealth

use

pl

an a

dher

ed to

Prog

ram

min

g o

f qu

arte

rly

outr

each

se

rvic

es•

Mix

of s

ervi

ces

• Ta

rget

reci

pien

ts’

sche

dule

• Ra

tio

of

infa

nts

(0-1

2 m

onth

s)

prov

ided

wit

h BC

G i

mm

uniz

atio

n to

th

e to

tal

num

ber

of

infa

nts

need

ing

BCG

imm

uniz

atio

n ba

sed

on th

e w

ell b

aby

heal

th u

se p

lan

• Ra

tio

of c

hild

ren

pro

vide

d w

ith

DPT

im

mun

izat

ion

to

the

tota

l nu

mbe

r of

chi

ldre

n ne

edin

g D

PT

imm

uniz

atio

n ba

sed

on t

he w

ell

baby

hea

lth

use

plan

• Ra

tio

of c

hild

ren

pro

vide

d w

ith

OPV

im

mun

izat

ion

to

the

tota

l nu

mbe

r of

chi

ldre

n ne

edin

g O

PV

imm

uniz

atio

n ba

sed

on t

he w

ell

baby

hea

lth

use

plan

• Ra

tio

of c

hild

ren

pro

vide

d w

ith

mea

sles

im

mun

izat

ion

to

the

tota

l num

ber

of c

hild

ren

need

ing

mea

sles

im

mun

izat

ion

base

d on

th

e w

ell b

aby

heal

th u

se p

lan

• Ra

tio

of c

hild

ren

pro

vide

d w

ith

imm

uniz

atio

n fo

r he

pati

tis

to t

he

tota

l num

ber

of c

hild

ren

need

ing

imm

uniz

atio

n fo

r he

pati

tis

base

d on

the

wel

l bab

y he

alth

use

pla

n

Out

reac

h•

Mix

of s

ervi

ces

• Fr

eque

ncy

• O

utre

ach

sche

dule


term

edia

teO

utco

me

Indi

cato

rs

Barr

iers

A

ddre

ssed

Inte

rmed

iate

Resu

lts/

Out

puts

Proc

ess/

Act

ivit

ies

Proc

ess

Indi

cato

rsIn

terv

enti

ons

• Ra

tio

of

child

ren

who

re

ceiv

ed

vita

min

A s

uppl

emen

tati

on t

o th

e to

tal

num

ber

of c

hild

ren

need

-in

g vi

tam

in

A su

pple

men

tati

on

caps

ules

bas

ed o

n th

e w

ell

baby

he

alth

use

pla

n•

Rati

o of

fam

ilies

pro

vide

d w

ith

drug

s an

d m

edic

ines

for

sick

chi

l-dr

en t

o th

e to

tal n

umbe

r of

fam

i-lie

s ne

edin

g dr

ugs

and

med

icin

es

for s

ick

child

ren

base

d on

the

sick

ch

ild h

ealt

h us

e pl

an•

Rati

o of

fam

ilies

pro

vide

d w

ith

child

nut

riti

on c

ouns

elin

g to

the

to

tal

num

ber

of f

amili

es n

eedi

ng

child

nut

riti

on c

ouns

elin

g ba

sed

on th

e si

ck c

hild

hea

lth

use

plan

• Ra

tio

of c

hild

ren

dew

orm

ed to

the

tota

l num

ber

of c

hild

ren

need

ing

dew

orm

ing

base

d on

th

e si

ck

child

hea

lth

use

plan

• N

umbe

r of

ha

rd-t

o-re

ach

FHB

bene

ficia

ries

ser

ved

by a

n ou

t-re

ach

grou

p (

Dat

a So

urce

s: F

HB

TWG

mon

thly

rep

orts

, N

avig

ator

ca

ll sh

eets

, FH

B Bo

ok)


Inte

rmed

iate

Out

com

e In

dica

tors

Barr

iers

A

ddre

ssed

Inte

rmed

iate

Resu

lts/

Out

puts

Proc

ess/

Act

ivit

ies

Proc

ess

Indi

cato

rsIn

terv

enti

ons

Prom

otio

n of

ou

trea

ch s

ervi

ces

• N

umbe

r of a

nnou

ncem

ents

, sch

edul

e of

out

reac

h se

rvic

es d

istri

bute

d (D

ata

Sour

ce: F

HB

TWG

mon

thly

repo

rts)

Cond

uct o

f out

reac

h•

Tota

l nu

mbe

r of

in

fant

s (0

-12

mon

ths)

ser

ved

• To

tal

num

ber

of

infa

nts

(0-1

2 m

onth

s) fr

om F

HB

fam

ilies

ser

ved

• To

tal n

umbe

r of

chi

ldre

n 1

to 5

yrs

ol

d se

rved

• To

tal n

umbe

r of c

hild

ren

1 to

5 y

rs

old

from

FH

B fa

mili

es s

erve

d•

Num

ber o

f FH

B fa

mili

es s

erve

d•

Num

ber o

f non

-FH

B Fa

mili

es s

erve

d•

Ratio

of a

ctua

l num

ber o

f out

reac

h se

rvic

es

to

plan

ned

num

ber

of

outr

each

ser

vice

s•

Freq

uenc

y of

num

ber

of o

utre

ach

serv

ices

in a

qua

rter

• Ra

tio o

f FH

B fa

mili

es s

erve

d to

the

tota

l num

ber o

f fam

ilies

ser

ved

(Dat

a So

urce

s: F

HB

TWG

mon

thly

re

port

s; N

avig

ator

cal

l sh

eets

, FH

B Bo

ok,

Out

reac

h m

onit

orin

g fo

rm,

Clie

nt s

atis

fact

ion

form

)


term

edia

teO

utco

me

Indi

cato

rs

Barr

iers

A

ddre

ssed

Inte

rmed

iate

Resu

lts/

Out

puts

Proc

ess/

Act

ivit

ies

Proc

ess

Indi

cato

rsIn

terv

enti

ons

Qua

lity

mon

itor

ing

• N

umbe

r of

cl

ient

s co

mpl

aini

ng

abou

t sto

ck-o

uts

of v

acci

nes

• N

umbe

r of

cl

ient

s co

mpl

aini

ng

abou

t st

ock-

outs

of

m

edic

ines

(a

nti-

conv

ulsa

nts,

O

RS,

oral

an

tibi

otic

s)•

Num

ber

of

clie

nts

com

plai

ning

ab

out

stoc

k-ou

ts

of

Vit

amin

A

caps

ules

• N

umbe

r of

cl

ient

s co

mpl

aini

ng

abou

t sc

hedu

le (

e.g.

Tar

dine

ss)

of

outr

each

act

ivit

ies


Ant

enat

al C

are

Cove

rage

Inte

rmed

iate

Out

com

e In

dica

tors

Barr

iers

A

ddre

ssed

Inte

rmed

iate

Resu

lts/

Out

puts

Proc

ess/

Act

ivit

ies

Proc

ess

Indi

cato

rsIn

terv

enti

ons

• N

umbe

r of

preg

nant

w

omen

with

at

leas

t fou

r an

tena

tal

visi

ts•

Num

ber o

f pr

egna

nt

wom

en

with

firs

t an

tena

tal

visi

t dur

ing

the

first

tr

imes

ter

• N

umbe

r of

preg

nant

w

omen

who

re

ceiv

ed ir

on

and

fola

te

supp

lem

en-

tatio

n

Lack

of

know

ledg

e on

ri

sks

and

cons

eque

nces

of

not

hav

ing

ante

nata

l car

e

• Bi

rth

heal

th u

se

plan

com

plet

ed•

Birt

h he

alth

use

pl

an a

dher

ed to

Book

Dev

elop

men

t•

Cont

ent

deve

lopm

ent

• Fo

rm

deve

lopm

ent

• Fi

nal p

roto

type

app

rove

d by

U

SAID

-OH

Book

+Nav

igat

or•

Mes

sage

s•

Form

s•

Know

ledg

e•

List

of h

ealth

pro

vide

rs•

Trai

ned

Nav

igat

ors

Book

dis

trib

utio

n•

Tota

l nu

mbe

r of

fam

ilies

ide

ntifi

ed

(Dat

a so

urce

: FH

B TW

G m

onth

ly re

port)

• To

tal

num

ber

of f

amili

es i

dent

ified

fr

om m

aste

rlist

(D

ata

sour

ce:

FHB

TWG

mon

thly

repo

rt)

• N

umbe

r of

fam

ilies

ide

ntifi

ed b

y co

-FH

B be

nefic

iarie

s (D

ata

sour

ce:

FHB

TWG

mon

thly

repo

rt, N

avig

ator

repo

rts)

• N

umbe

r of

fam

ilies

ide

ntifi

ed b

y N

avig

ator

s (D

ata

sour

ce: F

HB

TWG

m

onth

ly re

port

, Nav

igat

or re

port

s)•

Num

ber

of

fam

ilies

gi

ven

book

s (D

ata

sour

ce:

FHB

TWG

m

onth

ly

repo

rt, N

avig

ator

repo

rts)


term

edia

teO

utco

me

Indi

cato

rs

Barr

iers

A

ddre

ssed

Inte

rmed

iate

Resu

lts/

Out

puts

Proc

ess/

Act

ivit

ies

Proc

ess

Indi

cato

rsIn

terv

enti

ons

Recr

uitm

ent,

sele

ctio

n an

d tra

inin

g of

Nav

igat

ors

• Re

crui

tmen

t•

Dev

elop

men

t of

trai

ning

man

uals

• N

avig

ator

’s K

it

• N

umbe

r of N

avig

ator

s rec

ruite

d (D

ata

sour

ce: F

HB

TWG

mon

thly

repo

rts)

• N

umbe

r of

Nav

igat

ors

train

ed (

Dat

a so

urce

: FH

B TW

G m

onth

ly re

ports

)•

Num

ber

of N

avig

ator

s w

ho p

asse

d po

st-tr

aini

ng e

valu

atio

n (D

ata

sour

ce:

FHB

TWG

mon

thly

repo

rts)

• N

umbe

r of N

avig

ator

s w

ho q

uit (

Dat

a so

urce

: FH

B TW

G m

onth

ly re

ports

)

Fam

ily-N

avig

ator

m

atch

ing

• N

umbe

r of f

amili

es w

ith

assi

gned

N

avig

ator

s (D

ata

sour

ce: F

HB

TWG

m

onth

ly re

port

)•

Dis

trib

utio

n of

Nav

igat

ors

by ra

tio

of

Nav

igat

ors

to

fam

ilies

(D

ata

sour

ce: F

HB

TWG

mon

thly

repo

rt)

Fam

ily-N

avig

ator

Co

ntac

ts•

Vis

its

• FH

B ho

ur•

Ori

enta

tion

• In

tera

ctio

n w

ith

othe

r key

fam

ily

mem

bers

• Ra

tio

of

the

num

ber

of

FHB

bene

ficia

ries

w

ho

agre

ed

to

orie

ntat

ion

to

the

num

ber

of

FHB

bene

ficia

ries

(D

ata

sour

ce:

Fam

ily c

all s

heet

s)•

Num

ber o

f Nav

igat

ors

who

vis

ited

al

l ass

igne

d fa

mili

es a

t le

ast

once

a

mon

th (

Dat

a so

urce

: Su

mm

ary

call

shee

ts, N

avig

ator

jour

nal)


Inte

rmed

iate

Out

com

e In

dica

tors

Barr

iers

A

ddre

ssed

Inte

rmed

iate

Resu

lts/

Out

puts

Proc

ess/

Act

ivit

ies

Proc

ess

Indi

cato

rsIn

terv

enti

ons

• Pr

esen

ce

of

nego

tiat

ed

and

regu

lar

FHB

hour

(D

ata

sour

ce:

Nav

igat

or jo

urna

l, FH

Boo

k)•

Ratio

of

th

e nu

mbe

r of

FH

B be

nefic

iari

es w

hich

agr

eed

to b

e as

sess

ed to

the

num

bero

f fa

mili

es

whi

ch a

gree

d to

be

orie

nted

(Dat

a so

urce

: Su

mm

ary

call

shee

ts,

Nav

igat

or jo

urna

l)•

Num

ber o

f vis

its w

here

bot

h m

othe

r an

d fa

ther

are

key

info

rman

ts (D

ata

sour

ce: N

avig

ator

jour

nal)

• N

umbe

r of N

avig

ator

reas

sign

men

ts

(Dat

a so

urce

: FH

B TW

G m

onth

ly

mee

tings

)

Birt

h he

alth

use

pl

an d

evel

opm

ent

• Pr

ovid

er

orie

ntat

ion

• Pr

ovid

er fa

mily

co

ntac

ts

• N

umbe

r of

pro

vide

rs o

rien

ted

on

the

FHB

(Dat

a so

urce

: FH

B TW

G

mon

thly

repo

rt)

• Ra

tio

of n

umbe

r of

pro

vide

rs w

ho

fille

d ou

t Bi

rth

HU

P to

num

ber

of

prov

ider

s vi

site

d by

fam

ilies

(Dat

a so

urce

: Fa

mily

cal

l sh

eet,

Fam

ily

jour

nal)


term

edia

teO

utco

me

Indi

cato

rs

Barr

iers

A

ddre

ssed

Inte

rmed

iate

Resu

lts/

Out

puts

Proc

ess/

Act

ivit

ies

Proc

ess

Indi

cato

rsIn

terv

enti

ons

• Ra

tio

of

the

num

ber

of

FHB

bene

ficia

ries

w

ho

agre

ed

to

deve

lop

a Bi

rth

heal

th u

se p

lan

to

the

tota

l nu

mbe

r of

FH

B be

nefic

iari

es a

sses

sed

to h

ave

the

need

for a

bir

th h

ealt

h us

e pl

an

• N

umbe

r of

preg

nant

w

omen

with

at

leas

t fou

r an

tena

tal

visi

ts•

Num

ber o

f pr

egna

nt

wom

en

with

firs

t an

tena

tal

visi

t dur

ing

the

first

tr

imes

ter

Inac

cess

ibili

ty

of fa

cilit

ies

• Bi

rth

heal

th u

se

plan

com

plet

ed•

Birt

h he

alth

use

pl

an a

dher

ed to

Prog

ram

min

g o

f qu

arte

rly

outr

each

se

rvic

es•

Mix

of s

ervi

ces

• Ta

rget

reci

pien

ts’

sche

dule

• Ra

tio

of

preg

nant

wom

en w

ho

rece

ived

pr

e-na

tal

chec

k-up

to

th

e to

tal

num

ber

of

preg

nant

w

omen

ne

edin

g ba

sed

on

the

birt

h he

alth

use

pla

n•

Rati

o of

m

othe

rs w

ho r

ecei

ved

coun

selin

g (o

n m

ater

nal n

utri

tion

, br

east

feed

ing)

to

the

tota

l nu

mbe

r of

m

othe

rs

need

ing

coun

selin

g b

ased

on

the

birt

h he

alth

use

pla

n•

Ratio

of

pre

gnan

t w

omen

who

w

ere

scre

ened

fo

r hy

pert

ensi

on

to th

e nu

mbe

r of p

regn

ant w

omen

ne

edin

g hy

pert

ensi

on

scre

enin

g ba

sed

on th

e bi

rth

heal

th u

se p

lan

Out

reac

h•

Mix

of s

ervi

ces

• Fr

eque

ncy

• O

utre

ach

sche

dule


Inte

rmed

iate

Out

com

e In

dica

tors

Barr

iers

A

ddre

ssed

Inte

rmed

iate

Resu

lts/

Out

puts

Proc

ess/

Act

ivit

ies

Proc

ess

Indi

cato

rsIn

terv

enti

ons

• N

umbe

r of

preg

nant

w

omen

who

re

ceiv

ed ir

on

and

fola

te

supp

lem

en-

tatio

n w

ith

first

ant

ena-

tal v

isit

dur-

ing

the

first

tr

imes

ter

• N

umbe

r of

preg

nant

w

omen

who

re

ceiv

ed ir

on

and

fola

te

supp

lem

en-

tatio

n

• Ra

tio

of

preg

nant

w

omen

w

ho

rece

ived

to

xoid

te

tanu

s im

mun

izat

ion

to t

he t

otal

num

ber

of

preg

nant

w

omen

ne

edin

g to

xoid

te

tanu

s im

mun

izat

ion

base

d on

the

birt

h he

alth

use

pla

n•

Ratio

of

pr

egna

nt

wom

en

who

re

ceiv

ed

iron

and

fola

te

supp

lem

ents

to

the

tota

l nu

mbe

r of

pr

egna

nt

wom

en

need

ing

supp

lem

ents

bas

ed o

n th

e bi

rth

heal

th u

se p

lan

• N

umbe

r of

ha

rd-t

o-re

ach

FHB

bene

ficia

ries

se

rved

by

an

ou

trea

ch g

roup

. (D

ata

Sour

ces:

FH

B TW

G m

onth

ly r

epor

ts,

Nav

igat

or

call

shee

ts,

FHB

Book

, O

utre

ach

mon

itori

ng fo

rm)

• N

umbe

r of

m

othe

rs

need

ing

coun

selin

g b

ased

on

the

birt

h he

alth

use

pla

n•

Ratio

of

pre

gnan

t w

omen

who

w

ere

scre

ened

fo

r hy

pert

ensi

on

to th

e nu

mbe

r of p

regn

ant w

omen

ne

edin

g hy

pert

ensi

on

scre

enin

g ba

sed

on th

e bi

rth

heal

th u

se p

lan


term

edia

teO

utco

me

Indi

cato

rs

Barr

iers

A

ddre

ssed

Inte

rmed

iate

Resu

lts/

Out

puts

Proc

ess/

Act

ivit

ies

Proc

ess

Indi

cato

rsIn

terv

enti

ons

• Ra

tio

of

preg

nant

wom

en w

ho

rece

ived

to

xoid

te

tanu

s im

mu-

niza

tion

to

the

tota

l nu

mbe

r of

pr

egna

nt w

omen

nee

ding

tox

oid

teta

nus

imm

uniz

atio

n ba

sed

on

the

birt

h he

alth

use

pla

n•

Rati

o of

pr

egna

nt w

omen

who

re

ceiv

ed i

ron

and

fola

te s

uppl

e-m

ents

to

th

e to

tal

num

ber

of

preg

nant

wom

en n

eedi

ng s

uppl

e-m

ents

bas

ed o

n th

e bi

rth

heal

th

use

plan

• N

umbe

r of

ha

rd-t

o-re

ach

FHB

bene

ficia

ries

ser

ved

by a

n ou

t-re

ach

grou

p.

(Dat

a So

urce

s: F

HB

TWG

mon

thly

re

port

s, N

avig

ator

cal

l sh

eets

, FH

B Bo

ok, O

utre

ach

mon

itor

ing

form

)

Prom

otio

n of

ou

trea

ch s

ervi

ces

Num

ber

of a

nnou

ncem

ents

, sc

hedu

le

of o

utre

ach

serv

ices

dis

tribu

ted

(Dat

a So

urce

: FH

B TW

G m

onth

ly re

ports

)


Inte

rmed

iate

Out

com

e In

dica

tors

Barr

iers

A

ddre

ssed

Inte

rmed

iate

Resu

lts/

Out

puts

Proc

ess/

Act

ivit

ies

Proc

ess

Indi

cato

rsIn

terv

enti

ons

Cond

uct o

f Out

reac

h•

Tota

l num

ber

of p

regn

ant

wom

en

serv

ed•

Tota

l nu

mbe

r of

FH

B pr

egna

nt

mot

hers

ser

ved

• To

tal n

umbe

r of

non

FH

B pr

egna

nt

mot

hers

ser

ved

• Ra

tio o

f act

ual n

umbe

r of o

utre

ach

serv

ices

to

pl

anne

d nu

mbe

r of

ou

trea

ch s

ervi

ces

• Fr

eque

ncy

of n

umbe

r of

out

reac

h se

rvic

es in

a q

uart

er•

Ratio

of

FHB

Fam

ilies

ser

ved

with

th

e to

tal n

umbe

r of f

amili

es s

erve

d

(Dat

a So

urce

s:

FH

TWG

m

onth

ly

repo

rts,

Nav

igat

or c

all

shee

ts,

FHB

Book

, O

utre

ach

mon

itor

ing

form

, C

lient

sat

isfa

ctio

n fo

rm)


Inte

rmed

iate

Out

com

e In

dica

tors

Barr

iers

A

ddre

ssed

Inte

rmed

iate

Resu

lts/

Out

puts

Proc

ess/

Act

ivit

ies

Proc

ess

Indi

cato

rsIn

terv

enti

ons

Qua

lity

mon

itor

ing

• N

umbe

r of

cl

ient

s co

mpl

aini

ng

abou

t st

ock-

outs

of

ir

on

and

fola

te s

uppl

emen

ts•

Num

ber

of f

amili

es c

ompl

aini

ng

abou

t ab

senc

e of

ant

enat

al c

are

prov

ider

s du

ring

out

reac

h•

Com

plia

nce

with

tech

nica

l sta

ndar

ds•

Num

ber

of

clie

nts

com

plai

ning

ab

out

sche

dule

(e.

g. T

ardi

ness

) of

ou

trea

ch a

ctiv

itie

s

(Dat

a So

urce

s:

FH

TWG

m

onth

ly

repo

rts,

Nav

igat

or c

all

shee

ts,

FHB

Book

, O

utre

ach

mon

itor

ing

form

, C

lient

sat

isfa

ctio

n fo

rm)


App

endi

x 2.

Sum

mar

y Li

stin

g of

For

ms,

Pro

cess

Flo

w, a

nd T

imin

g of

Col

lect

ion

FOR

MS

Uni

t of

Obs

erva

tion

Dat

a Co

llec

tion

Freq

uenc

y of

Con

duct

Freq

uenc

y of

Col

lect

ion

Base

line

Surv

eys

(Pos

t-In

terv

enti

on)

Hou

seho

ldH

ouse

hold

; In

dex

Chi

ld/W

oman

HPD

PO

ne-t

ime

One

-tim

e

Inpa

tien

tIn

pati

ent

HPD

PO

ne-t

ime

One

-tim

e

Out

pati

ent

Out

pati

ent

HPD

PO

ne-t

ime

One

-tim

e

Phys

icia

ns, M

idw

ives

, and

Qua

lity

of C

are

(Vig

nett

es)

Hea

lth

Prof

essi

onal

HPD

PO

ne-t

ime

One

-tim

e

Faci

lity

Hos

pita

l, C

linic

, Lyi

ng-i

n, B

irth

ing

Hom

e, D

iagn

osti

c, P

harm

acy,

RH

UH

PDP

One

-tim

eO

ne-t

ime

Book

+Nav

igat

or F

orm

s

Fam

ily H

ealt

h Ri

sks

Asse

ssm

ent F

orm

Hou

seho

ldN

avig

ator

One

-tim

eO

ne-t

ime

Fam

ily J

ourn

alFa

mily

Nav

igat

orM

onth

lyQ

uart

erly

Hea

lth

Use

Pla

ns (H

UPs

)Fa

mily

Nav

igat

orEn

d Pr

ojec

t

HU

P: F

amily

Em

erge

ncy

Plan

HU

P: S

ick

Chi

ld P

lan

HU

P: W

ell B

aby

/Sic

k C

hild

Pla

n

HU

P: B

irth

Pla

n

HU

P: R

epro

duct

ive

Hea

lth

Plan

142 The Family Health BookFO

RM

SU

nit o

f O

bser

vati

onD

ata

Coll

ecti

onFr

eque

ncy

of C

ondu

ctFr

eque

ncy

of C

olle

ctio

n

Fam

ily C

all S

heet

Fam

ilyN

avig

ator

Mon

thly

Sem

estr

al

Nav

igat

or G

MP

Repo

rtin

g Fo

rmN

avig

ator

Mid

wife

Mon

thly

Qua

rter

ly

BHS/

RHU

Mon

thly

Rep

orti

ng F

orm

Mid

wife

Mid

wife

Mon

thly

Qua

rter

ly

Sum

mar

y C

all S

heet

Nav

igat

orN

avig

ator

Mon

thly

Sem

estr

al

Profi

le fo

rms

for

Fam

ilie

s an

d N

avig

ator

s

HH

Val

idat

ion

Form

Hou

seho

ldPH

O, M

idw

ife, H

PDP

One

-tim

eO

ne-t

ime

Soci

o-Ec

onom

ic S

urve

yH

ouse

hold

Nav

igat

orO

ne-t

ime

One

-tim

e

Tally

of H

UPs

+ N

avig

ator

Pro

file

Nav

igat

orKS

FI, H

PDP

Qua

rter

lyQ

uart

erly

(e

xcep

t SES

)

Nav

ski

lls1:

Fam

ily F

eedb

ack

Form

Nav

igat

orKS

FI, H

PDP

Qua

rter

ly

Nav

ski

lls2:

Obs

erva

tion

of N

avs

and

Fam

ilies

Nav

igat

orKS

FI, H

PDP

Qua

rter

ly

Nav

ski

lls3:

Eva

luat

ion

of F

orm

sN

avig

ator

KSFI

, HPD

PQ

uart

erly

Inte

rven

tion

s an

d ac

tivi

ty s

peci

fic

form

s

Rece

ipt F

orm

MH

O, N

avig

ator

HPD

PO

ne-t

ime

One

-tim

e

Rece

ipt F

orm

2N

avig

ator

Nav

igat

orO

ne-t

ime

One

-tim

e

Requ

est f

or O

utre

ach

(Mon

tevi

sta

only

)M

idw

ife

HPD

P, P

HO

Qua

rter

lyQ

uart

erly

Out

reac

h M

onit

orin

g Fo

rms-

Mon

tevi

sta

(dra

ft a

s of

Jul

y 21

, 200

9)C

lient

; Pro

vide

rH

PDP,

PH

O, M

HO

Qua

rter

lyQ

uart

erly


FOR

MS

Uni

t of

Obs

erva

tion

Dat

a Co

llec

tion

Freq

uenc

y of

Con

duct

Freq

uenc

y of

Col

lect

ion

Out

reac

h1_R

egis

trat

ion

Form

s

Out

reac

h2_S

urve

y of

Pro

vide

rs

Out

reac

h3_I

nven

tory

of S

uppl

ies

Out

reac

h4 F

eedb

ack

form

s

Out

reac

h5 R

epor

ting

For

m

Emer

genc

y fo

rms

144

2 “Giya sa Maayong Panglawas”:The Family Health Book Implementation in Compostela Valley

Rhodora A. Tiongson, Jhiedon Florentino, and Aleli D. Kraft

Abstract

The Family Health Book was implemented in Compostela Valley as Giya sa Maayong Panglawas (Guide to Good Health). Launched in September 3, 2008, implementation began with field testing of the Book prototypes and Navigator-family interactions.

The GMP carrier emerged as the preferred form for information documentation, and the Navigator’s Kit and training were revised based on feedback from the pilot implementation. Listing of GMP-eligible families was conducted. In areas where high mobility of families was noted, the lists were validated. Navigators were recruited and trained, and book distribution among the assigned families marked the start of full-scale implementation in May 2009.

Adjustments were made as field implementation proceeded, which included issuing advisories in handling mobile families as a response to family move-outs; partially substituting years of experience for educational requirements to come up with the required number of Navigators; and varying the number of assigned families per Navigator depending on the distance and density of families.

A demonstration training on the draft outreach protocol produced an outreach plan that included the selection of three target barangays with its GMP families for outreach services, outreach

145“Giya sa Maayong Panglawas”:

The Family Health Book Implementation in Compostela Valley

schedules, logistical arrangements, and resource-sharing among barangays, the municipality, and the province.

Assistance was provided in drafting the draft protocol for the health emergency transport and communication system in Compostela, and in advocating for the passage of barangay ordinances in support of the Compostela Network of Communications and Transport (CoNECT). Counterpart funds from the province were also released for operations. The total cost of FHB implementation was expected to amount to about PhP 53 million, which is the sum of developmental, pilot operations, and operations research costs. Of this amount, the pilot operations costs is the one relevant for the LGU roll-out of the initiative.

Implementation was monitored through data collection from family-Navigator interactions and qualitative mid-term assessments, and through random visits to families and outreach activities. These activities revealed that majority of target families had been profiled, their health risks assessed, and their health use plans developed. Outreach activities reached target recipients and enabled families to access services listed in their health use plans. Differences in utilization of GMP families with and without health use plans were also noted.

Introduction

Giya sa Maayong Panglawas (Guide to Good Health), the FHB, was launched in September 3, 2008 with the ceremonial gathering of selected family beneficiaries in the provincial capitol in Nabunturan. Full-scale implementation began in May 2009 with the distribution of books by the Navigators. This also signaled the start of family-Navigator interaction for health risk assessment, health use planning, and health care use.

Meanwhile, field testing was conducted to assess the Book prototypes, the contents and format of the Navigator training, and the process of family-Navigator engagement. Listing beneficiary families was done to determine their number and identify, recruit, and train the required number of Navigators to match the families.


Implementation of GMP was monitored through data collection on input and process indicators as well as through a qualitative mid-term assessment. Feedback from the families, Navigators, and local officials on difficulties encountered on the ground resulted in adjustments in the implementation of the operations research.

Section 2 of this report describes the conduct and results of the FHB field testing exercise, which determined the final form of the FHB and led to revisions of the training modules for Navigators and midwives.

Section 3 describes the steps undertaken in listing the families and the difficulties accompanying their high mobility. Section 4 describes the process of Navigator recruitment and training.

Section 5 reports on the process and results of family-Navigator interaction as implemented in Compostela Valley.

Sections 6 and 7 describe the actual implementation of the emergency and outreach interventions.

Section 8 describes complementary and supporting activities.

Section 9 reports on observations from the mid-project assessment and random visits.

Section 10 concludes with a report on the costs of the operations research and an illustration of the possible costs of rolling out the initiative in other areas.

FHB Field Testing

Prior to the FHB OR’s full-scale implementation in Compostela Valley, field testing of the FHB prototypes, the Navigator’s training course and kit, and the family-Navigator interaction was conducted for two weeks in November 2008. Six families were selected from each of the municipalities of Compostela, Mabini, Maco, and Montevista to assess the usefulness of the Book’s contents and to determine which format was more useful and



acceptable to the families and Navigators. The families used the book format for a week and then switched to the carrier2 format for another week.

Three field testing Navigators were also selected from each of the four municipalities to assess the usefulness of the training process, the Navigator’s Kit, and the ease of use of the various health forms. The Navigators were trained using the developed materials. They also interacted with the families chosen for the field testing (HPDP, 2008a).

The field testing also determined the possible role of midwives in the FHB initiative. FGDs were conducted at the midpoint and end of the field testing period to get feedback from families, Navigators, midwives, and MHOs. The highlights of the field testing are presented below, drawing heavily from a 2008 HPDP report (Acuin, 2008).

2 The carrier is a foldable bag which can be hung on the door or wall. It contains materials similar to those found in the book: family picture, letter to the family, health emergency contacts, key health messages, health use plans, health provider information and useful references such as the Mother and Child Book and Family Guide on PhilHealth Benefits.


Book At the end of field testing, most families favored the carrier over the book format. Families opting for the carrier format said the carrier could be easily seen and checked. Moreover, as the carrier with the family picture could be hung on a wall, it attracts visitors’ attention and at the same time is kept out of children’s reach.

Families felt that they could easily choose things they wanted to read in the carrier format, unlike in the book version. However, compared with the book format, the families said the carrier was bulky and not portable. Its pages could get disorganized, and some sections could be lost (see Table 2.1).

Overall, the pilot families found the FHB materials attractive, useful, and very helpful. The families suggested that the carrier be of a darker color and that the pages of the materials should be bound in order to keep them intact. They also suggested the use of tabs to separate and identify topics.

Pilot families and Navigators appreciated the use of the Visayan language in the writing of the Books. They also found the language easy to understand, clear, and inoffensive. Interestingly, families generally felt that the FHB contained new and more comprehensive information compared with the Mother and Child Book of UNICEF and WHO. Specifically, the families cited the following topics as memorable and interesting:

1) birth spacing, 2) child feeding, 3) delivery in a facility, and 4) immunization.



The topic on family planning and child care also stimulated discussions among couples and raised issues related to PhilHealth membership and membership renewal.

Table 2.1: Reasons for family FHB format preferences

Book Carrier

Pros

• Handy to carry and keep, can bring it where you want to read it

• Contents organized• Easy to look for specific

topic• Easy to share / lend to

others

• Easily seen, especially family picture, attracts visitors’ attention

• Serves as constant reminder

• Easy to check• Can be hung out of

child’s reach• Possible choice in what

one wants to read

Cons• Easy to hide and forget• Can be misplaced• Children can play with it

• Bulky, not easy to carry• Pages can be

disorganized and lost

Navigators Twelve BHWs were selected as pioneer Navigators to orient and guide the families.

They were selected based on their performance in their areas. The Navigators were provided with training, and eventually refresher courses, on the contents and use of the FHB. To supervise them, 11 midwives also underwent an orientation on the FHB.

The pioneer Navigators appreciated their training and stressed their need for it on issues like family planning and reproductive health. But they said the training should have been conducted closer to the sites, since most of them had families. They also asked for a better and more organized information tool on PhilHealth, possibly in manual form.


Selection of Navigators and their training

Midwives said the FHB initiative would give more responsibilities to BHWs as Navigators and this would pose a difficulty in recruiting Navigators.

During the field testing, midwives said only 25-30% of BHWs would be able to do FHB work well enough. They suggested that Navigators should at least be high school graduates.

Neither were they keen on hiring new staff to serve as Navigators since this would involve barangay captains, a process perceived as a political matter. The midwives also suggested that the training of Navigators include the development of interpersonal skills, especially for the younger and newer BHWs.

Family-Navigator contact

Couples felt that ideally, both husband and wife should be present during Navigator visits. But the husbands’ irregular work schedules made it difficult for couples to find a common time for the FHB intiative’s activities. To ensure the husbands’ availability, at least during the orientation, group orientations should be conducted instead of individual family visits.

Many families said the Navigators helped them understand how to use the FHB. Though most families felt that the forms were relatively easy to fill out, those with members of limited education relied heavily on the Navigators in working with the forms.

The families also said the Navigators were most helpful during follow-up activities and in giving referrals to health centers and facilities (the Navigators accompanied the families to these places). Most families said they strongly preferred Navigators they already knew and who lived nearby.



Management of Navigators

During the field testing, while a number of midwives accompanied Navigators during family orientations on the FHB, participating families said Navigators could conduct the orientation even without the midwives.

The Navigators also felt the same way. They were also concerned that the midwives would find it difficult to attend individual family orientations especially if the FHB initiative would be scaled up.

Outreach During field testing, the midwives felt that monthly outreach activities, like immunization, may be difficult to conduct, given the requirements needed.

Very frequent outreach activities may be taxing for midwives, who have other functions and duties. The midwives said the holding of quarterly activities was more feasible, as LGUs do have far-flung areas.

Listing of families

Books

Analysis of FHB Baseline Survey data showed that families with mothers who did not finish high school and which satisfy the following criteria would benefit most from the information provided by the FHB:

1) pregnant; or

2) non-pregnant, below 25 years old and with at least one child below five years of age; or

3) non-pregnant, 25 years old and above, and with at least two children below five years of age.


These conditions ultimately became the FHB eligibility criteria. Thus, identification and listing of families that satisfied the FHB eligibility criteria was one of the important preliminary activities.

Prior to the actual listing of families, national census data were used to project the number of women of reproductive age who qualified under the FHB eligibility criteria in the barangays of the intervention municipalities. The projected number was used as a guide in the actual listing of eligible families. To ensure that all areas in the municipalities would be covered, a listing of puroks within the covered barangays was conducted.

The FHB initiative engaged a team to coordinate with the municipalities’ midwives and barangay health workers (BHWs) on the identification of families which met the eligibility criteria for FHB interventions. The listing of families was conducted from December 2008 to February 2009. Using the list of families provided by the BHWs as an initial guide, the team visited the covered barangays and gathered the following data:

1) list of families residing in the barangays; 2) ages and number of children in the families; 3) mothers’ current pregnancy status; 4) families’ PhilHealth status; and 5) educational attainment of the mother and the father.

The team used a snowball approach, where information on other potential beneficiaries was solicited from residents to ensure full listing of families meeting FHB eligibility criteria. To ensure that households that were difficult to reach or which lived some distance from barangay and municipality centers would be listed, the team had quotas of families to enlist at the purok level.

The original eligibility criteria specified that qualified families should have mothers with less than high school education. However, initial feedback indicated that this requirement severely limited the number of potential beneficiaries. There were also reports that special programs (i.e., Sunday school and special certification programs) allowed residents to obtain a high school diploma. The educational criteria were thus changed to include families with mothers who had at most a high school diploma.



The initial listing of families resulted in a registry with 5,347 families (see Table 2.2). Field validation, at the BHW and midwife levels, was conducted and supervised by the FHB Coordinator based in Compostela Valley from February to March 2009. The midwives and BHWs validated information specific to the eligibility criteria (see Appendix 1).

The midwives and the BHWs also conducted minor corrections on the names and the purok addresses of the validated families. The barangay workers and the FHB Coordinator also did validation of households on randomly chosen puroks.

From the validation and visits on the randomly chosen puroks, the list of families satisfying the eligibility criteria was further trimmed down, due to the following reasons: 1) moving out of families or mothers; 2) double entry of families and mothers on the original list; 3) refusals; and 4) non-eligibility based on the criteria.

However, only 4,815 families of 5,347 target beneficiaries were actually given books, largely due to the high mobility of families in the municipalities. Between the listing of families to the validation of the list, new families migrated in and out of the FHB municipalities. Some families initially identified during the listing activities were found to have permanently migrated to other FHB sites or other areas.

Cases of double-listing of families or of a family member in two different barangays were also discovered. New families identified by the BHWs and midwives were added. The validated list of BHWs was used during the actual distribution of Books.


Table 2.2: Number of families targeted and given books

TargetGiven Books

Difference

Reasons for Difference

Families moved

out

Double Entry in Target

list

Refusal Others

Compostela 1601 1476 125 89 10 12 14

Mabini 850 727 123 43 15 1 64

Maco 1773 1588 185 157 8 7 13

Montevista 1123 1024 99 74 14 2 9

TOTAL 5347 4815 532 363 47 22 100

Navigator recruitment, training and deployment

With the list of FHB beneficiary families validated, initial recruitment of Navigators commenced as early as late 2008 in preparation for FHB implementation. With an initial estimate of 6,000 beneficiary families and a recommended 1:20 Navigator-families ratio, around 300 Navigators were targeted for recruitment.

With initial results indicating that the educational requirement of at least two years of high school limited the number of would-be Navigators. recruitment criteria were revised to allow for years of experience to partially substitute for the educational requirement. In easing the educational attainment criterion and stressing instead that BHWs should have at least two years of field experience, the target number of Navigators for FHB implementation was recruited.

The Rural Health Midwives (RHMs), being the ones familiar with the capacity of BHWs in their respective areas, led in identifying Navigators, guided by the following selection criteria:

1) have at least 2 years health-related experience in the community;

2) less than 60 years old;



3) able and willing to regularly visit the households assigned to them; and

4) with good interpersonal communication skills and highly motivated and respected in the community.

The selection process included the listing of FHB beneficiaries, to ensure easy access and familiarity of Navigators and families with each other.

Together with CHD XI, HPDP assisted the Compostela Valley Provincial Health Office (PHO) in preparing midwives for their roles in the GMP. A Midwife’s Kit was drafted and pre-tested before it was used in the midwives’ training (HPDP, 2008b). On March 20-21 and 26-27, all 43 midwives in the four FHB pilot municipalities were oriented on how to supervise Navigators, plan and manage the needed MNCHN commodities/services, including those for FHB families, coordinate outreach services, and serve as primary service providers.

HPDP – in cooperation with CHD XI, Compostela Valley PHO, the PhilHealth Davao Region, and other partners – conducted a training for Navigator trainors on March 23-26, 2009 to help prepare around 400 Navigators in the four FHB pilot municipalities in orienting families on the use of the GMP and assist them in developing and accomplishing their health use plans.

The training design developed for Navigator trainors also included orientation on MNCHN standards, principles of informed choice and voluntarism, relational skills training for effectively engaging families, and preparations on conducting health risk assessment, developing health use plans and correctly filling out FHB monitoring forms.

The series of trainings for around 400 Navigators from the four pilot sites were completed by the end of April. However, a spot check conducted in the first week of June 2009, revealed that there were GMP beneficiaries in certain puroks who still had to be assigned Navigators, or whose assigned Navigators had failed to participate in the Navigators’ training.


Additional Navigators had to be trained on June 18 and 19, 2009. A total of 448 Navigators were recruited and trained in the four pilot municipalities (See Table 2.3. Appendix 2 lists the number of Navigators trained per barangay).

After the selection, recruitment and training of the Navigators, they were matched with families based on the Navigator’s place of residence and proximity to the family, cultural background, existing relationship with the family, and pre-assigned catchment areas as determined by the midwife supervisor. While there was a recommended 1:20 Navigator-familiies ratio, the actual ratio more or less depended on the geographic dispersion of the families and/or the availability of trained Navigators in the barangay or community.

Navigators assigned to families outside of their place of residence or in far-flung sitios, had to express their willingness and commitment to visit and conduct follow-up visits on these families. While each Navigator had an average assignment of 12 families, there were variations per municipality. (see Table 2.4. Appendix 3 lists the family-Navigator matching per barangay.)

Table 2.3: Number of Navigators trained

Number of Navigators Trained (by Batch)

Training of Trainors

1st 2nd 3rd 4th 5th TOTAL

Compostela 3 25 25 24 29 14 120

Mabini 0 25 25 25 29 0 104

Maco 2 25 33 33 25 9 127

Montevista 0 25 25 25 15 7 97

TOTAL 5 100 108 107 98 30 448



Table 2.4: Family-Navigator matching

No. of Families validated by BHWs

No. of NavigatorsFamily-Navigator

Ratio

Compostela 1601 118 13.57

Mabini 850 109 7.8

Maco 1773 113 15.69

Montevista 1123 92 12.21

TOTAL 5347 432 12.38

Upon HPDP’s advice that the province’s MNCHN grant can be used to support the provision of MNCHN services, the PHO allotted PhP 160,000 from their FP grant to cover the Navigators’ per diem/travel allowances for their visits to FHB families.

After the approval of the Book’s contents in February 2009, the Book’s contents were translated to the Visayan language, Cebuano. Actual production of the books and carriers was carried out from March to April 2009. Implementation of the FHB began with the official turnover of GMP to the Municipal Health Offices of the pilot municipalities, for distribution to Navigators and GMP families: Montevista (May 5), Compostela (May 6), Maco (May 18), and Mabini (May 27).

Family-Navigator interaction

Family-Navigator engagement started with the orientation of the family on the FHB initiative during the first household visit. This initial contact is considered one of the most important stages of the FHB initiative.

During this first contact, Navigators are expected to establish rapport with the families assigned to them, give them a copy of the FHB and explain what the FHB is all about. A considerable part of the orientation saw Navigators going through the contents of the Book, explaining to the family the importance of the health


messages, what health use plans (HUPs) were, and how to use the list of providers as information on their options on which facility to go to for the appropriate health service indicated in the HUP. During this orientation, Navigators were expected to ask the families to fill in the family profile or socio-economic form (HPDP, 2008d).

After the first contact with the families, the Navigators’ next visit sought to identify health risks and needs. Using the health risks assessment (HRA) forms, Navigators were to elicit information which would eventually be used in the development of HUPs.

The HRA has three main parts, namely: Maternal and Newborn Health, Reproductive Health, and Child Health. Through the HRA, Navigators administer screening and follow-up questions, which gauge the families’ awareness of and their current health practices. The HRA also includes questions on immunization, current family planning methods, and utilization of ANC services.

After the health risks assessment, subsequent visits were made for the development of HUPs appropriate for the families. During this stage, the Navigator assisted the family in identifying services and commodities they need based on the risk assessment. Families are also assisted by Navigators in identifying health providers where they can avail of services for delivery, ANC, immunization, and FP counseling. All of these choices and information are reflected in the families’ HUPs, specifically the dates when the services and commodities should be accessed and the appropriate health provider.

Family-Navigator contacts: Results of monitoring activities

Most Navigators assigned to far-flung families administered the socio-economic status (SES) profile and health risks assessment (HRA) during the initial contact, the same time the Book was issued to the families. Some Navigators administered the SES and HRA during a different visit.



Figure 2.1. Stages of interaction of families and navigators

SES and HRA administration lasted from late May to August 2009. Several families were reported to have changed residence by the end of this period, resulting in a decreased number of families with SES and HRA data (see Table 2.5).

In response, the Provincial Health Office advised midwives on what to do upon finding out about a family which changed residence or is about to do so. The FHB Coordinator listed the names of relocated families or those about to move out, including their destinations, and endorsed them to the receiving midwives within the FHB sites.

The mobility of some of the families was believed to be seasonal, due to the sources of livelihood in the province (e.g., some families would move out to mining sites during the rainy season, moving back to their farms during harvesting months). Given this temporary nature of movements, Navigators and midwives were advised not to permanently remove families from their assigned lists.


Table 2.5: Tally of families by FHB process

Given Books Profiled Health Risks

Assessed

Compostela 1476 1,428 1428

Mabini 727 727 724

Maco 1588 1572 1555

Montevista 1024 998 990

TOTAL 4815 4725 4697

Tally of HUPs

After the distribution of Books and the assignment of Navigators to families, HPDP engaged a team to go to the midwives and Navigators to tally the list of families provided with a Book and the number of HUPs developed by the families (see Table 2.6). The initial tally of HUPs was done in early August to late September 2009. From the SES and HRA data, HPDP obtained an initial count of the number of pregnant mothers and infants.

Results of the first tally made the PHO concerned about the low number of Reproductive Health use plans (RH plan) compared with the number of non-pregnant mothers (at the time of the SES and HRA). As a response, the PHO conducted on-site re-training activities for midwives and Navigators, particularly on engaging the families and filling up the FHB forms.

A second tally of HUPs was conducted from April to June 2010 (Table 2.7). HPDP engaged a team to go through the list of FHB families and the HUPs developed for them. This second team also identified the families with pregnant mothers during the re-tally of HUPs. There was now more HUPs than during the initial months of the FHB initiative. More than 70% of the FHB families had an RH plan during the re-tally, while 75% of the mothers who were pregnant during the re-tally of HUPs already had a birth plan.

The issue of mobile families and moving out of mothers came up during the re-tally of HUPs. From the 4,725 families with SES, 140 families moved out of FHB sites. Navigators and midwives were again advised not to take these families out of their roster.



Tabl

e 2.

6: N

umbe

r of f

amili

es a

nd h

ealth

use

pla

ns, a

s of

Aug

ust t

o Se

ptem

ber 2

009

tally

Giv

en

Book

sPr

ofile

d N

umbe

r of

fam

ilie

s w

ith:

*N

umbe

r of

HU

Ps D

evel

oped

(a

s of

Aug

ust-

Sept

embe

r 20

09)

Preg

nant

m

othe

rsC

hild

less

than

1

year

old

RH

Pla

nBi

rth

Plan

Wel

l-Ba

by

Plan

Sick

Chi

ld

Plan

Com

post

ela

1476

1428

156

542

566

112

435

763

Mab

ini

727

727

7324

849

575

**14

953

9

Mac

o15

8815

7219

557

511

0216

657

012

34

Mon

tevi

sta

1024

998

135

327

563

146*

**20

940

0

TOTA

L48

1547

2555

916

9227

2649

913

6329

36

*fro

m th

e H

RA a

nd S

ES**

Dur

ing

the

tally

of H

UPS

, add

ition

al p

regn

ant m

othe

rs w

ere

enc

ount

ered

aft

er th

e SE

S an

d H

RA a

dmin

istr

atio

n


Tabl

e 2.

7: N

umbe

r of f

amili

es a

nd h

ealth

use

pla

ns, a

s of

Apr

il to

June

201

0 ta

lly

Giv

en

Book

sPr

ofile

d Pr

egna

nt d

urin

g th

e A

pril

-Jun

e 20

10 ta

lly*

Num

ber

of H

UPs

dev

elop

ed

RH

Pla

nBi

rth

Plan

*W

ell-

Baby

Pla

n

Com

post

ela

1476

1428

105

896

9147

7

Mab

ini

727

727

5657

917

393

Mac

o15

8815

7210

812

1681

587

Mon

tevi

sta

1024

998

8075

175

414

TOTA

L48

1547

2534

934

4226

418

71

*For

thos

e pr

egna

nt d

urin

g th

e re

-tal

ly o

f HU

Ps



Monitoring utilization of services of FHB families

In order to analyze utilization of MNCHN services by FHB families, the initial plan was to collect their HUPs. However, as the HUPs were important documents for the families, as these contain the scheduled services that they still need to access, the HPDP developed an editing form that was used to copy and extract information from the actual HUPs of families. Navigators were requested to gather the HUPs of the families assigned to them.

From August to December 2010, an HPDP team in Compostela Valley conducted the data extraction from the HUPs using the editing forms. The team went to the respective barangays to extract the data and fill in the editing forms. The data were then encoded and linked with the data from the tally of HUPs and the family profiles.

Using these data, the proportion of GMP families with HUPs who used MNCHN services was compared with those of GMP families without HUPs. For all the indicators, GMP families with HUPs have higher utilization of critical MNCHN services.

During field visits, Navigators and midwives noted that the HUPs served as reminders to most families of the services they needed. The Navigators also noted that the presence of HUPs with the families obliged them to conduct follow-up visits concerning scheduled services indicated in the HUPs.

According to data collected from the HUPs, 73.63% of the mothers were using a modern FP method during the FHB initiative (Table 2.8). The proportion of GMP mothers using any modern FP method was larger for families with RH Plans (85.82%), compared to those with no RH Plans (40.28%) (see Table 2.9).

Of the mothers who were pregnant during the FHB initiative, more than half were assisted by a skilled health provider, either at home or in a health facility (Table 2.10). There were more skilled health provider-asssisted deliveries among families with birth plans (55.34%) than among those with no birth plans (45.73%) (see Table 2.11).


Table 2.8: Number of families and MFP use

Given Books Profiled

Utilization of any MFP method

No. of families using any Modern FP method Percent

A B C D=C/B

Compostela 1476 1428 976 68.35

Mabini 727 727 588 80.88

Maco 1588 1572 1,263 80.34

Montevista 1024 998 652 65.33

TOTAL 4815 4725 3479 73.63

Table 2.9: Use of modern FP of non-pregnant mothers, with RH plan vs no RH plan*

With RH Plan No RH Plan

N Uses MFP % MFP N Uses

MFP % MFP

Compostela 896 773 86.27 507 192 37.87

Mabini 579 523 90.33 144 64 44.44

Maco 1216 1090 89.64 306 144 47.06

Montevista 751 568 75.63 242 83 34.30

TOTAL 3442 2954 85.82 1199 483 40.28

* RH plan based on April-June 2010 re-tally



Table 2.10: Number of pregnant mothers who delivered during FHB

Number of pregnant

mothers who completed pregnancy during FHB

Delivery location and attendant of those with completed pregnancy

% with Skilled

Birth AttendanceHome,

TBAHome,

midwife Facility

A B C D E=(D+C)/A

Compostela 319 176 52 91 44.83

Mabini 143 71 29 43 50.35

Maco 549 153 18 378 72.13

Montevista 378 265 17 96 29.89

TOTAL 1389 665 116 608 52.12

Table 2.11: Use of skilled birth attendance: With birth plan vs no birth plan

With Birth Plan No Birth Plan

n SBA % SBA N SBA % SBA

Compostela 138 70 50.72 184 74 40.22

Mabini 46 22 47.83 97 50 51.55

Maco 451 334 74.06 101 64 63.37

Montevista 292 87 29.79 86 26 30.23

TOTAL 927 513 55.34 468 214 45.73


Nine in every ten pregnant mothers during the FHB initiative utilized at least one ANC (Table 2.12). Moreover, the proportion of pregnant mothers with at least one ANC was also larger among families with birth plans compared to families with no birth plans (Table 2.13).

Table 2.12: ANC use among mothers who were pregnant during the FHB initiative

Number of pregnant women

during FHB

With at least one ANC

% with at least one ANC

A B C=A/B


Mabini 150 112 74.67

Maco 584 544 93.15


TOTAL 1493 1349 90.35

Table 2.13: With at least one ANC: With birth plan vs no birth plan*

With Birth Plan No Birth Plan

N W/ANC % SBA n W/ANC % SBA

Compostela 165 159 96.36 196 165 84.18

Mabini 51 49 96.08 99 66 66.67

Maco 477 477 100.00 98 71 72.45

Montevista 305 299 98.03 92 77 83.70

TOTAL 998 984 98.60 485 379 78.14

*cumulative (from 2009 to 2010)

While the FIC rate was high during the FHB initiative, with 78% of infants needing immunization able to complete all the services (Table 2.14), there were no significant differences in FIC rates between those with and without well baby plans (Table 2.15).



Table 2.14: FIC among number of infants needing immunization

Number of infants needing immunization

during FHB

Number of infants with full

immunization% FIC


Mabini 124 84 67.74

Maco 374 282 75.40


TOTAL 1071 843 78.71

Table 2.15: FIC rates, with and without well baby plan

With Well Baby Plan No Well Baby Plan

n FIC % SBA N FIC % SBA

Compostela 256 217 84.77 66 44 66.67

Mabini 115 77 66.96 9 7 77.78

Maco 370 279 75.41 4 3 75.00

Montevista 138 117 84.78 113 99 87.61

TOTAL 879 690 78.50 192 153 79.69

Emergency Transportation and Communication Network

Prior to the setup of the health emergency transportation and communication network, the mayor usually served as the ‘central dispatcher’ of the two ambulances and another standby emergency vehicle stationed at the municipal hall. Families from Compostela barangays and sitios could either call him directly or contact their barangay captain, who had direct access to the mayor. A vehicle would pick up patients from their houses and bring them straight to the municipal hall where a waiting ambulance would bring them to the hospital.


In the case of far-flung barangays, the municipality designated a Center that served as a health emergency base, and with a direct link to the mayor. It is equipped with a functional vehicle. Depending on their capacity to pay, families are asked to pay for full or partial cost of gasoline expenses3. The municipal government gives full subsidy to extremely poor families.

Since travel from the remotest barangay to the Poblacion takes an entire day, expectant mothers in those areas usually make arrangements to stay with relatives in the Poblacion two days before their expected delivery date to ensure availability of transportation that can immediately take them to hospital facilities.

HPDP provided the four pilot municipalities with health emergency contacts in the GMP book and provided assistance in organizing the Compostela Network of Communications and Transport (CoNECT), a network of transport and communication providers that the families of Compostela could tap during emergencies. HPDP helped in the development of a protocol for CoNECT.

A pamphlet containing the assigned providers per barangay within the municipality was also produced and translated into the local language. The protocol integrated suggestions from various groups, such as local transport providers and the private sector.

Majority of the 16 barangays of Compostela passed ordinances supporting CoNECT. The Memorandum of Agreement among the provincial LGU, Compostela, and other stakeholders, was finalized prior to endorsement to the Sangguniang Bayan/Panlalawigan (Municipal and Provincial Councils) for approval in November 2009. The governor committed to provide PhP 150,000 counterpart funds to sustain CoNECT operations.

3 About PhP 102 from Poblacion, Compostela to Compostela Valley Provincial Hospital [CVPH]; PhP 450 to Davao Regional Hospital [DRH]; and PhP 1,020 to Davao Medical Center.



Outreach

FHB outreach services were conducted regularly and targeted hard-to-reach communities to ensure their access to health services and adherence of families to health use plans.

In consultation with Municipal Health Offices, CHD XI, PHO, and other stakeholders, HPDP assisted in drafting the manual of operations for the regular conduct of outreach services in Montevista. It specified which core MNCHN services are to be offered during outreach activities and the criteria for selecting recipient barangays, and offered a guide for estimating logistical requirements and directions on how to conduct the outreach activity.

A demonstration training on the use of the manual was conducted on the third week of July 2009. This led to the crafting of an outreach plan for Montevista, which was carried out in August 2009. Lessons from this initial outreach were used to improve and finalize the manual of operations (Alcantara, 2009a).

Other salient parts of the manual of operations:

1. Creation of teams to plan, prepare, conduct, and monitor outreach activities:

• the planning team composed of the municipal LGU budget officer, procurement officer, PHO representative, and concerned barangay captains – to be headed by the MHO;

• the medical team composed of the PHO, MHO, and health workers of participating NGOs;

• the support team composed of the Navigators, barangay officials/volunteers, and NGOs; and

• the monitoring team from PHO and HPDP.


2. Barangays which meet the following selection criteria are chosen for outreach services:

• those with areas/sitios no more than 2 hours away, using the common modes of transportation, from the nearest RHU or government hospital;

• those with considerable number of FHB families (at least 30% of FHB families in the barangay residing in far-flung sitios);

• those with areas accessible by motorcycle or “habal-habal”; and

• those which pose no safety risks to the medical team.

Other factors to be considered in determining the number of barangays for outreach activities:

• the municipality’s budget; and• the capacity and willingness of the medical team and

barangay officials.

During the demonstration training, three barangays in Montevista (Mayaon, Banglasan, and San Vicente) were found to satisfy the criteria. GMP holders living in far-flung sitios in these barangays -- the target families for the outreach services -- numbered 57, 32, and 29 families, respectively.

Core MNCHN and other ancillary services were offered during the outreach activities:

1) prenatal/postnatal care (tetanus immunization, iron and folate supplementation, hypertension screening,etc.);

2) child care services (immunization, nutrition counseling);

3) reproductive health services (counseling and provision of FP commodities); and

4) birth registration and PhilHealth orientation.



The actual range of health services provided depended on the health needs identified by the health use plans. These were expected to be collected by end-July in the three barangays. The midwife in-charge of the barangay, assisted by the partner Navigators, consolidated these health use plans.

Outreach activities were so scheduled to not conflict with residents’ major activities during the planting, harvesting and fiesta seasons, and important weekday or weekend activities. The outreach activities in these barangays were branded as “GMP Day” to differentiate from other activities of the community. GMP families were prioritized in the availment of services, which were also available for non-GMP families which need them.

The Municipal Health Officer (who heads the planning and medical team) prepared the schedule, identified the venue and the participants, and prepared the logistic requirements for the outreach activities. Depending on the available budget, the MHO had the option to procure and/or request the assistance of other agencies (Provincial Health Office/Department of Health/other government offices and NGOs) to ensure availability of services and commodities.

The support team, headed by the barangay captain, prepared the venue and conducted promotional activities to ensure that GMP families attended and availed of the health services offered during the outreach activities.

The first GMP outreach activities -- jointly sponsored by the MHO and PHO -- were conducted in Barangay Banglasan on August 14, 2009 and in Barangay Mayaon on September 4, 2009. At least three rounds of outreach services were conducted at quarterly intervals up to April 2010. An average of about 75 percent of targeted families attended the outreach services. Although GMP families were the priority, non-GMP families also received services. A patient flow protocol ensured adequate and orderly provision of services.


Navigational support to families (how to update health use plans, health education, and referrals to appropriate providers) was also provided and patient and provider feedbacks gathered for improvement of subsequent outreach activities.

Unlike typical outreach activities conducted by LGUs in the province, FHB outreach activities mainly provided MNCHN services. The outreach services also provided the opportunity for families in the selected outreach puroks to utilize services indicated in their developed health use plans (see Table 2.16).

Random visits were also conducted to gather inputs and feedback from midwives handling the FHB outreach activities. Though ideally, these should be conducted in the puroks where the target families resided, logistical concerns made it difficult to do so. The puroks of the target families were only accessible by motorcycle or were reached after at least 30 minutes of walking.

One remedy adopted was to fetch the target families from their residences just before or on the day of the outreach activities and bring them to a more central location. To guarantee attendance, midwives ensured that the Navigators informed the target families days ahead of the FHB outreach dates.

The Navigators and midwives also reported that compared with regular outreach activities, there was less overestimation of supply requirements in FHB outreach activitites, as only services and commodities indicated in the HUPs were prepared.



Tabl

e 2.

16: N

umbe

r of f

amili

es a

cces

sing

pla

nned

ser

vice

s fr

om o

utre

ach

May

aon

Bang

lasa

nSa

n V

icen

te

Num

ber

of

fam

ilie

s w

ith

HU

P

Fam

ilie

s ac

cess

ing

plan

ned

serv

ices

du

ring

out

reac

h ac

tivi

ties

Num

ber

of

fam

ilie

s w

ith

HU

P

Fam

ilie

s ac

cess

ing

plan

ned

serv

ices

du

ring

out

reac

h ac

tivi

ties

Num

ber

of

fam

ilie

s w

ith

HU

P

Fam

ilie

s ac

cess

ing

plan

ned

serv

ices

du

ring

out

reac

h ac

tivi

ties

Birt

h pl

an0

166

0

Repr

oduc

tive

H

ealt

h pl

an6

223

84

3

Wel

l-ba

by p

lan

31

1211

11

Sour

ce: H

UP

editi

ng fo

rms


Other complementary and supporting activities

Providers’ orientation

The Provincial Health Office of Compostela Valley conducted providers’ orientation of the MNCHN services last May 22, 2009. The participants were providers from the local government units (LGUs) such as the PHO of Compostela Valley, the MHOs of the municipalities of Mabini, Nabunturan, Montevista, and Compostela, as well as the private providers. The FHB initiative and the role of providers in the initiative were discussed. Kits were distributed to the providers, containing the FHB primer, a CD of the maternal and child health standards, and the GMP carrier. Unfortunately, the core referral hospitals such as the CVPH and DRH were not able to send their representatives.

Hence, the FHB orientation for the staff of the CVPH was held by the PHO last June 4, 2009. During the said orientation, it was discovered that the staff of CVPH were unaware of the FHB initiative. While the Chief of CVPH has been informed of the FHB, the information was not echoed to his staff. As a result of the orientation, CVPH physicians agreed to provide the information needed in the FHB. Commitment to provide the FHB Navigators and CoNECT operatives free basic laboratory procedures and consultations were secured.

Support to Compostela Valley Provincial Hospital

In a Memorandum of Agreement between the Department of Health and the province on the implementation of PIPH, Compostela Valley invested PhP10 million as local counterpart for the upgrading of CVPH. It was a priority intervention in the PIPH because CVPH served as the end-referral facility for the province on MNCHN services. Upon the request of the province, HPDP also facilitated the conduct of a meeting among the Compostela Valley PHO and DOH officials to follow up on the DOH counterpart to the upgrading of CVPH last July 1, 2009.



In addition, HPDP assisted HealthGov in introducing the “Quality Assurance Partnership Committees” (QAPC) to the province and CVPH on June 16, 2009, contextualizing it within the FHB initiative in the province. The creation of QAPC is part of the Health Systems 20/20 Initiative which aims to address issues on access and quality of MNCHN services in local facilities. Institutionalizing QAPC in CVPH, the end-referral facility for maternity care services in the province, forms part of HealthGov’s support to FHB. HealthGov will develop the QAPC workplan for Compostela Valley with technical inputs from HPDP. It will also provide SDExH training for CVPH as part of QAPC.

As part of its support to CVPH and upon the request from CHD XI Regional Director Baluma as well as Compostela Valley provincial LGU/PHO, HPDP linked the province to La Union Medical Center to expose the former to the experience of the latter in converting hospitals into economic enterprises. In line with this, HPDP supported the participation of selected Compostela Valley officials in the Study Tour Program in La Union from June 30 to July 1, 2009. The Compostela Valley team was composed of the Governor’s Executive Assistant on Fiscal Matters, Sangguniang Panlalawigan Board Member and Committee on Health Chair, CVPH Chief, and the Provincial Planning and Development Officer.

PhilHealth benefit delivery

HPDP assisted the PHO in terms of securing accreditation of critical facilities in the province through the assessment of PhilHealth accreditation deficiencies and operational hindrances of critical facilities. Following the assessment, technical support was provided to fast-track accreditation of RHUs in the four pilot municipalities for OPB, TB-DOTS, and MCP by facilitating preliminary evaluation of their facilities by PhilHealth, estimating resource requirements for RHUs’ accreditation, and linking the RHUs with key officials from the MHOs, local Sanggunians, and the PhilHealth Regional Office in the course of troubleshooting technical and operational bottlenecks in accreditation. HPDP further assisted in advocating with the Sangguniang Bayan and Panlalawigan budgetary allocations for the enhancement and


construction of maternity care centers needed to facilitate MCP accreditation. Assistance for the renewal of accreditation of the district and provincial hospitals as primary and secondary level facilities was given as well. Moreover, support was provided to local Sanggunians in drafting Appropriation Ordinances for the estimated resource requirements.

Part of the assistance of HPDP was advocacy with LGUs for the need and advantages of enroling their indigent population to PhilHealth. HPDP assisted in advocating with the Mayors and local Sanggunians for budget allocations for the PhilHealth enrolment of FHB families and Navigators. While these were considered in the municipal LGUs’ 2009 Supplemental Budget, allocations were not sufficient to cover all proposed enrolees given current local budget limitations. On the whole, the province needed to cover the PhilHealth premium counterpart payment for around 5,153 of the 5,347 GMP families and 396 Navigators. However, total funds from the provincial LGU, the municipal LGUs, and the Priority Development Assistance Fund (PDAF) were not enough to enrol around 976 families and Navigators.

Application of families in PhilHealth was slowed down by the tedious process of identifying which FHB families will be sponsored by the municipal LGUs, assisting families in accomplishing the family data survey forms, and checking the accuracy and completeness of these forms by the Municipal Social Welfare and Development Officers (MSWDOs). Since the FHB families were not included in the enrolment of sponsored program families at the start of the year, the MSWDOs perceived this as an additional burden on their part. The determination of the criteria for selection of families for enrolment has largely been left to the local government units.

Mid-project assessment and random visits

A mid-project assessment was conducted for the FHB after the distribution of Book in May to July 2009 (Acuin, 2009). A series of FGDs were conducted among the early recipients of the Book. For Maco, the families for the FGD were from the most remote barangays; for Montevista, families from the poblacion were



included; while for Compostela and Mabini, it was a mix of poblacion and remote barangay residents. All the families in the FGD had a mother who was pregnant during the FGD or recently delivered during the FHB period.

FGDs were also conducted among the Navigators. Navigators in Maco handling more than 20 families were included for the FGD, while Navigators assigned to far-flung areas and were handling less than 20 families were drawn from the other three municipalities.

Random visits to the field were also conducted to determine and address concerns related with the FHB interventions. In particular, visits on outreach sites were conducted to check whether FHB outreach activities were regularly conducted. Visits to far-flung areas and barangays were also done to determine whether Navigator visits were regularly performed

Book and Navigator

During the FGDs, the families expressed their appreciation of the efforts exerted by the Navigators, especially during the orientation and follow-up visits. Families, especially those residing in far-flung barangays and who have never been to the RHU, felt that after a long time someone is paying attention to their health needs. Most families felt that Navigators are better than the BHWs since the former conduct actual home visits.

However, an issue that arose was the variation in terms of the number of Navigators‘ visits experienced by families. Families with Navigators who were also neighbors and relatives experienced weekly visits. However, families located in far-flung areas and were assigned to Navigators residing in different puroks expressed that visits were done at most once a month. Families from remote barangays in Maco, in fact, were not immediately visited by their Navigator.

One of the concerns raised by the families was that the FHB carrier was difficult to carry around. Some couples with limited educational attainment, expressed that a discussion by the Navigator should be done instead of them actually reading the contents. Another concern was that the fathers’ participation, at


least during the orientation, was difficult to ensure. The mothers felt that their partners’ presence during the orientation and Navigator visits was relevant since the discussion during the FHB visits brought up the role of the fathers in health care.

The health workers and volunteers felt that being Navigators made them more involved with the health issues and problems of families under their care. They also noticed that people were treating them with higher regard as Navigators. Most of the Navigators gave credit to the training they received, particularly those on family planning, PhilHealth, and newborn screening.

Though health workers realized that they were better appreciated as Navigators, they were concerned of their heavier responsibility relative to their BHW tasks. In particular, they worried about the implications on their workload. Also, at the start of the FHB, it was found out that some Navigators were initially assigned with more than 20 families. Moreover, some Navigators suggested that they should handle at the most ten families, and preferably those near their residences.

Some Navigators admitted that some families assigned to them were visited late and infrequently followed-up. These Navigators cited that some families were not accessible by basic transportation and required travel by foot (one to two hours required walking). In selected barangays and puroks, transportation cost was a big factor. Especially in the far-flung areas of Maco, like the Masaralines, a one-way trip can reach up to PhP400 to PhP600 per person. Due to this, Navigators handling families in these types of areas requested additional compensation or transportation allowance.



Cost of the FHB OR

Costs associated with the FHB initiative can be classified into three components;

• developmental costs;• costs of pilot implementation • operations research costs.

The developmental costs include one-time expenses associated with technical assistance obtained to define and design the FHB interventions including prototype development of the Books and Navigators’ Kits, training design for Navigators, development of PhilHealth guides for families and providers, protocol design for emergency and outreach services, and field coordination and management to secure buy-in of local officials. Detailed costs for these developmental activities are given in Table 2.17. Around PhP 13 million was incurred for the development of the FHB intervention packages, which were shared by HPDP and other CAs.

The costs of implementing the pilot include expenses incurred for the following: 1) the listing and validation of eligible families; 2) the translation, production, and distribution of the Books and forms; 3) the selection, training, and deployment of Navigators (e.g., transportation expense vouchers); 4) the investments required for accreditation of facilities; 5) premium payments for PhilHealth enrolment; 6) the investments for the hospital upgrade; 7) marketing and social advocacy; and 8) management costs including Steering Committee and TWG meetings. Because of the pilot nature of the implementation, some of the costs that are expected to be shouldered by LGUs in a normal implementation were initially shouldered by HPDP. Some of these costs, for instance, PhilHealth premium payments, would have been incurred by LGUs even without the FHB interventions. It would be primarily from this cost component where the roll-out costs would be extracted.


Around PhP 30.8 million is the estimated cost of running the FHB pilot (see Table 2.18), a significant amount of which represents the estimated cost of supporting the upgrade of the hospital. Around half of these costs were shouldered by the provincial and municipal LGUs, with around one-third being shouldered by HPDP and by the DOH.

The operations research costs pertain to those related to assessing the impacts of the FHB interventions, i.e., the monitoring and evaluation activities. These are costs that are not expected to be incurred by the LGUs in the roll-out. Around PhP 9.5 million was expected to be spent for these activities (see Table 2.19).

Thus, the FHB implementation in Compostela Valley was to cost around a total of PhP 53 million (see Table 2.20).

However, not all of these expenses are expected to be incurred by provinces wishing to implement the interventions, particularly the developmental costs and the operations research costs. The expected roll-out costs for LGUs would mainly be extracted from the costs of implementing the pilot. Preliminary estimates of these unit costs are given in Table 2.21. These were derived by simply dividing the estimates of the operational costs of the pilot by the applicable number of units in Compostela Valley.



Tabl

e 2.

17: F

HB

deve

lopm

enta

l cos

ts

AC

TIV

ITY

SOU

RCE

OF

FUN

DS

TOTA

LH

PDP

Oth

er C

As

LGU

DO

HPh

ilH

ealt

h

Dev

elop

men

tal c

ost

Dev

elop

men

t of c

once

pt p

aper

and

pi

lot s

trat

egy

475,

585.

0047

5,58

5.00

Cons

ulta

tive

mee

ting

s an

d va

lidat

ion

wor

ksho

ps o

n FH

B Co

ncep

t29

2,49

9.00

292,

499.

00

Form

ulat

ion

of c

ore

mat

erna

l and

ne

onat

al s

tand

ards

683,

400.

0068

3,40

0.00

Revi

ew o

f Inc

lusi

on P

aram

eter

s an

d U

pdat

ing

Syst

em fo

r Pre

ferr

ed P

rovi

ders

and

Sta

ndar

ds

for C

ompl

ianc

e M

onit

orin

g

643,

099.

0064

3,09

9.00

Dev

elop

men

t of c

ompl

ianc

e m

onit

orin

g to

ol

and

outr

each

sta

ndar

ds71

8,25

0.00

718,

250.

00

Dra

ftin

g of

tem

plat

e fo

r MO

U o

n FH

B im

plem

enta

tion

281,

884.

0028

1,88

4.00

Conc

eptu

aliz

atio

n, d

esig

n an

d va

lidat

ion

of F

H

“Boo

k” in

clud

ing

deve

lopm

ent o

f Phi

lHea

lth

guid

e fo

r fam

ilies

1,91

9,98

6.00

1,91

9,98

6.00

Dra

ftin

g an

d up

dati

ng o

f Nav

igat

or’s

Kit

355,

550.

0035

5,55

0.00


AC

TIV

ITY

SOU

RCE

OF

FUN

DS

TOTA

LH

PDP

Oth

er C

As

LGU

DO

HPh

ilH

ealt

h

Fiel

d te

stin

g of

FH

B pr

otot

ypes

and

N

avig

ator

’s k

it28

1,55

4.00

281,

554.

00

Dev

elop

men

t of t

rain

ing

desi

gn,

mod

ule

and

faci

litat

or’s

gui

de fo

r tra

iner

s,

Nav

igat

ors

and

mid

wiv

es

1,65

1,20

9.00

1,65

1,20

9.00

Dra

ftin

g/pr

e-te

stin

g of

man

ual f

or m

idw

ives

in

clud

ing

mon

itor

ing

form

s19

6,80

0.00

196,

800.

00

Dev

elop

men

t of o

utre

ach

man

ual o

f ope

ratio

ns14

9,24

0.00

149,

240.

00

Dev

elop

men

t of h

ealt

h em

erge

ncy

tran

spor

t an

d co

mm

unic

atio

n pr

otoc

ol98

8,57

5.00

988,

575.

00

Gui

de fo

r Phi

lHea

lth e

nrol

men

t and

acc

redi

tatio

n56

4,90

0.00

564,

900.

00

Cre

atio

n of

Qua

lity

Assu

ranc

e Pa

rtne

rshi

ps

Com

mit

tees

(QAP

C)

3,76

0,00

0.00

3,76

0,00

0.00

Fiel

d co

ordi

nati

on a

nd m

anag

emen

t67

5,50

0.40

Tota

l dev

elop

men

tal c

ost

9,87

8,03

1.40

3,76

0,00

0.00

12,9

62,5

31.0

0



Tabl

e 2.

18: F

HB

pilo

t im

plem

enta

tion

cost

s

AC

TIV

ITY

SOU

RCE

OF

FUN

DS

TOTA

LH

PDP

Oth

er C

As

LGU

DO

HPh

ilH

ealt

h

Cost

of

Pilo

t Im

plem

enta

tion

Inte

grat

ion

of F

HB

in C

ompo

stel

a Va

lley

PIPH

and

AO

Ps26

9,03

8.00

170,

000.

0043

9,03

8.00

FHB

Stee

ring

Com

mit

tee

and

TWG

mee

ting

s78

,000

.00

78,0

00.0

0

Advo

cacy

and

soc

ial m

arke

ting

: Cu

stom

izat

ion

of F

HB

Book

(V

isay

an tr

ansl

atio

n, p

ictu

re-

taki

ng o

f fam

ilies

), or

ient

atio

ns

for C

HD

, PH

O, p

rovi

ders

, loc

al

offici

als,

and

sta

keho

lder

s,

and

assi

stan

ce to

FH

B la

unch

ing

Prod

ucti

on a

nd d

istr

ibut

ion

of

book

s an

d ca

rrie

rs

(init

ial 8

0 pl

us 7

500)

1,05

0,80

0.00

2,80

0.00

1,05

3,60

0.00

Enlis

ting

and

val

idat

ion

of fa

mili

es54

3,18

6.00

50,0

00.0

059

3,18

6.00

Nav

igat

or s

elec

tion

, rec

ruit

men

t an

d m

atch

ing

wit

h fa

mili

es50

,000

.00

50,0

00.0

0

Trai

ning

of m

idw

ives

170,

821.

0010

,800

.00

181,

621.

00


AC

TIV

ITY

SOU

RCE

OF

FUN

DS

TOTA

LH

PDP

Oth

er C

As

LGU

DO

HPh

ilH

ealt

h

Trai

ning

of t

rain

ers

and

Nav

igat

ors

2,63

1,31

5.00

67,5

00.0

02,

698,

815.

00

Tran

spor

tati

on a

llow

ance

for

Nav

igat

ors

513,

312.

00

Trai

ning

of C

VPH

per

sonn

el

on s

ervi

ce d

eliv

ery

stan

dard

s (S

DEx

H)

940,

000.

0094

0,00

0.00

Supp

ort t

o Ph

ilHea

lth

accr

edit

atio

n as

sess

men

t and

ap

plic

atio

n of

sel

ecte

d RH

Us;

ad

voca

cy fo

r the

incl

usio

n of

bud

get f

or a

ccre

dita

tion

in

vest

men

t req

uire

men

ts in

the

2009

Sup

plem

enta

l Fun

d

PhilH

ealt

h en

rolm

ent o

f fam

ilies

an

d N

avig

ator

s1,

800,

000.

001,

800,

000.

003,

600,

000.

00

Map

ping

of h

ealt

h em

erge

ncy

cont

acts

/ p

rovi

ders

141,

225.

0014

1,22

5.00

Man

agem

ent o

f hea

lth

emer

genc

y ne

twor

k (m

eeti

ngs,

aw

aren

ess-

rais

ing,

trai

ning

of

oper

ativ

es, v

ehic

le re

pair

s an

d m

aint

enan

ce, i

nsta

llati

on o

f rad

io

base

s, M

&E)

1,16

1,00

0.00

1,16

1,00

0.00



AC

TIV

ITY

SOU

RCE

OF

FUN

DS

TOTA

LH

PDP

Oth

er C

As

LGU

DO

HPh

ilH

ealt

h

Upg

radi

ng o

f RH

Us

to c

ompl

y w

ith

PhilH

ealt

h re

quir

emen

ts95

7,15

3.00

957,

153.

00

Upg

radi

ng o

f Com

post

ela

Valle

y Pr

ov. H

ospi

tal

10,0

00,0

00.0

010

,000

,000

.00

20,0

00,0

00.0

0

Asse

ssm

ent o

f CV

PH C

EmO

NC

ca

paci

ty63

,960

.00

63,9

60.0

0

Prin

ting

of F

HB

mon

itor

ing

form

s:

a. h

ealt

h ri

sk a

sses

smen

t fo

rms

148,

500.

0014

8,50

0.00

b. fa

mily

cal

l she

ets

36,0

00.0

036

,000

.00

c. h

ealt

h us

e pl

ans

4,50

0.00

4,50

0.00

d. re

sour

ce in

vent

ory

shee

ts60

0.00

600.

00

Cond

uct o

f out

reac

h ac

tivi

ties

305,

987.

25

Fiel

d co

ordi

nati

on a

nd

man

agem

ent

1,57

6,16

7.60

1,57

6,16

7.60

Tota

l cos

t of p

ilot i

mpl

emen

tati

on8,

981,

152.

6094

0,00

0.00

15,4

65,3

52.2

510

,002

,800

.00

1,80

0,00

0.00

30,8

30,7

24.0

0

186 The Family Health BookTa

ble

2.19

: Cos

ts o

f FH

B op

erat

ions

rese

arch

AC

TIV

ITY

SOU

RCE

OF

FUN

DS

TOTA

LH

PDP

Oth

er C

As

LGU

DO

HPh

ilH

ealt

h

Ope

rati

ons

rese

arch

cos

t

Base

line

data

gen

erat

ion

Base

line

surv

ey (P

hase

1)

Hou

seho

ld s

urve

y an

d in

itia

l fac

ility

map

ping

in

Com

post

ela

Valle

y

1,58

4,00

0.00

1,58

4,00

0.00

Base

line

surv

ey (P

hase

2)

Phys

icia

n an

d m

idw

ife s

urve

y an

d qu

alit

y-of

-ca

re (Q

OC

) ass

essm

ent u

sing

vig

nett

es

1,10

5,95

0.00

1,10

5,95

0.00

Eval

uatio

n of

phy

sici

an a

nd m

idw

ife v

igne

ttes

fo

r ass

essi

ng Q

OC

in C

ompo

stel

a Va

lley

310,

500.

0031

0,50

0.00

Fiel

d au

dit o

f ran

dom

hou

seho

ld s

urve

y in

Com

post

ela

Valle

y40

6,35

0.00

406,

350.

00

Surv

ey o

f pat

ient

s, h

ealt

h fa

cilit

ies,

and

oth

er

heal

th c

are

prov

ider

s30

0,53

0.00

300,

530.

00

Pret

esti

ng o

f ins

trum

ents

for F

HB

base

line

surv

eys

26,0

65.0

026

,065

.00

Mon

itor

ing

and

eval

uati

on o

f OR

Tagg

ing/

enco

ding

of P

hilH

ealt

h ID

11,1

00.0

011

,100

.00



AC

TIV

ITY

SOU

RCE

OF

FUN

DS

TOTA

LH

PDP

Oth

er C

As

LGU

DO

HPh

ilH

ealt

h

Repr

oduc

tion

of:

a. s

ocio

econ

omic

sur

vey

form

(SES

)4,

500.

004,

500.

00

b. s

umm

ary

heal

th ri

sks

and

need

s9,

000.

009,

000.

00

c. N

avig

ator

’s m

onth

ly G

MP

repo

rtin

g fo

rm7,

200.

007,

200.

00

d. R

HU

/BH

S m

onth

ly G

MP

repo

rtin

g fo

rm2,

400.

002,

400.

00

e. o

utre

ach

mon

itor

ing

form

4,00

0.00

4,00

0.00

Enco

ding

of S

ES a

nd c

olle

ctio

n of

form

s by

m

id-y

ear a

nd y

eare

nd20

0,00

0.00

200,

000.

00

Spot

che

ck/fi

eld

edit

ing

of S

ES a

nd h

ealt

h ri

sk a

sses

smen

t for

m (e

nd o

f Jul

y 20

09)

50,8

00.0

050

,800

.00

Nav

igat

or a

sses

smen

t1,

052,

526.

001,

052,

526.

00

Year

-end

hou

seho

ld s

urve

y2,

000,

000.

002,

000,

000.

00

Year

-end

pat

ient

-exi

t sur

vey

3,53

0.00

3,53

0.00

Year

end

CV

PH p

hysi

cian

sur

vey

and

qual

ity-

of-c

are

(QO

C) a

sses

smen

t usi

ng v

igne

ttes

1,50

0,00

0.00

1,50

0,00

0.00

OR

man

agem

ent t

eam

Dat

a en

codi

ng a

nd a

naly

sis

819,

000.

0081

9,00

0.00

OR

supe

rvis

ion

120,

000.

0012

0,00

0.00

Tota

l OR

cos

t9,

517,

451.

009,

517,

451.

00


Table 2.20: Total costs of FHB implementation

AMOUNT

Developmental Cost 12,962,531.00

Cost of Pilot Implementation 30,830,724.00

Operations Research Cost 9,517,451.00

TOTAL COST 53,310,706.00

Table 2.21: Estimated unit costs of roll-out

INTERVENTION/COST ITEM Frequency Unit Unit Cost

Book and Navigator

Advocacy and social marketing (customization of the Book: translation into local vernacular, health emergency contacts, picture-taking of families, customization of PhilHealth guide; FHB launching; orientation of regional/local political/health officials, service providers and other stakeholders)

One time Family 286.55

Identification and validation of beneficiaries

Recurrent Family 90.53

Production of books and carriers Recurrent Family 120.00

Training of midwives, trainers,and Navigators

One time Navigator 6,471.45

Reproduction of monitoring forms Recurrent Family 31.60

TEV of Navigators Recurrent Navigator 1,185.48

Emergency network

Mapping of health emergency contacts One time Municipality 141,225.00

Management of health emergency communication and transportation network (training, meetings, monitoring, gas, vehicle repairs and maintenance)

Recurrent Municipality 500,000.00



INTERVENTION/COST ITEM Frequency Unit Unit Cost

Outreach Services

Quarterly outreach for one year covering 30% of the population of one barangay (includes procurement of 30% of MNCHN commodities required)

Recurrent Municipality 305,987.25

PhilHealth Enrolment

Premiums (Assuming 50% LGU share) Recurrent Family 600.00

Support to upgrade of facilities One time Facility Variable

Management

FHB Steering Committee and TWG meetings

Recurrent Province 78,000.00

References

Acuin, C. 2008. Conduct of Focus Group Discussions (FGDs) on Field Testing of the Family Health Book (FHB) in Selected Municipalities in Compostela Valley Province. Report submitted to Health Policy Development Program, Quezon City, Philippines.

Acuin, C. 2009. Mid-year Assessment of FHB Implementation. Report submitted to the Health Policy Development Program, Quezon City, Philippines.

Alcantara, M.G. 2009a. Reaching Far and High: Providing health services in remote barangays, a guide for local leaders. Report submitted to the Health Policy Development Program, Quezon City, Philippines.

Alcantara, M.G. 2009b. FHB Outreach Intervention. PowerPoint slides submitted to the Health Policy Development Program, Quezon City, Philippines.

Florentino, J. 2010. Trip Report: Visit to Compostela Valley, Tagum, Davao City. Report submitted to the Health Policy Development Program, Quezon City, Philippines.


Health Policy Development Program. 2008a. The Family Health Book Navigator’s Kit. Quezon City, Philippines, UPecon Foundation, Inc.-Health Policy Development Program.

__________. 2008b. The Family Health Book Midwives’ Kit. Quezon City, Philippines, UPecon Foundation, Inc.-Health Policy Development Program.

__________. 2008c. Navigator’s Training Modules. Quezon City, Philippines, UPecon Foundation, Inc.-Health Policy Development Program.

__________. 2008d. FHB Collection of Forms. Excel file submitted to the Health Policy Development Program, Quezon City, Philippines.



App

endi

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Appendix 2. Number of Navigators trained per barangay

Number of Navigators Trained (by Batch)TOTALTraining of

Trainors 1st 2nd 3rd 4th 5th

Compostela 3 25 25 24 29 14 120

Aurora 0 4 0 0 0 0 4

Bagongon 0 0 3 0 2 0 5

Gabi 0 4 0 0 1 0 5

Lagab 0 0 0 3 1 0 4

Mangayon 0 4 0 0 2 0 6

Mapaca 0 0 3 0 2 0 5

Marapat 0 0 0 6 0 0 6

New Allegria 0 0 0 4 3 0 7

Ngan 0 9 0 6 2 3 20

Osmena 0 0 5 0 1 4 10

Panansalan 0 0 0 0 1 0 1

Poblacion 2 0 6 0 6 4 18

San Jose 0 0 3 2 1 0 6

San Miguel 0 0 0 3 5 3 11

Siocon 1 4 0 0 1 0 6

Tamia 0 0 5 0 1 0 6

Mabini 0 25 25 25 29 0 104

Anitapan 0 9 1 0 3 0 13

Cabuyuan 0 3 1 3 4 0 11

Cadunan 0 0 6 0 5 0 11

Cuambog (poblacion)

0 0 7 4 3 0 14

Del Pilar 0 0 0 3 3 0 6

Libodon 0 2 3 0 0 0 5

Maraut 0 6 0 5 3 0 14

Pangibiran 0 0 2 1 0 0 3

Pindasan 0 4 0 8 3 0 15

San Antonio 0 0 1 0 1 0 2

Tagnanan 0 1 4 1 4 0 10




Maco 2 25 33 33 25 9 127

Anibongan 0 0 6 0 1 0 7

Anislagan 0 0 0 0 0 0 0

Binuangan 1 5 2 0 0 2 10

Bucana 0 0 1 0 1 0 2

Calabcab 0 0 0 0 0 0 0

Concepcion 0 0 2 0 0 0 2

Dumlan 0 0 3 0 0 0 3

Elizalde 0 0 0 6 6 0 12

Gubatan 0 0 0 0 1 0 1

Hijo 0 2 0 0 0 1 3

Kinuban 0 0 0 0 0 0 0

Langam 0 0 3 0 0 0 3

Lapu-Lapu 1 0 3 1 2 0 7

Libay-Libay 0 0 0 5 1 2 8

Limbo 0 0 0 3 0 0 3

Lumatab 0 0 2 0 0 0 2

Magangit 0 0 0 1 0 0 1

Mainit 0 1 1 0 0 0 2

Malomodao 0 0 0 4 2 0 6

Manipongol 0 0 0 0 0 0 0

Mapaang 0 0 0 0 3 0 3

Masara 0 0 0 4 0 0 4

New Asturias 0 0 0 0 1 0 1

New Barili 0 0 0 1 1 0 2

New Leyte 0 4 0 4 0 0 8

New Visayas 0 0 0 1 0 1 2

Panangan 0 1 0 1 0 0 2

Pangi 0 0 3 0 0 2 5

Panibasan 0 0 0 0 1 0 1





Panoraon 0 4 4 0 0 0 8

Poblaction 0 5 0 0 0 0 5

San Juan 0 0 0 1 0 0 1

San Roque 0 0 0 1 0 0 1

Sangab 0 0 0 0 0 0 0

Tagbaros 0 3 3 0 0 1 7

Taglawig 0 0 0 0 1 0 1

Teresa 0 0 0 0 4 0 4

Montevista 0 25 25 25 15 7 97

Banagbanag 0 0 3 2 1 0 6

Bangkerohan Norte 0 0 0 0 0 0 0

Bangkerohan Sur 0 0 4 0 0 0 4

Banglasan 0 2 0 0 0 0 2

Camansi 0 3 0 0 0 0 3

Camantangan 0 2 0 0 0 0 2

Canidkid 0 3 0 0 0 0 3

Concepcion 0 0 2 0 2 0 4

Dauman 0 0 2 0 0 2 4

Lebanon 0 3 0 0 1 0 4

Linoan 0 0 0 5 1 3 9

Mayaon 0 0 6 0 2 0 8

New Calape 0 0 2 0 0 0 2

New Cebulan 0 1 0 1 2 0 4

New Dalaguete 0 2 0 0 0 0 2

New Visayas 0 0 6 2 2 2 12

Prosperidad 0 6 0 0 3 0 9

San Jose poblacion 0 0 0 9 0 0 9

San Vicente 0 3 0 0 1 0 4

Tapia 0 0 0 6 0 0 6


Appendix 3. Family-Navigator Matching, by barangay


No. of Navigators Family-Navigator Ratio

TOTAL 5347 432 12.38


Aurora 58 4 14.5

Bagongon 36 5 7.2

Gabi 77 5 15.4

Lagab 51 3 17

Mangayon 96 6 16

Mapaca 44 5 8.8

Marapat 60 7 8.57

New Allegria 65 4 16.25

Ngan 196 19 10.32

Osmena 88 11 8

Panansalan 19 1 19

Poblacion 383 15 25.53

San Jose 100 7 14.29

San Miguel 167 12 13.92

Siocon 98 9 10.89

Tamia 63 5 12.6

Mabini 850 109 7.8

Anitapan 117 16 7.31

Cabuyuan 80 10 8

Cadunan 117 16 7.31

Cuambog (poblacion)

125 15 8.33

Del Pilar 57 9 6.33

Libodon 21 3 7

Maraut 106 11 9.64





Pangibiran 38 2 19

Pindasan 84 13 6.46

San Antonio 8 5 1.6

Tagnanan 97 9 10.78

Maco 1773 113 15.69

Anibongan 82 4 20.5

Anislagan 41 3 13.67

Binuangan 106 8 13.25

Bucana 18 1 18

Calabcab 17 1 17

Concepcion 39 2 19.5

Dumlan 60 3 20

Elizalde 111 6 18.5

Gubatan 23 1 23

Hijo 69 2 34.5

Kinuban 40 2 20

Langam 58 3 19.33

Lapu-Lapu 56 6 9.33

Libay-Libay 83 6 13.83

Limbo 36 3 12

Lumatab 43 2 21.5

Magangit 28 1 28

Mainit 14 1 14

Malomodao 70 4 17.5

Manipongol 25 2 12.5

Mapaang 48 3 16

Masara 43 4 10.75

New Asturias 21 1 21




New Barili 11 1 11

New Leyte 62 4 15.5

New Visayas 25 2 12.5

Panangan 25 1 25

Pangi 58 5 11.6

Panibasan 113 6 18.83

Panoraon 59 4 14.75

Poblaction 112 9 12.44

San Juan 20 1 20

San Roque 11 2 5.5

Sangab 20 1 20

Tagbaros 45 3 15

Taglawig 18 1 18

Teresa 63 4 15.75


Banagbanag 42 6 7

Bangkerohan Norte 14 1 14

Bangkerohan Sur 37 3 12.33

Banglasan 34 2 17

Camansi 38 3 12.67

Camantangan 36 2 18

Canidkid 46 3 15.33

Concepcion 21 4 5.25

Dauman 50 3 16.67

Lebanon 58 4 14.5

Linoan 69 7 9.86

Mayaon 100 9 11.11

New Calape 31 2 15.5

New Cebulan 37 4 9.25

New Dalaguete 22 2 11





New Visayas 107 10 10.7

Prosperidad 95 8 11.88

San Jose poblacion 138 9 15.33

San Vicente 59 4 14.75

Tapia 89 6 14.83

204

3 An Analysis of the Impacts of the Family Health Book Interventions

Jhiedon L. Florentino, Aleli D. Kraft, Julio M. Galvez, and Orville Solon

Abstract

This paper presents evidence from the Family Health Book (FHB) operations research on the impact of the FHB interventions on:

1) modern family planning (MFP), 2) antenatal care (ANC) by pregnant women; 3) skilled birth attendance (SBA) at home or in a facility; and 4) immunization (as determined by the number of fully-

immunized children, or FIC).

The FHB families’ use of these services is compared with that of similar families at baseline, using combined data from the FHB Baseline Survey and those collected from the FHB families as part of the operations research monitoring activities.

FHB interventions are represented by variables that indicate whether the families:

1) were given critical information through a “Book” and assigned to trained community health workers called “Navigators”;

2) developed appropriate health use plans (HUPs) for their health needs and risks; and

3) were recipients of outreach services.


Multivariate techniques were used, and socio-economic, location, and supply side characteristics were controlled in estimating the impacts.

One year after the distribution of the Book and assignment of Navigators, improvements were noted in the utilization of MFP, SBA, and ANC services. Provision of key information through the Book and Navigator resulted in improvements in MFP and SBA service utilization. These improvements were amplified by the development of HUPs. In the case of ANC, the impacts emerged only after the development of appropriate HUPs in response to the information provision. No additional impacts were seen in the FIC when HUPs were developed.

The measured improvements in the utilization of key maternal, neonatal, and child health and nutrition (MNCHN) services are consistent with field observations of both clients and health workers from the municipalities where the FHB OR was implemented. These results also validate findings in the international literature on the effectiveness of “patient” Navigators in assisting families for both MNCHN and non-MNCHN concerns.

The results imply that providing key information through a physical medium, supported by personalized guidance and assistance from Navigators that eventually result in families developing plans to address their health risks, are effective in addressing information barriers to utilization of key MNCHN services.

Introduction

From 2008 to 2010, the HPDP conducted the FHB operations research in the province of Compostela Valley. This operations research sought to establish evidence on the impacts of the FHB integrated package of interventions that aimed at increasing the utilization of critical family planning, maternal, neonatal, and child health care services.

The framework, design and interventions of the FHB are described in the operations research document (see Chapter 1). This paper describes the data and methods used to estimate the impacts


and analyzes results of the FHB’s impact on critical intermediate outcomes of interest. It also discusses observations from the field that explain the results, as well as issues that may impact on future implementation.

Specifically, the FHB interventions’ impact on the utilization of the following services and commodities are evaluated:

• modern family planning (MFP);• antenatal care (ANC) by pregnant women;• skilled birth attendance at home or in a facility (SBA); and • immunization (as determined by the number of fully-

immunized children, or FIC).

The use of these services by FHB families is compared with that of similar families at baseline using the combined data from the FHB Baseline Survey and data collected from FHB families as part of the operations research monitoring activities. The latter includes data from forms accomplished in the course of the family and FHB Navigator interactions which form part of the FHB interventions, and special tallies used for mid-term assessment and monitoring.

FHB interventions are represented by variables that indicate whether the families:

1) were given critical information through a “Book” and assigned to trained community health workers called “Navigators”;

2) developed appropriate health use plans (HUPs) for their health needs and risks; and

3) were recipients of outreach services.

Multivariate techniques were used, and socio-economic, location, and supply side characteristics were controlled in estimating the impacts.

A year after the distribution of the Book and assignment of Navigators, improvements were noted in the utilization of MFP, SBA, and ANC services. Providing families with Books and assigning them to Navigators improved the likelihood of pregnant mothers delivering in a facility (with a skilled birth attendant) by more than 15 percentage points. If the families developed


health use plans, there was a 35 percentage-point increase in the likelihood of delivering in a facility. Mothers in families which had Books and Navigators and also developed HUPs had increased likelihood by more than 25 percentage points of using a modern FP method. Receiving a Book, being assigned to Navigators, and developing a birth plan increased the likelihood of having at least one ANC visit by 10 percentage points. Families provided with information through the Books and Navigators increased FIC by 35 percentage points.

The paper also discusses issues related to the FHB operation, and insights from the Navigators, midwives, MHOs, and families to explain improvements seen in SBA and MFP use. Selected experiences from the field, such as dealing with mobile families and identification of beneficiaries, are also examined.

Section II reviews FHB interventions and study sites. Section III follows with a review of analysis methods, data and models. Section IV presents detailed results for MFP, ANC, SBA, and FIC. Section V discusses the study in the context of field operations and observations. Section VI presents the study’s conclusions.

Operations Research Setting

Study site and population

The FHB operations research was conducted in Compostela Valley from 2008 to 2010. Compostela Valley was chosen because of its high rates of maternal and infant mortality, and its low rates for contraceptive prevalence (CPR), antenatal care (ANC), skilled birth attendance (SBA), and fully-immunized children (FIC) despite the presence of basic service delivery infrastructures.

The municipalities of Compostela, Mabini, Maco, and Montevista were further chosen on the basis of high maternal and infant mortality rates and low utilization rates of health services. All the 81 barangays in these municipalities were included in the operations research.


Based on the FHB Baseline Survey results, families which would benefit most from the FHB interventions as they had the lowest rates of use of critical maternal and child health care services were those with mothers who did not finish high school education and were:

• pregnant; • below 25 with at least one child below

five years old; or• aged 26 and above, with at least two

children below five years old.

Some 6,940 potential FHB families met the initial screening. Community health workers validated the initial list and reduced the number to 5,361.

From this validated list, only some 4,730 were given Books and assigned to Navigators due to the very high mobility of target families. Some permanently transferred residence to non-FHB areas even before the distribution of the Books.

Interventions, sites, and timelines

All of the families in the four municipalities satisfying the eligibility criteria were provided with a “Book” and assigned to a “Navigator.”

The Book contains critical health information and health messages that prompt specific actions depending on the needs of the families. Health messages include modern family planning methods, discussion of the importance of prenatal care, danger signs during and after delivery, the need for skilled birth attendance during deliveries, and prevention of common child illnesses.


Other information presented in the Book are:

1) the list of providers and services given;

2) information on PhilHealth, the country’s national health insurance program; and

3) contact information of persons who operate or deploy vehicles in cases of health emergencies.

To guide the families in understanding the Book, community health workers were recruited and trained as “Navigators.” Navigators were selected from the ranks of community health workers and volunteers who satisfied the following criteria:

1) with at least two years of health-related activities in the community;

2) able to work with local officials;

3) finished at least two years of high school education or had at least elementary education, but with at least two years of health-related experience;

4) able and willing to regularly visit assigned households;

5) with good inter-personal communication skills and highly motivated; and

6) respected in the community.


The community workers’ training for their navigational functions with FHB families involved the following components:

1) an overview of the over-all health situation in the province;

2) the FHB Initiative and its components;

3) family planning and maternal and child health concepts ;

4) PhilHealth benefit entitlements and claim procedures;

5) instructions on their key roles, such as health risk assessment, formulation of HUPs, and accomplishment of various FHB forms; and

6) modules on communication and relational skills.

The trained Navigators were matched with the FHB families, and on average, assigned to handle around 10 to 12 families. This was less than the originally-planned 20 families per Navigator.

The Navigators assisted the families in determining their health risks and needs. They also guided them, together with health providers, in developing their HUPs.

HUPs contain the list and schedule of identified commodities and services which families require for their health concerns. They also identify the provider of these services and where these may be accessed. The HUPs also serve as a basis for Navigators to remind families and monitor their utilization of critical MNCHN services.


The FHB has five separate HUPs:

1) a Reproductive Health (RH) Plan for reproductive health and family planning needs;

2) a Birth Plan (BP) for antenatal care and delivery;

3) a Well-Baby plan (WBP) for immunization and other services for infants;

4) a Sick Child Plan (SCP) for consults and services for children 2 to 5 years old; and

5) an Emergency Plan (EP) that lists health emergency contacts.

The second FHB intervention sought to organize and conduct outreach services to address the health needs of families in far-flung areas. Unlike typical community outreach activities, FHB outreach services were regularly scheduled, targeted far-flung areas, and were based on identified health services and commodities in the HUPs of families in targeted barangays.

The targeted barangays were identified based on:

1) length of travel time to nearest rural health unit or health provider;

2) number of potential beneficiaries; and 3) accessibility to common transport.

The barangays of Banglasan, Mayaon, and San Vicente were selected based on the criteria while intervention was randomly assigned to Montevista. At least four rounds of outreach services were conducted during the FHB initiative (August 2009- March 2010).


The last FHB intervention sought to establish a functional health emergency communication and transport network that would actively coordinate with providers, transport groups and the private sector for availability of funding- and logistically-supported emergency transport 24 hours a day, 7 days a week.

The municipality of Compostela was randomly chosen to receive this intervention. After a baseline assessment of its capacity to respond to emergency cases, and consultation with the province’s and town’s health officers, a new round of meetings were held to design the protocol and to draft the Memorandum of Agreement between the province and Compostela for funding support to the network.

Eventually, the health emergency network operations were integrated into the municipality’s network for general emergencies (see Appendix 1 for the timing of the interventions).

Methods

Data To analyze the impacts of the FHB interventions, information from two main sources was merged -- the FHB Baseline Survey conducted as part of the design phase of the operations research, and the forms accomplished during family-Navigator interactions and during monitoring of FHB implementation activities.


The latter source included:

• special tallies for monitoring the conduct of FHB activities and for the mid-year assessment of the FHB implementation;

• FHB forms used by the Navigators; and • collected and encoded HUPs.

The FHB Baseline Survey data represented pre-intervention scenarios while FHB forms and tallies from the field were used to gather information on post-intervention utilization of critical MNCHN services of recipient families.

The FHB baseline surveys consisted of household, facility, physician, midwife, and patient exit surveys that sought to provide baseline information on the health utilization and health-seeking behavior of Compostela Valley residents, as well as the status of Compostela Valley providers. The surveys, conducted from December 2007 to around March 2008, covered all the municipalities of the province.

Sample barangays were randomly selected and families with either a pregnant woman or a child below 12 months of age were sampled. Families eligible for the survey were further limited to those whose primary decision maker was either the husband of the pregnant woman or the father of the infant, or the spouse.

From the 2,021 sampled households in all the municipalities, only those from the four FHB municipalities were included; and from these families, only those that met the FHB eligibility criteria. This yielded a total of 402 households from the baseline survey, with 114 from Compostela, 76 from Mabini, 139 from Maco, and 73 from Montevista.


From May 2009 to September 2010, the FHB operations research conducted various data collection and monitoring activities. The effort was a collaboration between HPDP, the Navigators, midwives, and the provincial government (refer to Appendix 2 on data collection efforts).

Data on the socio-economic status (SES) of the families and Navigators were collected at about the same time the Books were distributed to the families in May 2009. Afterwards, Navigators simultaneously or in the next visit conducted health risk assessment for the families.

HPDP encoded data from the submitted accomplished HRA forms. These forms also provided information on the families’ previous use of MNCHN services and some indicators of the health risks they faced. However, resource constraints impeded collection of subsequent health risk assessment forms accomplished in the wake of changing family circumstances (delivery of children and new pregnancies, etc.).

The mobility of families and members became apparent during the collection of the HRA and SES. Families identified as mobile -- initial feedback from the field -- were still included in the list of families for subsequent data collection.

Data on utilization during the FHB OR were collected from three sources:

1) the monitoring forms used by the Navigators;

2) forms and tallies from HPDP monitoring activities; and

3) the HUPs kept by the families.


Since the families retained the HUPs to remind them of scheduled utilization of services and commodities, Navigators’ monitoring forms were the initial data sources for the midterm monitoring of utilization patterns. The Navigators recorded and summarized in the Family Call Sheet (FCS) the scheduled and actual use of services indicated in the HUPs. HPDP began collecting and encoding data from FCS in December 2010. This provided information on the use of services from the start of Book distribution to the date of the collection.

In September 2009, HPDP inventoried the health use plans during the post-training assessment of Navigators. Relying heavily on Navigator reports validated by MHOs and nurses, HPDP complied a list of individuals who assisted (and where the assistance was done) in the delivery of those pregnant at the time of the FH Book distribution.

HPDP made another tally of health use plans -- supplemented by Navigator reports -- in the second quarter of 2010 to check whether FHB mothers who got pregnant after the Book distribution received visits and had health use plans, and whether infants born of mothers who were pregnant as of the book distribution had well-baby plans. HPDP also gathered information on utilization of modern family planning methods.

A year after the Book distribution and assignment of Navigators, a team of editors and encoders recorded all information found in the HUPs. The team obtained additional information on utilization (not required to be listed in the HUPs, such as the name of the actual birth attendant, place of delivery of FHB


mothers, dates of visits by the FHB families to facilities for services not reflected in the HUPs) from the families and the Navigators. Records, like target client lists for family planning services, in facilities visited by FHB familiies also provided utilization data. But data from these sources cannot be verified.

Data from the FHB Baseline Survey and the FHB monitoring forms did not allow for adequate assessment of the functional health emergency and communication network’s impacts. The FHB Baseline Survey made no inquiries on the use of emergency transport services during cases of illness, nor did FHB monitoring forms indicate the mode of transport used for emergency cases. With the use of emergency transport and communication services not limited to FHB families, a household survey would have been the better vehicle to assess whether FHB and non-FHB families benefited from this intervention.

Models and variables

To determine the impact of FHB interventions, FHB families’ utilization of services was compared with those of non-FHB families in similar situations at baseline. Regression models were estimated to determine the contribution of key FHB interventions on MFP use, antenatal care visits of pregnant women, delivery by skilled birth attendants at home and in facilities, and full immunization of children, controlling for family, Navigator, and area characteristics.


The general form of the model used is:

Ui = α + φBi + κCi + λDi + θEi+ F’iυ + G’iπ + ϵi

where Ui is the utilization of services/commodity by individual family member i.

To represent the FHB interventions, the following variables were used:

Bi -- dummy variable denoting whether individual i belonged to a family which received the FHB Book and was assigned to a Navigator;

Ci -- dummy variable denoting whether the individual’s family was provided a Book, assigned to a Navigator, and developed an HUP applicable to the service/commodity as indicated by a specified health goal in the HUP3;

Di -- dummy variable denoting whether the individual’s family was provided a Book, assigned to a Navigator, and resided in an area targeted for FHB outreach services; and

Ei -- a dummy variable denoting whether the individual’s family was provided a Book, assigned to a Navigator, resided in an area targeted for outreach services, and developed the applicable HUP.

4

4 Having a health goal indicates that the family actually developed or filled out HUP forms.


The different coefficients capture the following information:

Coefficient B -- captures the impact of the information provided by the Book and the Navigator;

Coefficient C -- captures the impact of families developing appropriate HUPs in response to information provided by the Book and the Navigator;

Coefficient D -- captures the combined impact of having a Book and the Navigator and being in an area where FHB outreach services were conducted; and

Coefficient E -- captures the combined impact of families having Books and Navigators, developing their HUPs, and living in an area where outreach services were conducted.

The impacts of the HUP and the FHB outreach activities were always combined with the basic intervention of information provision through the Book and the Navigator.

In estimating these impacts, the effects of family characteristics (such as mother’s age, father or mother’s educational attainment, income, and PhilHealth membership status on utilization of services), F’, was controlled. These effects are captured by v.


The vector G’ is composed of municipality dummies and the distance from the individual’s barangay residence to the municipality’s poblacion. These site characteristics are included to capture the effects of unobserved supply-side variables that may influence differences in utilization.

To capture modern FP use, a variable was constructed that took on a value of “1” in the tally of HUPs if the Navigator indicated that the mother was using modern FP or if there were records of modern FP utilization (e.g., restocking of pills, condoms) from the FCS and the encoded RH Plan. If not , the variable took on a “0” value.

For FHB baseline sample mothers, modern FP use took on a value of “1” based on the response to the questions on family planning methods used. Because there could be differences in the accuracy of FP utilization data from the various sources, another variable was added to control for the source of data, especially for the presence of the HUP.

In addition, previous use of FP by FHB mothers was also controlled by using a variable that took on a value of “1” if the mother had indicated modern FP use in the HRA. Unfortunately, previous FP use for the baseline sample could not be controlled, so the reference category for this dummy was FHB mothers without previous use and all sample mothers at baseline.


As family planning services were also provided during outreach services, variables that indicated whether the families resided in target outreach barangays were included. A logit regression model was used to estimate the impacts on the sample of FHB non-pregnant mothers and comparable non-pregnant mothers from the baseline.

For antenatal care visits, a variable was assigned a value of “1” if a mother had indicated at least one antenatal care visit for the current pregnancy (if currently pregnant) or for the last pregnancy (if non-pregnant) from the FHB Baseline Survey, or if there was at least one antenatal care visit recorded in the HRA or at least one antenatal care visit recorded in the birth plan.

An indicator of residence in outreach barangays was also included since antenatal care visits were also provided in such outreach activities. A logit regression model was used to estimate the impacts on the sample of mothers who were currently pregnant during the distribution of the Books or became pregnant in the course of the FHB intervention.

To capture place and attendant during delivery, a variable was constructed to indicate whether the pregnant mother had been assisted by a traditional birth attendant and delivered at home, assisted by a skilled birth attendant and delivered at home, or assisted by a skilled birth attendant and delivered in a health facility.


For the baseline sample, the questions on birth attendance referred to the last birth. For the FHB sample, the names of the attendants and place of delivery were obtained from pregnant mothers who had already delivered by the time of the HUP encoding.

This consisted of mothers who were initially pregnant during the health risk assessment and mothers who became pregnant in the course of the FHB intervention. Midwives and Navigators validated the information on birth attendance and location. A multinomial logit regression model was estimated.

To determine whether infants and young children received all the basic immunizations, immunization records received before the health risk assessment for infants and those obtained from family call sheets, and the encoded HUPs were used.

Those infants who had already reached one year old and expected to have completed the immunizations were included in the sample. From baseline families, children who were at least nine months old and those whose immunization status were obtained from vaccination cards were included. An indicator of residence in target outreach areas was likewise included. A logit regression model was estimated.


Results

Modern FP Use

Only 23% of families comparable with those of the FHB were found to be users of any modern FP method (Table 3.1).

Mothers aged 18 years old or below accounted for 15% of baseline mothers, while FHB mothers in that age group only accounted for 2% of all the FHB mothers.

Mothers aged 35 years or above accounted for 12% of baseline mothers, while FHB mothers in that age group was 9% of all FHB mothers.

Baseline families had a slightly higher number of children under five years old; however, this might be due to the baseline survey’s sampling criteria. For both baseline and the FHB families, roughly 50% of fathers reached elementary level. FHB families were also poorer compared to the baseline. More than half of the number of FHB families had monthly incomes lower than PhP 3,000.

In comparing the groups, two regression models were used: one controlled for whether the FHB mother was already a modern FP user prior to the intervention; the other did not, although a non-FHB mother could not be tagged if she was a previous user of modern FP prior to the baseline interview. Since utilization of modern FP for the FHB mothers came from various data collection sources in the course of the operation of the FHB, data source was also controlled for when determining the impact of the intervention.

For both regression runs, more than 70% of mothers were found to be non-users of modern FP methods at baseline (see Table 3.2 for the marginal effects and refer to Appendix 3 for the estimated logit equation).


Table 3.1: Descriptive statistics of variables: use of any modern family planning method

Baseline FHB

n mean n mean

Use of Modern FP (%) 248 22.98 4441 75.19

Mother is 18 years or below (%) 248 15.32 4441 2.43

Mother is 35 years or above (%) 248 11.69 4441 9.10

Number of children less than 5yrs old

248 1.91 4441 1.50

Father attained at most elementary education (%)

248 51.21 4441 48.28

Monthly family income is lower than PhP 3000 (%)

248 46.77 4441 57.89

Distance of barangay to poblacion/center (km)

248 19.08 4441 14.35

Mother attained at most elementary education (%)

248 64.92 4441 39.83

Source: Authors’ calculations based on FHB data sets.

Mothers aged 35 years old and above were also less likely to use any modern FP methods. Income and distance of barangay to the municipality’s poblacion did not significantly affect utilization of modern FP methods.

In the model that did not control for FHB mothers’ previous use of modern FP, the provision of the Book and assignment of a Navigator increased the likelihood of modern FP use by 10 percentage points.

In the regression run controlling for previous use of modern FP prior to the intervention, the likelihood of modern FP use by families provided with a Book and a Navigator approximated that of the baseline sample. However, this may understate the impact of the Book and the Navigator because the baseline utilization figure is a combination of the utilization of previous as well as new acceptors of modern FP methods.


Table 3.2: Marginal effects of regression runs on utilization of any modern FP method (MFP)

Model 1: Not controlling for

previous use of MFP (N=4710)

Model 2: Controlling for previous use of

MFP (N=4689)

Marginal effects Std. Err. Marginal

effects Std. Err.

Has Book and Navigator 0.095* 0.036 0.006 0.035

Has Book, Navigator, and RH Plan 0.295* 0.021 0.300* 0.022

Has Book, Navigator, and in Outreach Barangay

0.102* 0.048 0.102* 0.050

Has Book, Navigator, RH Plan, and in Outreach Barangay

0.029 0.087 -0.011 0.091

Mother is 18 years or below -0.075 0.042 -0.053 0.044

Mother is 35 years or above -0.123* 0.024 -0.104* 0.025


0.002 0.011 0.003 0.011

Father attained at most elementary education

-0.005 0.017 -0.003 0.017

Mother attained at most elementary education

-0.034* 0.017 -0.023 0.017

Monthly family income is lower than PhP 3000

-0.031* 0.016 -0.020 0.016

Distance of barangay. to poblacion (in km)

3.32E-04 4.61E-04 1.68E-04 0.000

Municipality=Compostela 0.109* 0.021 0.116* 0.022

Municipality=Mabini 0.205* 0.027 0.209* 0.028

Municipality=Maco 0.136* 0.023 0.143* 0.024

Family with Health Use Plan during mid year tally

0.405* 0.011 0.404* 0.011

FHB mother is previous user of modern FP

0.213* 0.018

*Significant at the 5% levelSource: Authors’ calculations


Figure 3.1. Predicted probabilities, MFP useSource: Author’s calculations

Development of an RH plan, together with the provision of the Book and assignment to a Navigator, increases the likelihood of MFP use in both models. Not taking into account previous use of modern FP by FHB families, the presence of an HUP increases the likelihood of modern FP use around 45 percentage points compared to non-FHB mothers (Figure 3.1).

Even when taking into account previous use of modern FP in the model, FHB mothers who were previous non-users of modern FP but developed an HUP were more likely to use modern FP by around 35 percentage points compared to non-FHB mothers.

The provision of targeted FHB outreach activities also improved modern FP utilization by families with Books and assigned to Navigators. Not controlling for previous use of modern FP by FHB families, the provision of regular and targeted outreach activities improved utilization by around 23 percentage points compared to non-FHB mothers.


Taking into account previous use of modern FP in the model, FHB mothers who were previous non-users of modern FP but were located in areas provided with regular FHB outreach activities were more likely to use modern FP by around 10 percentage points compared to non-FHB mothers.

Outreach services did not improve utilization if mothers had already developed RH plans. However, the likelihood of modern FP utilization was still higher among FHB mothers with RH plans than among FHB mothers who lived in outreach areas but did not develop plans.

Ante-natal care

Even before the FHB intervention, the proportion of pregnant women with at least one ANC visit during the last pregnancy was already high at 87% (Table 3.3). For both baseline and FHB families, 50% had fathers who reached elementary level education at most. Mothers who were recently or currently pregnant at baseline had an average age of 27, almost similar to the average age observed among pregnant FHB mothers. FHB families were also poorer compared with families at baseline.

From the regression runs, older mothers were less likely to have at least one ANC visit (see Table 3.4 for estimated marginal effects; logit estimates are shown in Appendix 4). On the other hand, the number of children less than five years old, income, and distance of the barangay to the municipality poblacion did not affect utilization of ANC services. However, one could note that there were municipality differences in the likelihood of pregnant women having at least one ANC visit.

Even as the proportion of pregnant non-FHB mothers with at least one ANC visit was already high at 85%, this figure further increased for pregnant FHB mothers who developed birth plans (Figure 3.2). Those who developed birth plans in combination with having Books and Navigators had an increased likelihood of having at least one ANC. However, providing outreach services no longer increased the likelihood of utilization of ANC services of FHB families.


Table 3.3: Descriptive statistics of variables: ANC

Baseline FHB

n mean n mean

Had at least one ANC visit (%) 392 86.99 1402 92.01

Age of mother 392 26.82 1402 25.85

Number of children less than 5 yrs old

392 1.52 1402 1.39


392 45.15 1402 60.34

Distance of barangay to poblacion/center (km)

392 19.10 1402 16.99

Father attained at most elementary schooling (%)

392 51.79 1402 50.64

Mother attained at most elementary schooling (%)

392 64.80 1402 43.01


Table 3.4: Marginal effects of regression runs on utilization of at least one ANC

Mother uses at least one ANC

Marginal effects Std. Err.

Has Book and Navigator 0.002 0.019

Has Book, Navigator, and Birth Plan

0.187* 0.045


0.028 0.077

Age of Mother -0.005* 0.001


-0.010 0.010


0.007 0.017

Distance of barangay to poblacion (in km)

4.84E-05 0.000


0.002 0.018





-0.001 0.018

Municipality=Compostela 0.086* 0.026

Municipality=Maco 0.109* 0.025

Municipality=Montevista 0.093* 0.029


Figure 3.2. Predicted probabilities, At least one ANC visitSource: Author’s calculations


Skilled birth attendance in facilities

More than 70% of the mothers at baseline chose to deliver at home and sought the assistance of traditional birth attendants (TBAs) during delivery (Table 3.5).

Only 25% of baseline mothers sought assistance from trained health providers during delivery. During the FHB initiative, a large proportion of mothers gave birth with the assistance of a skilled birth attendant in a facility.

Baseline and FHB mothers who gave birth had an average age of 27. FHB families were poorer compared to baseline families.

More than 50% of FHB families with a mother who recently gave birth had a PhilHealth-covered member, a figure much higher compared to that of baseline families. This may be explained by enrolment efforts exerted by the provincial and municipal governments in enroling FHB families in PhilHealth.

Regression results revealed that mothers with more children aged less than five years were more likely to seek assistance of TBAs (see Table 3.6 for the marginal effects and Appendix 5 for the estimated equation).

Similarly, mothers from families with low incomes relied more on TBAs during delivery than on skilled birth attendants in facilities.

Location of the barangay where the family resides also figured significantly on the choice of provider during delivery. Mothers residing in barangays far from the poblacion center of the communities were more likely to be assisted by TBAs than by trained health providers.


Table 3.5: Descriptive statistics of variables: SBA

Baseline FHB

n mean n mean

Delivery by Traditional Birth Attendant

374 74.87 1318 48.3308

Delivery by Skilled Birth Attendant, Home

374 12.03 1318 8.49772

Delivery by Skilled Birth Attendant, Facility

374 13.10 1318 43.17147

Age of mother 374 27.05 1318 25.8308


374 1.59 1318 1.39302


374 52.67 1318 50.60698


374 65.24 1318 42.79211


374 44.65 1318 60.54628

Family with PhilHealth member (%)

374 23.80 1318 55.31108


374 18.80 1318 17.24765


Mothers from families provided with Books and assigned to Navigators were more likely to deliver in a health facility than non-FHB mothers. The likelihood of going to a facility for delivery further increased by six percentage points for families who developed a birth plan with the Navigator.

However, provision of the Book, assistance of a Navigator, and development of HUP did not significantly affect the likelihood of shifting from TBAs to home delivery assisted by a skilled health provider. Overall, the FHB intervention decreased the likelihood of utilizing traditional birth assistance by around 19 to 27 percentage points and increased that of going to a facility for delivery by around 20 to 30 percentage points (Figure 3.3).


Table 3.6: Marginal effects of FHB interventions on SBA

Mother assisted by a traditional birth attendant

Mother assisted by a trained

health provider during home

delivery

Mother assisted by skilled health

provider and delivered in a health facility

Marginal Effects

Std error

Marginal Effects

Std error

Marginal Effects

Std error

Has Book and Navigator -0.140* 0.027 -0.01 0.02 0.147* 0.015

Has Book, Navigator and Birth Plan

-0.054* 0.026 -0.01 0.02 0.060* 0.018

Age of Mother -0.003 0.002 1.42E-03 0.00 0.001 0.001


0.070* 0.014 -0.03* 0.01 -0.038* 0.010


0.064* 0.021 -0.03 0.02 -0.037* 0.015


0.052* 0.022 -0.02 0.02 -0.036* 0.015


0.047* 0.021 -0.01 0.02 -0.037* 0.014

Family has a Philhealth member

-0.035 0.023 -0.02 0.02 0.051* 0.017

Distance of barangay to municipality's poblacion (in km)

0.003* 0.001 0.00* 0.00 -0.002* 0.000

Municipality=Compostela -0.098* 0.024 0.08* 0.02 0.021 0.012

Municipality=Mabini -0.222* 0.040 0.18* 0.04 0.043* 0.020

Municipality=Maco -0.293* 0.030 0.07* 0.02 0.223* 0.028



Figure 3.3. Predicted probabilities: SBASource: Authors’ calculations

Fully-immunized children

There was a significant increase in the number of infants with complete immunization.

More than 70% of infants were fully immunized during the FHB initiative. The baseline sample only registered 36%.

While there was not much difference in the average age of mothers with an infant at least nine months old during the baseline and the FHB initiative, more than 40% of FHB families with infants had fathers who attained elementary education, a figure higher than in the baseline.

From the regression runs, utilization of FIC services by FHB families provided with Books and Navigators was significantly higher compared with the baseline. However, the development of well-baby plans or location in outreach barangays did not bring further improvements on FIC (see Table 3.8; estimated regressions are in Appendix 6).


Table 3.7: Descriptive statistics of variables: FIC

Baseline FHB

n mean n mean

Fully Immunized (%) 66 36.36 1023 78.98

Age of Mother 66 26.11 1023 26.11


66 1.83 1023 1.48


66 39.39 1023 47.70


66 59.09 1023 40.86

Monthly family income lower than PhP 3000 (%)

66 37.88 1023 61.78

Distance of barangay to poblacion/center (in km)

66 20.31 1023 15.56

Source: Authors’ calculations

Table 3.8: Marginal effects of regression runs on FIC

Delta Method


Has Book and Navigator 0.347* 0.063

Has Book, Navigator and Well-Baby Plan

0.089 0.053

Has Book, Navigator and in Outreach Barangay

0.307 0.240

Has Book, Navigator, Well-Baby Plan, and in Outreach Barangay

-0.234 0.276

Age of Mother 0.003 0.003


-0.013 0.021


-0.045 0.037


-0.009 0.038


Delta Method



-0.027 0.036

Distance of barangay to poblacion/center (in km)

-0.003* 0.001

Municipality=Compostela 0.090 0.054

Municipality=Maco 0.080 0.048



Figure 3.4. Predicted probabilities: FICSource: Authors’ calculations


Discussion

Whether the utilization of critical MNCHN services improved with the implementation of the FHB package of interventions was analyzed, using data from the FHB Baseline Survey and from the operations research monitoring activities.

Controlling for family characteristics and location characteristics, the provision of information through the Book and reinforcement by Navigators improved skilled attendance and facility delivery by 15 percentage points, and full immunization of children by about 34 percentage points.

Families acting on the information provided by appropriately-developed health use plans increased modern family planning use by about 27 percentage points, antenatal care use by 18 percentage points, and skilled birth attendance in a facility by an additional 6 percentage points.

Outreach services significantly increased utilization of modern FP services for families which received information even if these families did not develop plans. These findings showed that information provided in a way that would make families act on their health risks and needs (i.e., with visits, assistance, and monitoring of Navigators) could substantially increase utilization of MNCHN services.

Field observations and interviews validated these findings. The mid-project FGD conducted among recipient families after initial visits by the Navigators, elicited mainly positive reactions. Families expressed appreciation for Navigators’ efforts in conducting actual visits, information dissemination, and health risks assessment. The orientation process on the FHB, the Book, risks assessment, and the HUP development made families residing in far-flung areas feel that they were being looked after for the first time. Many of these families, especially those residing in upland barangays, have never been to the health stations or rural health units.


Field observations and random household visits conducted to determine the accuracy of the observed improvement in SBA among FHB mothers revealed that the ordinances in Maco and Compostela banning TBAs from assisting mothers during deliveries could not be fully credited for these improvements.

During random household visits in the municipality of Compostela5, the families said the Navigators were the sole source of information regarding implementation of the ordinance promoting SBAs. The mothers cited that Navigators referred them to midwives, facilities, and even emergency transport providers during delivery.

Mothers also said that the Navigators linked up pregnant mothers and health providers. This was crucial in dispelling notions regarding giving birth in RHUs and other facilities. Some mothers felt that doctors performed unnecessary and painful procedures during deliveries in facilities.

In one of the families randomly visited, a mother with five children who recently gave birth in the RHU said she was initially afraid of going to the facility to deliver because of stories she had heard from neighbors about the painful injections given during delivery. Her earlier pregnancies were all assisted by a TBA at home.

Encouraged by her Navigator, she delivered her fifth child in the RHU. This changed her ideas about doctors. She said she was immediately able to perform basic household chores a few days after delivery and did not suffer after delivery.

The Navigators were also instrumental in starting discussions among couples on health issues. In many families, the Navigator referred couples to the BHS and RHUs for FP counseling. Though Navigators in the FHB did not perform health service delivery functions, the families appreciated their efforts in referring them to health providers.

5 HPDP staff conducted random, unannounced household visits -- in July and November 2009; January and March 2010; and April 2011 -- to validate records and Navigators’ and midwives’ reports.


A mother from one of the families randomly visited said her Navigator constantly reminded her of the importance of adhering to the schedule for taking birth control pills. In another family, the presence of a Navigator helped settle disagreements on limiting the number of children. The wife wanted to undergo ligation but the husband refused to sign the consent form for the procedure. Through the Navigator, the wife was referred to the midwife for counseling and was presented with options on various FP methods. The couple subsequently agreed on using an intra-uterine device (IUD).

Discussions with the MHOs were conducted to validate data extracted from monitoring forms and to draw observations from the provider viewpoint on the impacts of the FHB initiative on families. The MHO and other health personnel in the municipalities credited the improvements in the utilization of MFP commodities and services and SBAs to the efforts of the Navigators in referring mothers to health facilities and midwives for FP counseling.

Health providers in RHUs also noticed that early in the FHB initiative, many pregnant mothers from FHB families consulted for ANC during their first trimester. Midwives and doctors observed that some FHB families were familiar with the brand and prices of birth control pills.

According to the MHO, mothers visiting the RHUs credited the Navigators for giving them basic advice on taking pills. Mothers who recently gave birth cited the Navigator’s specific advice that lactating mothers could take birth control pills.

Navigators themselves recognized that their interaction with the families was the main difference between their tasks under the FHB initiative and their usual work as BHWs. Some Navigators cited that as BHWs, they did not individually visit families. Their previous interactions with families occurred mostly during community-level activities, such as vaccination drives and general outreach activities. They indicated that the training given to them boosted their morale and confidence in performing their FHB tasks.


However, provision of assistance to families entailed a significant level of effort on the part of the Navigators, depending on the number of families assigned. From the suggested ratio of 1 Navigator per 20 families, Navigator reassignments were made in consideration of actual difficulty and distance from the Navigator’s residence to the families being handled.

Navigators assigned to families living in the poblacion or lowland barangays were made to handle more families (some even up to 30), while those assigned to families living in small, upland areas with high degree of dispersion of families, and which required large transport costs were assigned less families (some even less than ten).

Despite these adjustments, Navigators still cited the difficulty of conducting regular visits due to the lack of transportation allowances, especially for those handling families in far-flung areas. This was consistent with the observations of some MHOs on the declining number of pregnant FHB mothers visiting the RHUs for their antenatal care, which they attributed to the failure of Navigators to conduct visits. Some Navigators overcame these difficulties by asking for transportation assistance from barangay officials.

Other challenges faced by Navigators:

• difficulty in using some of the FHB monitoring forms;• absence of the mother or father during monitoring visits; and• mobility of families.

To partly alleviate these, some midwives deployed other available community health workers to assist Navigators in follow-up activities.


Outreach The additional impact of the FHB outreach services can be attributed to measures that ensured that families were informed ahead of time of outreach schedules and were able to attend outreach services.

For instance, as some of the far-flung areas proved to be inaccessible especially during the rainy months, the MHO and PHO conducted outreach activities in the poblacion areas of the targeted barangays but provided transportation to the outreach sites for families living in far-flung areas.

There were also difficulties encountered in conducting FHB outreach activities. During a random visit in one of the outreach barangays, midwives cited the need to be up-to-date on the scheduled services indicated in the HUPs of families.

Midwives also indicated the advantages of having cost-effective FHB outreach activities compared to regular outreach activities. According to one midwife, the usual practice of putting up a buffer, or over-projecting the need for commodities, would amount to more than 70% of the needs of the identified beneficiaries.

She said there was overprojection since there was no prior information on the needs, or even the actual counts of beneficiaries, on the ground. On the other hand, the HUPs provided them with prior information on the number of beneficiaries and the required commodities and services.


Evidence on other health Navigators

Findings in Compostela Valley were consistent with the international experience in the use of health Navigators and/or health navigational functions. There is a wide body of literature on the role of health Navigators in providing information for target groups, which ultimately affect behavior and health outcomes. In Bangladesh and Nepal, community health workers (Manandhar et al., 2004; Baqui et al., 2008; McPherson et al., 2006) were assigned to expectant mothers and assisted them in preparing for childbirth. Through focus group discussions, targeted women were given information about the importance of ANC and SBA.

In another intervention, health workers provided targeted women with keychains and flipcharts containing health messages on desired behaviors for birth-preparedness. (McPherson et al., 2006).

Results indicated that community health workers positively influence intermediate health outcomes. But, as some studies note, health services being promoted by health workers should be services actually available in the communities (McPherson et al., 2006).

Other studies assert that health Navigators should be sensitive to the cultures of the communities they serve (Garcia et al., 2009; Guadagnolo et al., 2011). Providing culturally competent Navigators who are able to provide appropriate solutions for their clients results in better client satisfaction, and consequently, improved intermediate health outcomes.


In this regard, some patient Navigator programs in the USA (Hendren et al., 2010) require potential Navigators to be fluent in a language other than English; for instance, Spanish. Potential health Navigators are also required to attend training programs, where basic health diagnostics and patient Navigator roles are taught. Some studies indicate that while health Navigators might be effective, “overburdening” them with a large group of clients may result in dampened impact on behavior change, and ultimately on health outcomes.

A study on the National Family Planning program in Vietnam showed that patient Navigators, called “collaborators,” did not continue with follow-up meetings for women who adopted a long-term contraceptive method. The collaborators felt overburdened since they were also expected to be service providers aside from being patient Navigators (Tuan and Johnston, 2002).

Patient navigation is in fact a current trend in developed countries and even involves the private sector. Patient navigation programs have been successful in guiding breast cancer patients through the health care system, and survival rates of cancer patients have increased5 (Battaglia et al., 2006; Freeman, 2006).

6

6 The first patient Navigator program established in Harlem Hospital for breast cancer patients reported that five-year survival rates from 1995 to 2000 increased from 29% to 78%. The incidence of late-stage cancers dropped from 40% to 28%, then to 21%.


These services are being increasingly used in the United States as they provide cost savings for patients, particularly those afflicted with chronic diseases such as cancer, HIV/AIDS, and diabetes.

A study of diabetes patients in West Baltimore, Maryland, USA showed that patient Navigators resulted in cost savings of at least $2,245 per year (Fedder et al., 2003). Hourly wages may vary from as little as $15 to as much as $50 for community health worker (CHW) volunteers, shooting up to $200 per hour for private patient Navigators (Bank, 2009; Fayerman, 2011), which indicates that the provision of patient Navigator services constitutes a lucrative business.

Limitations

Our results show increased key intermediate outcomes for FHB families which received Books and were engaged by their Navigators. However, these results may be biased by the limited information obtained on eligible and highly-mobile families during the intervention period. These families, who would most likely benefit from the FHB interventions may be the less likely ones to utilize care.

The high mobility of the eligible population became apparent even before the distribution of Books: the initial list of families for the FHB needed to be validated twice to confirm the families’ addresses. There were less families who received the Book than those found in the validated lists, as some families were known to have moved out of the pilot sites.


During follow-up visits by Navigators and midwives, the common types of mobility observed included the following:

1) permanent transfer of a family to a non-FHB site (either within or outside the province);

2) permanent transfer of a family within the FHB site; 3) temporary move-outs to non-FHB sites; and 4) temporary move-outs to FHB sites.

Given the mobility of families, the Provincial Health Office advised families to bring the Book and HUPs with them when transfering residence.

Endorsement among Navigators of families transferring residence within FHB sites was also recommended. Navigators were also instructed not to drop those families transferring residence from their rosters, just in case these return again to FHB sites. Despite these instructions, no more follow-ups were done on some families, especially those who have transferred to non-FHB sites.

Mobility of family members also included the following:

• temporary moving out of either the mother or father to non-FHB sites during specific months of the year;

• temporary move-outs of mothers from residence; and • permanent move-outs of mothers from residence.

Temporary transfer of residence within the province was a seasonal phenomenon. During rainy seasons, men went to the mining sites for gold panning. Some families only returned to their residences during the rainy season for harvesting.

Some mothers leave their families to work in nearby cities as household help. The general advice given by Navigators to families with mothers leaving behind children: endorse the Book and the HUP to the father or relatives living nearby.

Cases of temporary move-outs made it difficult for Navigators to conduct follow-up visits. Some families would not be in their usual addresses for months. In some cases, the mother would


bring along the Book and the family’s HUPs, where the children’s scheduled services were recorded. Navigators thus had to reconstruct HUPs by reviewing their records and logs.

Conclusions

The FHB operations research conducted in Compostela Valley sought to assess whether a package of demand-side interventions could increase utilization of critical MNCHN services. Families were given critical information through a Book, assigned to trained community health workers who assisted them in developing appropriate HUPs for their health needs and risks, and were recipients of outreach services.

Using multivariate techniques on a combined baseline household data set and data collected from FHB monitoring activities, the FHB package of interventions was shown as exerting a significant impact on the use of modern family planning, antenatal care visits, skilled birth attendance at a facility, and immunizations for children.

These results are robust even after controlling for the following:

• individual and family characteristics that affected demand;• distance and municipality characteristics that affected

supply conditions and geographic access; and • noise that arise from data sources.

In the case of MFP and SBA, the provision of key information through the Book and Navigators resulted in cases of better utilization which were further reinforced by the development of HUPs. The impacts were seen only in ANC cases when appropriate HUPs were developed. Meanwhile, no additional impacts were seen in the incidence of FIC even when HUPs were developed. But seen from a larger context, the results imply that addressing informational barriers to utilization of key MNCHN services by providing key information through a physical medium, then giving support to beneficiary families through personalized guidance and assistance from Navigators, are effective ways to persuade families to develop plans which address their health risks.


Both clients and health workers validated the measured improvements in utilization of key MNCHN services. FHB families appreciated efforts of Navigators to assist them in understanding their risks and the available options to address these risks. Community health workers assigned to these families felt empowered by the training provided to them, and which boosted their morale and confidence to perform their navigational functions.

Field observations also highlighted that logistical support, specifically transportation allowances from both the provincial as well as municipal governments, was crucial in facilitating Navigators’ visits to their assigned families. Support from provincial, municipal, and barangay officials was also instrumental in ensuring the outreach activities’ success. Adjustments in the assignment of the number of families assigned to Navigators were also needed.

The high mobility of FHB families proved to be a challenge for Navigators and health workers. Advisories and operational adjustments prove insufficient to ensure that FHB families received the proper care in their new residence areas, especially in cases of permanent transfers and transfers to non-FHB municipalities.

The literature reveals that in both developed and non-developed country settings, the use of patient Navigators is effective in assisting families for both MNCHN as well as non-MNCHN concerns. Results from the FHB operations research in Compostela Valley reinforced the literature, with its findings that the provision of critical information through the Book, the Navigator, and through guided assistance in developing HUPs were effective interventions that could increase utilization of critical MNCHN services. Expanding these FHB interventions at the provincial, regional, and nationwide levels is something worth considering in order to improve MNCHN outcomes.


References

Acuin, C. 2008. Conduct of Focus Group Discussions (FGDs) on Family Planning Behaviors Among Men and Women in Selected Municipalities of Compostela Valley Province. Report submitted to the Health Policy Development Program, Quezon City, Philippines.

Bank, D. 2009. Encore ‘Navigators’ improve health, reduce costs. Retrieved from http://www.encore.org/news/encore-navigators-work-i.

Baqui, A., El-Arifeen, S., Darmstadt, G.L., Ahmed, S., Williams, E.K., Seraji, H., …, and Black, R. 2008. Effect of community-based newborn-care intervention package implemented through two service-delivery strategies in Sylhet district, Bangladesh: A cluster-randomised controlled trial. Lancet 371 (9628), 1936-1944.

Battaglia, T.A., Roloff, K., Posner, M. A., and Freund, K. M. 2006. Improving follow-up to abnormal breast cancer screening in an urban population. Cancer 109 (12), 359-367.

Fayerman, P. 2011. Canadians unwilling to pay for private care. Retrieved from http://www.vancouversun.com/news/patient-navigationseries/Canadians+unwilling+private+care/4374666/story.html.

Fedder, D.O., Chang, R., Curry, S., and Nichols, G. 2003. The effectiveness of a community health worker outreach program on healthcare utilization of West Baltimore City Medicaid patients with diabetes, with or without intervention. Ethnicity and Disease 13 (1), 22-27.

Freeman, H. 2006. Patient navigation: A community based strategy to reduce cancer disparities. Journal of Urban Health 83 (2), 139-141.

Garcia, E.L., Viveros, L., and Feldman, N. 2009. Patient navigation: Lay patient Navigators and delivery of breast cancer treatment to indigent Hispanic women. Abstract presented in the American Society of Clinical Oncology Breast Cancer Symposium, San Francisco, California.


Guadagnolo, B.A., Boylan, A., Sargent, M., Koop, D., Brunette, D., Kanekar, S., and Petereit, D. G. 2011. Patient navigation for American Indians undergoing cancer treatment: Utilization and impact on care delivery in a regional healthcare center. Cancer 117 (12), 2754-2761.

Health Policy Development Program. 2009. The Family Health Book Operations Research Design. Quezon City, Philippines: UPecon Foundation, Inc.-Health Policy Development Program.

Hendren, S., Griggs J.J., Epstein, R.M., Humiston, S., Rousseau, S., Jean-Pierre, P., and Fiscella, K. 2010. Study protocol: a randomized controlled trial of patient navigation-activation to reduce cancer health disparities. BMC Cancer 10 (551).

Manandhar, D., Osrin, D., Shrestha, B.P., Mesko, N., Morrison, J., Tumbahangphe, K.M., and Costello, A.M. 2004. Effect of a participatory intervention with women’s groups on birth outcomes in Nepal: Cluster-randomised controlled trial. Lancet 364 (9438), 970-979.

McPherson, R., Khadka, N., Moore, J., and Sharma, M. 2006. Are birth-preparedness programs effective? Results from a field trial in Siraha district, Nepal. Journal of Health Population and Nutrition 24 (4), 479-488.

Palmer, L., Hill, I., and Magazimik, A. 2007. HealthConnect in our community: What do health Navigators, community health workers, and families say about the program? Washington, DC: The Urban Institute.

Simmons, J. 2011. Patient Navigator Improves Outcomes, Incomes. Retrieved from http://www.healthleadersmedia.com/page-2/MAG-246087/Patient-Navigator-Improves-Outcomes-Incomes.

Tuan, N. A., and Johnston, H. 2002. Can Vietnam’s Family Planning Collaborators Improve Grassroots Reproductive Health Services? Results of an assessment in two communes. Chapel Hill, North Carolina: Ipas.


App

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M8

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M10

M11

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M13

M14

May

Jun

July

Aug

Sept

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Nov

Dec

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MOP finalized

Ordinances drafted

CoNECT MOA signed, Baseline assessment conducted

Training of operatives


Appendix 2. FHB data collection efforts

Forms/FHB data Period of Collection

Number of Families

with Submitted

Data

1) Validation of Families on FHB eligibility

April to May 2009 5261

2) Acknowledgment Receipt Books by families from Navigators

June to August 2009 4725

3) Tally of Health Use Plans August to October 2009 4725

4) Socio-economic profile of FHB families and Health Risks Assessment forms

October to December 2009 4725

5) Family Call Sheets and Journals, Tally of delivery data of pregnant FHB mothers

March to May 2010 4725

6) Re-tally of HUPs and utilization of modern FP

May to June 2010 4652

7) Collection of HUPs August to December 2010 4537


Appendix 3. Logit runs: MFP

Family uses any modern FP method

Family uses any modern FP method

Coef Standard Error Coef Standard

Error

Has Book and Navigator 0.498* 0.175 0.0283603 0.179787

Has Book, Navigator, and RH Plan 1.550* 0.101 1.543* 0.104


0.536* 0.252 0.523* 0.255

Has Book, Navigator, RH Plan, and in Outreach Barangay

0.154 0.459 -0.059 0.467

Mother is 18 years or below -0.392 0.222 -0.275 0.226

Mother is 35 years or above -0.645* 0.128 -0.534* 0.132


0.010 0.056 0.014 0.057


-0.027 0.087 -0.014 0.089


-0.161* 0.082 -0.104 0.084


0.002 0.002 0.001 0.002


-0.177* 0.087 -0.116 0.090

Municipality=Compostela 0.573* 0.112 0.595* 0.114

Municipality=Mabini 1.077* 0.141 1.075* 0.144

Municipality=Maco 0.714* 0.121 0.736* 0.124

Family with Health Use Plan during mid year tally

2.127* 0.086 2.077* 0.088

FHB mother is previous user of modern FP

1.095* 0.086

Constant -1.596* 0.221 -1.695* 0.223

N 4710 4689

LR chi2(15) 1536.08 1698.73



Appendix 4. Logit runs: At least one ANC visit


Coefficient Standard Error


Has Book, Navigator and Birth Plan 1.882* 0.385

Has Book, Navigator and in Outreach Barangay

0.281 0.768

Age of Mother -0.047* 0.014

Number of children less than 5 yrs old

-0.104 0.106

Monthly family income is lower than PhP 3,000

0.066 0.174

Distance of barangay to poblacion / center (in km)

4.87E-04 0.004


0.020 0.181


-0.011 0.183




Constant 2.574* 0.476

N 1794

LR chi2(12) 96.73



Appendix 5. Multinomial logit: SBA at facility

Skilled Birth Attendance

at Facility

CoefficientStandard

Error

(Base outome = Delivery assisted by TBA)

(Outcome= Delivery at home and assisted by SBA)


Has Book, Navigator and Birth Plan 0.041 0.232


Number of children less 5yrsold -0.422* 0.118

Father attained at most elementary education -0.358* 0.189

Mother attained at most elementary education -0.243 0.191

Monthly family income is lower than PhP 3,000 -0.170 0.184

Family has a Philhealth-member -0.082 0.199

Distance of barangay to poblacion -0.017* 0.005


Municipality=Mabini 1.895* 0.326


Constant -2.139* 0.530

(Outcome=Delivery at health facility)


Has Book, Navigator and Birth Plan 0.519* 0.151


Number of children less than 5yrs old -0.392* 0.079

Father attained at most elementary education -0.373* 0.127

Mother attained at most elementary education -0.347* 0.128

Monthly family income is lower than PhP 3000 -0.347* 0.125

Family has a Philhealth member 0.419* 0.133


Skilled Birth Attendance

at Facility

CoefficientStandard

Error

Distance of barangay to municipality poblacion -0.018* 0.003


Municipality=Mabini 0.863* 0.242


Constant -1.871* 0.359

N 1692

LR chi2(24) 480.400


Appendix 6. Logit runs: FIC

Fully-Immunized Child

CoefficientStandard

Error


Has Book, Navigator and Well Baby Plan 0.393 0.237

Has Book, Navigator, and in Outreach Barangay 1.357 1.056

Has Book, Navigator, Well Baby Plan, and in Outreach barangay -1.036 1.221


Number of children less than 5yrs old -0.059 0.093

Father in the family reached at most elementary education -0.200 0.165

Mother in the family reached at most elementary education -0.040 0.166

Monthly family income is lower than PhP 3,000 -0.119 0.160

Distance of barangay to poblacion/center (in km) -0.013* 0.004

Municipality=Compostela 0.422 0.257

Municipality=Maco 0.378 0.232


Constant -0.860 0.482


255

4 Baseline Family Health Book (FHB) Survey Documentation Report

Health Policy Development Program (HPDP)UPecon Foundation Inc.

Abstract

This report details the contents of the FHB Baseline survey conducted to provide data for analysis of maternal and child health practices in Compostela Valley. The survey has three components: the household survey, physician and midwife survey, and hospital and clinic survey.

The household survey provided information on health care utilization and mapped health facilities and providers patronized by residents in Compostela Valley. The physician and midwife survey generated information on practice characteristics and health care providers’ case/patient load. The hospital and clinic survey yielded data on patient characteristics, their health use patterns, and satisfaction from provided health care services.


Background

The Health Policy Development Program (HPDP) is a five-year project funded by the United States Agency for International Development (USAID) and is mandated to assist the Department of Health (DOH) in shaping the policy environment towards achieving better health outcomes, a more responsive health system, and equitable health care financing. The HPDP is managed by the UPecon Foundation, Inc.—a private non-profit organization composed of faculty from the UP School of Economics.

The Family Health Book (FHB) initiative is one of HPDP’s flagship products. The FHB initiative aims to improve utilization of critical services to help reduce the risk of maternal and child morbidity and mortality. FHB interventions aim to mitigate these risks by addressing some family-level barriers to using critical services, which include

• lack of information on what services to access; • where these services can be accessed;• how these services can be accessed; • the means through which these services can be financed; and • the lack of logistical support to accessing care.

An innovation under the FHB initiative is the use of health Navigators to assist families recognize their health risks and plan for the utilization of health services to address those risks. To test the effectiveness and efficiency of the FHB intiative prior to a nationwide scale up, a pilot implementation was conducted In the province of Compostela Valley in partnership with the Center for Heath Development XI (CHD XI), and the Compostela Valley LGUs.

To support the conduct of the FHB pilot, a Baseline Survey was done to:

• identify pilot sites for the initial launching of the FHB initiative;• determine core services to be offered; and • define how providers should be linked together into

service delivery networks.


The Baseline Survey had three component surveys which generated data for situational analysis of maternal and child health practices in Compostela Valley. It also mapped health services providers and quality of care.

Component Surveys

Household survey

This component survey gathered information on health care utilization and mapped health facilities and providers patronized by residents in Compostela Valley. The information generated by the Household Survey also included access to maternal, newborn, and child health services, as well as family planning counseling and medical commodities.

Physician and midwife survey

This component survey, administered among physicians and midwives, generated information on practice characteristics and case/patient load.

It also included clinical vignettes that measured the quality of select maternal and child health care services provided by physicians and midwives in Compostela Valley.

Hospital and clinics survey

This survey generated information on the operation of health facilities (including pharmacies).

It also included patient exit interviews that provided data on patient characteristics, their health use patterns, and satisfaction from provided health care services.


Description of the FHB Baseline Survey

Overview

The FHB Baseline Survey consisted of component surveys on households, health care providers, health facilities, and patient exits conducted between 2007 and 2008.

The household survey covered the following number of households:

Compostela 203 Monkayo 339

Laak 199 Montevista 110

Mabini 109 Nabunturan 216

Maco 219 New Bataan 144

Maragusan 147 Pantukan 223

Mawab 112

The health facilities survey covered practically all facilities in Compostela Valley except for hospital-based clinics, and the Davao Regional Hospital and its corporate clinics in Tagum City, which is in the adjoining province of Davao del Norte.

This survey enumerated 12 hospitals (five public and seven private) and 21 private clinics, 11 RHUs, and 21 pharmacies.

The health provider survey covered 94 health professionals (physicians, nurses, and midwives). Disaggregated by health facility where they practiced,

• 25 came from public hospitals; • 13 came from private hospitals;• 2 came from hospital-based clinics;• 17 came from free-standing clinics;• 34 from RHUs and satellite units; and • 3 from birthing home/lying-in clinics.


The patient exit survey enumerated respondents from all surveyed hospitals and clinics. They included the following:

• 6 inpatient and 5 outpatients from the regional hospital; • 4 inpatients and 5 outpatients from district and

municipal hospitals; • 4 inpatients and 3 outpatients from private hospitals; and • 3 outpatients from private clinics and RHUs.

In all, the patient exit survey covered a total of 61 inpatient (23 maternal and 38 pediatric cases) and 166 outpatient (48 maternal and 118 pediatric cases) respondents.

Sampling Design

Household Survey

To measure health care utilization (particularly of maternal, neonatal, and child health services) in Compostela Valley, a random survey of households was conducted in select barangays in each of its municipalities.

Respondent households were selected using multi-stage stratified sampling with clustering. Barangays from each municipality were selected using probability-proportional-to-size (PPS).

Random sampling of households was done in each cluster. In developing a barangay sampling frame, barangay officials, barangay health workers, social workers, and rural health center staff were consulted to identify households with pregnant women or children below 1 year old.

The survey allowed for a 20-percent maximum drop-out rate; thus, from the sampling frame, 52 households (104 for 2-cluster barangays) were randomly drawn. Attaining 43 respondent households (86 for 2-cluster barangays) sufficed for the quota for a barangay.


The following table shows the barangays selected per municipality and number of households drawn:

Table 4.1: Sample barangays and number of sample households per municipality

MUNICIPALITY Sampled BarangaysNo. of Household

Respondents

COMPOSTELA 203

1 Gabi 41

2 New Alegria 41

3 Poblacion* 80

4 Siocon 41

MONTEVISTA 110

1 Camantangan 37

2 New Visayas 37

3 Tapia 36

NABUNTURAN 216

1 Libasan 44

2 Mainit 43

3 Pangutosan 43

4 Poblacion 43

5 Bukal3 43

MABINI (DOÑA ALICIA)

109

1 Cuambog (Pob.) 55

2 Golden Valley (Maraut) 54



Respondents

MACO 219

1 Binuangan 44

2 Elizalde (Somil) 44

3 Libay-libay 44

4 Panibasan 44

5 Sangab 43

MAWAB 112

1 Nueva Visayas 56

2 Poblacion 56

PANTUKAN 223

1 P. Fuentes 45

2 Kingking (Pob.) 45

3 Magnaga 45

4 Napnapan 44

5 Tibagon 44

LAAK (SAN VICENTE)

199

1 Il Papa 40

2 Langtud 40

3 Amor Cruz 40

4 Imelda 40

5 Santo Niño 39

MARAGUSAN(SAN MARIANO)

147

1 Mapawa 37

2 Maragusan (Pob.) 37

3 Langgawisan 37



Respondents

4 Tandik 36

MONKAYO Batch 3 339

1 Awao 43

2 Casoon 43

3 Mamunga 43

4 Poblacion 42

5 Rizal 42

6 Tubo-tubo (New Del Monte)

42

7 Mount Diwata* 84

NEW BATAAN Batch 3 144

1 Camanlangan 48

2 Cabinuangan (Pob.) 48

3 Andap 48

2021*Sample barangay with 2 clusters


Some households were dropped from the sample on the following bases:

1) respondent household could not be located; 2) respondent household refused to participate in the survey; 3) household number and name of household head did not

match with what is in the field; and4) the house was all closed up and the neighbor said no

one lived there, or the respondent household moved away permanently.

In these cases, the enumerator proceeded to the next household in the list. If household members were temporarily unavailable for interview, the enumerator scheduled a call back. A household was dropped from the sample only after six (6) failed call-backs.

In case the household transferred within the same barangay, the enumerator should find the household in the new location and administer the questionnaire.

Physician and Midwife Survey and Quality of Care Assessment Using Vignettes

This survey collected data on the characteristics and clinical and non-clinical practices of health care providers in Compostela Valley. Through clinical vignettes, it also measured the quality of maternal and child health care services provided.

All facility-based and free-standing/independent physicians attending to maternal, neonatal, and child-health/pediatric cases were considered eligible for the survey. The following table shows the vignettes and number of respondents selected in all public and private hospitals in Compostela Valley.


Table 4.2: Vignettes and number of respondents for the health provider survey

InstrumentPhysician

respondentMidwife

respondent

Prenatal vignette and survey

1 OB GYN 1 midwife (1 instrument only)

Normal delivery vignette and survey

1 OB GYN

Postpartum hemorrhage vignette and survey


Pre-eclampsia vignette and survey

1 OB GYN

Neonatal sepsis vignette and survey

1 pediatrician -

Pneumonia or diarrhea vignette and survey

1 pediatrician -

Neonatal resuscitation vignette and survey

1 pediatrician

UTI and pregnancy vignette and survey


The following sampling rules were employed:

• If the facility has more than two obstetrician/gynecologists (OB-Gyns), two OB-Gyn respondents are to be randomly selected;

• If facility has no OB-Gyns, any physician who usually attends to maternal cases, preferably normal and Cesarean Section (CS) deliveries, is to be selected;

• If facility has more than two midwives, three midwife respondents are to be selected;

• If facility has no in-house midwife, any nurse who usually attends to normal deliveries without the close supervision of a physician is to be selected.


• If facility has more than two pediatricians, two pediatrician respondents are to be randomly selected;

• If facility has no pediatrician, any physician who usually attends to pediatric cases is to be selected.

• For free-standing or independent physicians attending to maternal, neonatal, and pediatric cases, either prenatal or normal delivery vignette and survey AND either postpartum hemorrhage or preeclampsia vignette and survey should be administered to all independent OB-Gyns, Family Medicine practitioners, general practitioners (GPs), and midwives.

• Eligible respondents who cannot be located (after 6 call-backs), who refuse to participate in the survey and sign a waiver form, who are on leave for more than a week, or who have permanently relocated outside Compostela Valley are considered drop-outs.

In such a case, the enumerator should randomly choose another facility-based respondent. In addition, respondents who refuse to answer one or two vignettes should sign a waiver form.


Health Facility Survey

This survey covered all public and private hospitals in Compostela Valley, and included the Davao Regional Hospital in Tagum City. It also all pharmacies and RHUs. The survey aimed to collect data on facility staff, equipment inventory, and facility pricing and services. Table 4.3 shows the sampling design by facility type.In case of refusal by the selected facility, the enumerator should request the facility administrator to sign a waiver form. If the administrator refuses to sign, the enumerator should inform the HPDP field auditor as soon as possible for further instructions.

For refusals in the patient exit survey, the enumerator should list down the names of refusing respondents and their reasons for refusal. Another qualified respondent must be identified to replace the dropped respondent.

Description of Survey Instruments

Four questionnaires composed the FHB baseline survey:

1) household survey;2) health provider survey (for physicians, nurses, and

midwives);3) facility questionnaire (for public and private hospitals,

RHUs, facility-based and free-standing clinics, and birthing homes; and

4) patient exit survey (for inpatients and outpatients).

The household survey collect baseline data on characteristics of households and their health-seeking behavior, particularly that of pregnant mothers and children below a year old. The questionnaire is composed of the following blocks:

• sampling information; • household information (number of members, sex,

employment, lifestyle, among others); • socio-economic status;


Tabl

e 4

.3: S

ampl

e of

faci

litie

s an

d nu

mbe

r of p

atie

nts

Type

of

faci

lity

Num

ber

of

resp

onde

nts

Type

of

resp

onde

nt

Regi

onal

hos

pita

ls6

inpa

tien

ts

per h

ospi

tal

3 m

ater

nal c

ases

(1 u

ncom

plic

ated

nor

mal

del

iver

y, 1

com

plic

ated

del

iver

y, 1

CS

), 2

pedi

atric

cas

es (a

ny 2

of t

he ff

: acu

te re

spira

tory

infe

ctio

n (A

RI),

diar

rhea

, m

alnu

triti

on, o

r ped

iatr

ic T

B), 1

neo

nata

l sep

sis

or o

ther

neo

nata

l cas

es

5 ou

tpat

ient

s pe

r hos

pita

lM

ater

nal o

r ped

iatr

ic c

ases

Priv

ate

hosp

ital

s4

inpa

tien

ts

per h

ospi

tal

2 m

ater

nal c

ases

(1 n

orm

al d

eliv

ery

and

1 CS

), 2

pedi

atric

cas

es (a

ny 2

of

the

ff: A

RI, d

iarr

hea,

mal

nutr

ition

, or p

edia

tric

TB)

Hos

pita

l-ba

sed

priv

ate

clin

ics*

3 ou

tpat

ient

s pe

r clin

ic1

mat

erna

l cas

e, 2

ped

iatr

ic c

ase

(imm

uniz

atio

n, A

RI, d

iarr

hea,

mal

nutr

itio

n,

or p

edia

tric

TB)

Prov

inci

al, c

omm

unit

y, m

unic

ipal

, an

d di

stri

ct h

ospi

tals

4

inpa

tien

ts

per h

ospi

tal

2 m

ater

nal c

ases

(1 u

ncom

plic

ated

nor

mal

del

iver

y, 1

com

plic

ated

del

iver

y),

2 pe

diat

ric

case

s (a

ny 2

of t

he ff

: ARI

, dia

rrhe

a, m

alnu

trit

ion,

or p

edia

tric

TB)

5 ou

tpat

ient

s pe

r hos

pita

lM

ater

nal o

r ped

iatr

ic c

ases

Lyin

g-in

s an

d bi

rthi

ng h

omes

2 in

pati

ents

pe

r clin

ic2

mat

erna

l cas

es

RHU

s3

outp

atie

nts

per R

HU

1 m

ater

nal c

ase,

2 p

edia

tric

cas

e (im

mun

izat

ion,

ARI

, dia

rrhe

a, m

alnu

trit

ion,

or

ped

iatr

ic T

B)

Free

-sta

ndin

g cl

inic

s*3

outp

atie

nts

per c

linic

1 m

ater

nal c

ase,

2 p

edia

tric

cas

e (im

mun

izat

ion,

ARI

, dia

rrhe

a, m

alnu

trit

ion,

or

ped

iatr

ic T

B)

*Mat

erna

l, pe

diat

ric,

gen

eral

and

fam

ily m

edic

ine,

and

mid

wife

ry c

linic

s. H

ospi

tal-

base

d pr

ivat

e cl

inic

s ar

e lo

cate

d w

ithin

the

prem

ises

of a

pub

lic o

r a

priv

ate

hosp

ital a

nd a

re p

riva

tely

ope

rate

d by

phy

sici

ans.

All

elig

ible

hos

pita

l-ba

sed

priv

ate

clin

ics

are

to b

e in

terv

iew

ed.


• health-status, health-seeking behavior, and health financing (health care expenditures of pregnant mothers and one-year-old children and below; preventive care and morbidity for infants; and

• family planning practices.

The physician and midwife survey questionnaire collected data on physician characteristics and the quality of their service. It contained the following information blocks:

• general provider information; • practice characteristics; • practice time allocation; • case load and mix; • referrals; • PhilHealth accreditation; and • income distribution by source.

The clinical vignettes measured provider quality and had the following domains:

• Routine/Normal pregnancy care;• Specialized/additional/complicated pregnancy care;• Outline/normal labor and delivery care;• Specialized/additional/complicated labor and delivery care;• Routine neonatal care (neonatal resuscitation);• Specialized/additional/complicated newborn care;• Routine general pediatric care (including immunization); and• Specialized/additional/complicated general pediatric care.

For the facility survey, different questionnaires were administered for hospitals, clinics, lying-in and birthing homes, and RHUs.

The RHU/clinic questionnaire had the following information blocks:

• general clinic characteristics; • facility management; • patient load and mix; • laboratory services; • equipment/supplies availability; • drugs and contraceptives availability;


• financing; • services packages; • networking; and • provider satisfaction.

The hospital survey questionnaire had the followinginformation blocks:

• general hospital characteristics; • hospital management;• patient load and mix; • laboratory services; • equipment availability; • drugs and medicine availability; • medical supplies availability; • networking; and • hospital administration satisfaction.

The patient exit survey is composed of inpatient and outpatient questionnaires designed to capture the following data:

• general information of patients; • health status; • pre-hospitalization events; • description of confinement; • services and medical expenditures; • records review; • provider satisfaction; • development and general well-being index; and • housing, assets, expenditure, and income.


Highlights of the FHB Household Survey

General information on all other family members

The following sections show the summary statistics for all other family members covered in the household survey.

Table 4.4 below shows the average household size, average monthly household expenditure, proportion employed, and average number of children.

The proportion of employed household members was computed by generating the row total of employed household members (there is a binary variable for each household member) and dividing it by the total number of household members.

Table 4.4: General information of households

MunicipalityHousehold

Size

Monthly Household

Expenditure

Proportion of Employed HH

members*

Number of

Children

Compostela 4.9 3,996 26.1% 2.7

Laak 5.0 3,253 25.3% 2.9

Mabini 4.6 4,447 27.1% 2.4

Maco 4.9 4,460 26.1% 2.7

Maragusan 4.4 4,989 31.2% 2.1

Mawab 4.6 4,619 27.4% 2.5

Monkayo 4.8 4,533 24.6% 2.6

Montevista 5.2 3,816 24.7% 3.0

Nabunturan 4.6 4,678 27.8% 2.4

New Bataan 4.9 4,774 26.0% 2.7

Pantukan 5.2 4,644 25.5% 3.0

TOTAL 4.8 4,384 26.3% 2.7* Average proportion of employed members per household


Using the questions on the household income and expenditure block, a variable for wealth index quintiles was also generated. Using the given household’s asset ownership, the following values for asset scores were assigned:

1 = poorest2 = second to the poorest3 = middle4 = second to the wealthiest 5 = wealthiest.

The following table shows the distribution of households (in percent) according to their wealth index quintiles.

Table 4.5: Distribution of households according to wealth index by facility

MunicipalityWealth Index Quintiles

(5 richest, 1 poorest) Total1 2 3 4 5

Compostela 15% 19% 17% 23% 26% 203

Laak 38% 23% 22% 12% 5% 199

Mabini 34% 15% 9% 20% 22% 109

Maco 21% 18% 23% 15% 22% 219

Maragusan 12% 19% 20% 21% 28% 147

Mawab 19% 16% 9% 20% 37% 112

Monkayo 19% 22% 24% 20% 15% 339

Montevista 25% 19% 17% 23% 15% 110

Nabunturan 9% 19% 16% 26% 30% 216

New Bataan 10% 22% 26% 24% 18% 144

Pantukan 28% 15% 23% 20% 13% 223

TOTAL 21% 19% 20% 20% 20% 2,021


PhilHealth membership

Table 4.6 shows the distributions of Compostela Valley families with PhilHealth membership and the types of members.

PhilHealth membership values were derived from questions E.16 and E.17 of the household survey. Binary variables that indicate whether a household had at least one PhilHealth member, indigent member, and paying member were generated. Those households with at least one member were summed and divided with the total number of households to generate the proportions.

In all the Compostela Valley municipalities, only 30 percent of the households had at least one PhilHealth member. Ten percent of all members are indigent (non-paying and/or had GMA cards).

Table 4.6: Distribution of families with PhilHealth membership and type of membership

MunicipalityWith

PhilHealth

With indigent member

With paying member

Total

Compostela 33% 10% 23% 203

Laak 13% 9% 4% 199

Mabini 25% 18% 5% 109

Maco 25% 7% 16% 219

Maragusan 65% 7% 56% 147

Mawab 65% 29% 32% 112

Monkayo 21% 5% 13% 339

Montevista 36% 28% 7% 110

Nabunturan 33% 9% 22% 216

New Bataan 22% 8% 12% 144

Pantukan 22% 7% 15% 223

TOTAL 30% 10% 18% 2,021


Health-care utilization of other family members

The next three tables show data on the average incidence of sickness of other household members, health care provider, and the average consultation and admission rates per municipality.

The number of times sick was generated from question E.22 of the baseline survey, while outpatient consultations and inpatient admissions data were taken from E.22.1 and E.22.2, respectively.

Outpatient consultations and inpatient admissions for each household represented the number of members who either consulted or were admitted in a facility.

Table 4.7 values show that in all the municipalities, families rarely visit a health professional in a year.

Table 4.7: Average number of times sick, consultations, and hospital admissions

MunicipalityNumber of times sick

for the past 12 monthsOutpatient

ConsultationsInpatient

admissions

Compostela 7.6 0.46 0.09

Laak 11.5 0.55 0.11

Mabini 9.5 0.58 0.07

Maco 10.2 0.76 0.06

Maragusan 8.7 0.69 0.14

Mawab 10.3 0.59 0.30

Monkayo 9.8 0.45 0.10

Montevista 8.7 0.73 0.14

Nabunturan 11.1 0.69 0.12

New Bataan 10.9 0.68 0.13

Pantukan 11.3 0.70 0.09

TOTAL 10.0 0.61 0.11


Table 4.8 describes where a typical household went in case of sickness and highlights the average number of members who visited a public or private practitioner. The number of family members which visited which practitioner is summed for each household and averaged by municipality.

Table 4.8: Type of health provider visited

MunicipalityOutpatient Inpatient

Public Private Public Private

Compostela 1.6 1.3 1.0 1.1

Laak 1.6 1.3 1.1 1.0

Mabini 1.5 1.5 1.0 .

Maco 1.7 1.2 1.0 1.0

Maragusan 1.5 1.2 1.1 1.0

Mawab 1.5 1.5 1.0 1.4

Monkayo 1.4 1.2 1.0 1.0

Montevista 2.1 1.6 1.0 1.3

Nabunturan 1.6 1.2 1.1 1.1

New Bataan 1.6 1.4 1.0 1.6

Pantukan 1.8 1.2 1.1 1.2

TOTAL 1.6 1.3 1.1 1.2

Table 4.9 shows the average cost incurred by a household in case of sickness of other family members. The costs are summed for each household member, excluding the index mother and the index child.


Table 4.9: Cost of consultation for all other family members

Municipality Cost of consultation Cost of hospital admission

Compostela 550 3,592

Laak 244 4,287

Mabini 450 4,871

Maco 337 4,143

Maragusan 95 2,109

Mawab 128 2,403

Monkayo 416 3,740

Montevista 207 1,893

Nabunturan 298 7,114

New Bataan 100 5,257

Pantukan 181 3,610

TOTAL (Pesos) 282 3,872

General information: Maternal care

The following sections shall present the summary tables for maternal/index women cases, which primarily capture their health-seeking behaviour in terms of prenatal, delivery, and postpartum care.

Most of the variables presented here were directly taken from the information blocks G and H of the household survey.

Table 4.10 shows the general characteristics of the index women in terms of years of education, employment, and number of pregnancies.

Maragusan had the highest average years of education (from Grade 1) attained at 9.2 years. About 13 percent of all households in Compostela Valley had employed mothers/index women. Meanwhile, Laak had the highest average number of pregnancies for a typical mother at 4.1.


Table 4.10: General characteristics of index women by municipality

MunicipalityAverage Years of Education

% of households

with employed mothers

Average Number of Pregnancies

Compostela 8.8 13% 3.5

Laak 7.0 8% 4.1

Mabini 7.5 13% 3.3

Maco 8.0 14% 3.7

Maragusan 9.2 20% 2.8

Mawab 8.8 16% 3.3

Monkayo 7.9 8% 3.6

Montevista 7.1 14% 4.0

Nabunturan 8.7 16% 3.4

New Bataan 8.1 14% 3.8

Pantukan 7.8 13% 3.9

TOTAL 8.1 13% 3.6

Outpatient prenatal care

Table 4.11 shows summary statistics of prenatal care and costs of consultation (time of travel, transportation cost, and consultation cost).

The prenatal checkup cost refers only to the woman’s first prenatal care (PNC) consultation.

Table 4.12 shows the distribution of index women who went to a particular outpatient facility for prenatal check-up by municipality. The facility type is captured by question G.13.2.

Table 4.13 shows the cost for prenatal check-ups by wealth quintile. The given PNC cost refers only to the first prenatal check-up.


Table 4.11: Outpatient prenatal care descriptive statistics

Municipality, facility type

% of mothers with at least

4 prenatal check-ups

Travel Time (in minutes)

Trans-portation

cost (in Php)

Prenatal check-up

cost (in Php)

ALL MUNICIPALITIES

RHU 30.8% 12 7 28

Gov’t hospital outpatient

1.3% 39 30 132

Private clinic 3.8% 64 64 504

Gov't birthing home/lying-in

0.2% 15 9 145

Private birthing home/lying-in

0.1% 17 12 239

Private hospital outpatient

0.9% 53 64 450

Other facility 38.2% 15 4 18

TOTAL 75.3% 17 9 54

COMPOSTELA

RHU 58.2% 12 9 20


0.7% 10 0 5





0.7% 33 20 439


TOTAL 72.3% 17 12 45






Trans-portation

cost (in Php)

Prenatal check-up

cost (in Php)

LAAK

RHU 1.6% 23 15 23







TOTAL 20 5 21

MABINI

RHU 16.9% 15 3 42


1.4% 30 30 260





5.6% 38 110 440


TOTAL 56.3% 27 20 143






Trans-portation

cost (in Php)

Prenatal check-up

cost (in Php)

MACO

RHU 51.1% 13 4 13


0.7% 60 60 30




0.7% 30 17 250



TOTAL 79.3% 16 7 27

MARAGUSAN

RHU 3.2% 4 0 0


1.1% 180 120 60





1.1% 120 160 1380


TOTAL 83.0% 20 11 55






Trans-portation

cost (in Php)

Prenatal check-up

cost (in Php)

MAWAB

RHU 43.9% 11 11 71


3.0% 67 38 470





4.5% 35 25 367


TOTAL 71.2% 17 14 139

MONKAYO

RHU 13.6% 13 16 40


0.5% 25 14 25





0.5% 150 150 500


TOTAL 20 10 54






Trans-portation

cost (in Php)

Prenatal check-up

cost (in Php)

MONTEVISTA

RHU 44.1% 17 5 17


8.8% 21 11 24

Private clinic





TOTAL 72.1% 19 6 17

NABUNTURAN

RHU 47.7% 9 4 12


0.8% 10 0 150



1.5% 7 0 5


0.0% 10 12 50


0.8% 30 36 150


TOTAL 85.6% 12 7 43






Trans-portation

cost (in Php)

Prenatal check-up

cost (in Php)

NEW BATAAN

RHU 28.4% 9 5 27


1.0% 10 10 120





1.0% 120 70 575


TOTAL 82.4% 15 10 42

PANTUKAN

RHU 32.4% 10 10 15


1.4% 60 92 110




0.0% 10 7 280



TOTAL 73.2% 14 13 20*Mothers included in this table were not currently pregnant


Table 4.12: Distribution of index women by facility and municipality

Municipality RHUGov’t

hospital outpatient

Private clinic

Gov't birthing home /lying-in

Private birthing home /lying-in

Private hospital

Compostela 81% 1% 4% 0% 0% 1%

Laak 2% 0% 3% 0% 0% 0%

Mabini 31% 1% 13% 0% 0% 6%

Maco 64% 1% 4% 0% 1% 0%

Maragusan 3% 1% 5% 0% 0% 1%

Mawab 56% 5% 11% 0% 0% 5%

Monkayo 20% 1% 4% 0% 0% 1%

Montevista 56% 13% 0% 0% 0% 0%

Nabunturan 57% 1% 5% 2% 1% 1%

New Bataan 34% 1% 4% 0% 0% 1%

Pantukan 42% 2% 4% 0% 1% 0%

TOTAL 40% 2% 5% 0% 0% 1%

Table 4.13: Average prenatal consultation cost by wealth index quintiles, in PhP


(5 richest, 1 poorest)

1 2 3 4 5

Compostela 13 20 55 35 85

Laak 14 12 43 21 8

Mabini 45 54 44 205 374

Maco 11 11 32 11 68

Maragusan 16 12 23 28 118

Mawab 35 38 175 82 269

Monkayo 17 23 28 38 181

Montevista 10 41 16 8 9

Nabunturan 22 12 17 27 100

New Bataan 32 19 26 89 37

Pantukan 19 12 17 13 44

TOTAL 20 20 33 45 121


Delivery outcome

Table 4.14 shows delivery outcome by facility type.

Most mothers delivered at home and in hospitals. However, 98 percent of those who delivered at home had complications, and 83 percent of them died.

On the other hand, 82 percent of mothers who went to the hospital had normal uncomplicated deliveries, but 62 percent of hospital-born babies had complications.

Table 4.14: Delivery outcome by facility

Delivery Outcome

Place of Delivery

At homeBirthing

HomeHospital Center Total

Mother and newborn without complication

0% 18% 82% 0% 361

Mother with complication

98% 0% 2% 0% 1,453

Baby with complication

36% 2% 62% 0% 86

Baby died 83% 0% 17% 0% 23

Total 77% 4% 20% 0% 1,923

Delivery expenses

Summary statistics for delivery expenditure are sorted for home delivery and facility-based delivery.


Home-based delivery

Table 4.15 shows the average for home-based delivery expenditure according to PhilHealth membership. Delivery expenditure was taken from question H.8. There is a variation of expenses between the insured and uninsured; having PhilHealth coverage does not necessarily mean a lower delivery expense.

Table 4.16 shows the average expenditure according to household wealth quintile.

There is some variation in the average expenditures as belonging to a higher wealth index quintile does not automatically mean incurring higher delivery expenses.

Table 4.15: Average delivery expense by PhilHealth coverage, in PhP

Municipality PhilHealth-insured Not insured

Compostela 1,945 1,908

Laak 1,276 1,157

Mabini 2,041 2,198

Maco 1,757 1,462

Maragusan 1,936 1,798

Mawab 1,971 2,212

Monkayo 2,203 1,816

Montevista 1,804 1,719

Nabunturan 2,055 1,787

New Bataan 1,154 1,317

Pantukan 1,455 1,404

TOTAL 1,832 1,636


Table 4.16: Average delivery expenses by wealth index, in PhP


(5 richest, 1 poorest)

1 2 3 4 5

Compostela 1,818 1,747 1,720 2,060 2,213

Laak 1,118 1,181 1,146 1,316 1,575

Mabini 2,136 2,277 2,342 2,157 2,015

Maco 1,278 1,441 1,595 1,502 1,895

Maragusan 1,964 2,026 1,831 1,595 1,955

Mawab 1,947 1,870 1,880 2,106 2,371

Monkayo 1,319 1,791 1,706 2,250 2,741

Montevista 1,494 1,455 1,989 1,912 2,065

Nabunturan 1,529 1,702 1,769 2,018 2,060

New Bataan 929 1,171 1,150 1,440 1,768

Pantukan 1,181 1,312 1,639 1,594 1,443

TOTAL 1,419 1,589 1,616 1,857 2,089

Facility-based delivery

The next four tables show average expenditures for facility-based delivery.

There is some variation in the averages in terms of insurance coverage as not all those necessarily paid less for delivery care.

Table 4.18 shows average expenses by type of municipality. A’tn index mother paid more in a private hospital (average of PhP 12,824) than in a public hospital (PhP 3,790). Average expenditures in a public birthing home was almost at par with those in a private counterpart.

Table 4.19 shows the average delivery expense by wealth quintiles. There is some variation in the averages across quintiles and municipalities.


Table 4.17: Average delivery expense, by insurance coverage, in PhP

MunicipalityAverage delivery

expenditurePhilHealth-

insured Not

insured

Compostela 3,899 2,842 4,527

Laak 3,249 3,625 3,191

Mabini 6,123 12,007 3,377

Maco 4,369 3,458 5,122

Maragusan 4,223 5,052 2,880

Mawab 3,854 3,408 5,245

Monkayo 5,021 3,386 5,838

Montevista 3,003 1,260 3,406

Nabunturan 4,878 6,245 3,791

New Bataan 5,920 4,685 6,990

Pantukan 5,789 7,670 5,099

TOTAL 4,609 4,693 4,549

Table 4.18: Average delivery expense, by facility, in PhP

Municipality

Gov’t birthing home/

lying-in

Gov’t hospital

Private birthing home/

lying-in

Private hospital

Other facility

Compostela 1,833 3,776 3,494 9,412

Laak 2,100 2,786 5,250 7,500

Mabini 3,382 2,500 24,667 700

Maco 2,500 4,219 7,000 5,900 0

Maragusan 5,022 2,989 4,460 20,091 0

Mawab 6,750 2,923 4,616 5,060

Monkayo 1,400 5,032 4,112 13,639 1,643

Montevista 1,833 3,405 3,600 1,500

Nabunturan 4,250 3,294 3,246 15,569 300

New Bataan 3,905 3,884 15,800 900

Pantukan 14,000 4,829 3,000 12,825

TOTAL 3,974 3,790 3,951 12,824 1,146


Table 4.19: Average delivery expense, by wealth index quintiles, in PhP


1 2 3 4 5

Compostela 2,000 3,243 2,961 5,887 3,513

Laak 3,067 3,025 3,081 3,250 4,004

Mabini 1,950 6,750 2,500 3,810 10,994

Maco 3,500 5,200 3,260 9,206 3,370

Maragusan 2,375 1,100 1,119 1,818 6,619

Mawab 3,950 2,750 3,167 4,995 3,811

Monkayo 5,471 3,250 6,416 3,405 5,567

Montevista 1,858 12,000 3,000 2,743 1,140

Nabunturan 10,000 1,663 800 3,995 6,728

New Bataan 2,900 3,384 2,763 12,529 4,767

Pantukan 3,160 2,503 3,256 4,672 11,597

TOTAL 3,395 3,241 3,454 4,818 5,709

Postpartum care: General information

Table 4.20 shows postpartum care-seeking behavior among previously/current pregnant respondents. Only 11 percent of index women respondents received postpartum care.

Postpartum expenditure

The next two tables show the average postpartum consultation expenditure by type of facility.


Table 4.20: Percentage of index women who received postpartum care

MunicipalityReceived Postpartum Care

Yes % Total

Compostela 29 15% 199

Laak 9 5% 189

Mabini 11 11% 101

Maco 27 13% 207

Maragusan 17 13% 135

Mawab 16 16% 102

Monkayo 22 7% 323

Montevista 11 10% 109

Nabunturan 34 17% 206

New Bataan 16 11% 140

Pantukan 11 5% 218

TOTAL 203 11% 1,929

Table 4.21a: Postpartum expenditure by facility (Public), in PhP

Municipality RHUGov't

Hospital Outpatient

Gov't Birthing Home/

Lying in

Barangay Health Center

Don't know/Can't remember

Total

Compostela 8 255 25 172

Laak 25 162 117

Mabini 67 71 199

Maco 6 126 0 73

Maragusan 151 26 127

Mawab 34 66 83

Monkayo 17 42 10 49

Montevista 100 451 513

Nabunturan 34 93 25 300 72

New Bataan 13 400 0 118

Pantukan 10 161 148


Table 4.21b: Postpartum expenditure by facility (Private), in PhP

MunicipalityPrivate Clinic

Private Hospital

Outpatient

Private Birthing Home/

Lying in

Total

Compostela 125 525 172

Laak 75 70 117

Mabini 425 199

Maco 130 73

Maragusan 225 120 127

Mawab 152 0 83

Monkayo 175 150 49

Montevista 2,187 513

Nabunturan 93 75 20 72

New Bataan 325 0 118

Pantukan 165 148

Index child: General information

This section presents key statistics covering index children (children below a year old), summarizing the health status and health-seeking behavior of children in Compostela Valley.

Table 4.22 shows the average number of times index children got sick in a 12-month period.

As the tabulated data show, children typically got sick two to three times per year in each municipality. Most cases were only treated at home. Health professionals saw about only one sickness episode per child.


Table 4.22: General information, index child

MunicipalityIncidence of

SicknessTreated at

homeSeen by Health

ProfessionalAdmitted

to Hospital

Compostela 1.9 1.6 0.8 0.1

Laak 2.3 2.1 0.6 0.1

Mabini 2.1 1.6 0.9 0.2

Maco 2.4 1.5 1.0 0.1

Maragusan 2.7 2.0 0.9 0.2

Mawab 2.0 1.4 1.0 0.2

Monkayo 2.3 2.0 0.6 0.1

Montevista 1.6 1.7 0.5 0.1

Nabunturan 2.5 2.1 1.3 0.1

New Bataan 2.3 1.9 0.8 0.1

Pantukan 2.5 2.0 1.0 0.1

TOTAL 2.3 1.8 0.9 0.1

Cost of outpatient consultation

Table 4.23 presents the average cost of outpatient consultation (length of travel time to the facility, transportation and consultation costs) per municipality and type of facility.


Table 4.23: Average cost of outpatient visit, index child


Travel Time

Transportation cost (in PhP)

Visit cost (in PhP)

ALL MUNICIPALITIES

Government hospital outpatient

32 53 458

RHU/CHC 15 27 155

Barangay health center 18 9 178

Private clinic 48 81 629

Private hospital outpatient 44 90 1,049

Other facility 17 0 0

TOTAL 34 55 462

COMPOSTELA


66 72 2,126

RHU/CHC 16 29 107



Private hospital outpatient 21 56 810

Other facility

TOTAL 33 51 596

LAAK


53 73 366

RHU/CHC 70 93 373




Other facility

TOTAL 83 114 643



Travel Time


Visit cost (in PhP)

MABINI


60 121 193

RHU/CHC 31 34 240




Other facility

TOTAL 52 94 483

MACO


27 40 380

RHU/CHC 6 2 70




Other facility n/a n/a n/a

TOTAL 31 58 513

MARAGUSAN


19 27 197

RHU/CHC 17 18 188


Private clinic 120 187 1,337

Private hospital outpatient n/a n/a n/a


TOTAL 24 34 251



Travel Time


Visit cost (in PhP)

MAWAB


30 60 597

RHU/CHC 14 12 58

Barangay health center n/a n/a n/a




TOTAL 17 23 344

MONKAYO


60 129 1,794

RHU/CHC 15 77 353



Private hospital outpatient n/a n/a n/a


TOTAL 34 79 647

MONTEVISTA


34 24 672

RHU/CHC 21 13 151





TOTAL 37 26 563



Travel Time


Visit cost (in PhP)

NABUNTURAN


7 36 555

RHU/CHC 10 16 99





TOTAL 22 26 351

NEW BATAAN


240 550 849

RHU/CHC 12 17 137





TOTAL 36 58 369

PANTUKAN


16 28 264

RHU/CHC 10 42 254

Barangay health center n/a n/a n/a




TOTAL 22 35 341


Outcome of confinement

The next tables present highlights of inpatient care for index children.

Table 4.24 summarizes percentages of index children with a particular outcome of confinement, grouped by the type of facility where they were admitted.

A large percentage (82 percent) of inpatient index child admissions in government hospitals ended in discharges where patients “felt better” but not “fully recovered.” More patients from government hospitals were discharged fully recovered (71 percent) compared to private hospitals (26 percent).

Table 4.24: Outcome of confinement by facility type

Outcome of ConfinementGov’t

HospitalPrivate

HospitalPrivate Clinic

Total

Discharged fully-recovered 71% 26% 3% 62

Discharged feeling better but not fully recovered

82% 15% 3% 33

Discharged feeling worse and referred to another facility

67% 33% 0% 3

Discharged feeling worse with continued home medication

50% 50% 0% 4

Left the facility against medical advice

0% 100% 0% 2

TOTAL 72% 25% 3% 104

Average length of confinement

Table 4.25 shows the average length of confinement of index children per type of facility.

The longest average length of stay in a government hospital was 7.9 days, while it was 9.3 days in a private hospital.


Table 4.26 shows the average length of stay of an inpatient child by wealth index.

Table 4.25: Average length of confinement by facility type

Municipality Gov’t Hospital Private Hospital Private Clinic


Laak 4.3 3.0 .

Mabini 7.9 6.7 .

Maco 7.0 9.3 3.0

Maragusan 5.3 6.5 .

Mawab 5.0 3.8 .

Monkayo 5.0 6.0 .

Montevista 4.6 3.0 .

Nabunturan 6.0 2.0 .

New Bataan 7.6 1.7 2.0

Pantukan 4.4 . .

Table 4.26: Average length of confinement, by wealth index


1 2 3 4 5

Compostela 7.0 1.0 3.3 3.0 3.3

Laak 1.0 3.0 3.3 14.0 n/a

Mabini 7.8 n/a 12.0 7.0 5.5

Maco 11.0 9.0 n/a 5.0 4.3

Maragusan n/a 6.8 5.5 3.0 5.0

Mawab 3.0 3.0 7.0 5.0 4.0

Monkayo 7.0 4.0 6.0 6.0 4.4

Montevista n/a 5.0 6.0 n/a 3.3

Nabunturan n/a 3.0 4.0 5.0 7.5

New Bataan 1.5 7.0 1.5 10.0 6.0

Pantukan 4.0 6.3 n/a n/a 2.7

TOTAL 5.8 5.8 4.9 6.3 4.5


Cost of confinement

Table 4.27 presents average hospital bills according to health service provider settings and inpatient professional fees.

Generally, private providers charged higher hospital bills and professional fees than their public counterparts.

Table 4.27: Average cost of confinement, in PhP

Municipality

Public Health Service Provider

Private Health Service Provider

Inpatient professional

fees

Hospital bill

Inpatient professional

fees

Hospital bill

Compostela 660 4,786 0 1,960

Laak 400 780 3,000

Mabini 560 4,901 0 8,062

Maco 490 6,194 2,000 8,575

Maragusan 489 2,423 7,375 26,675

Mawab 0 1,900 250 1,965

Monkayo 0 758 10,000 20,800

Montevista 113 306 1,200 3,750

Nabunturan 400 1,000 450 1,950

New Bataan 2,750 3,550 1,687 2,667

Pantukan 402 2,291 800

Highlights of Health Provider Survey

General information

Table 4.28 presents the distribution of health service providers across municipalities. The entry for Tagum City represents health service providers from the Davao Regional Hospital.


Tabl

e 4.

28: D

istr

ibut

ion

of h

ealth

ser

vice

pro

vide

rs a

cros

s m

unic

ipal

ities

Mun

icip

alit

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ener

al

prac

titi

oner

OB-

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Pedi

aFa

mil

y m

edic

ine

Surg

ery

Inte

rnal

m

edic

ine

Infe

ctio

us

dise

ases

Nur

seM

idw

ife

TOTA

L

Tagu

m C

ity

0%22

%44

%0%

0%0%

0%0%

33%

9

Com

post

ela

31%

0%8%

8%0%

0%0%

8%46

%13

Laak

67%

0%0%

0%0%

0%0%

0%33

%6

Mab

ini

50%

0%0%

0%0%

0%0%

0%50

%2

Mac

o43

%14

%0%

14%

0%14

%0%

0%14

%7

Mar

agus

an0%

0%0%

20%

0%0%

0%0%

80%

10

Maw

ab67

%0%

0%0%

0%0%

0%17

%17

%6

Mon

kayo

17%

0%0%

33%

0%0%

0%0%

50%

6

Mon

tevi

sta

13%

13%

13%

13%

13%

0%0%

0%38

%8

Nab

untu

ran

27%

0%9%

18%

0%0%

0%0%

45%

11

New

Bat

aan

50%

0%0%

0%0%

0%0%

0%50

%4

Pant

ukan

42%

0%0%

0%0%

0%8%

17%

33%

12

TOTA

L30

%4%

7%10

%1%

1%1%

4%41

%94


Table 4.29a: Average years of practice, by facility type

Facility Type Years of practice Years of specialty training

Public Hospital

Regional 7 2

District 12 4

Municipal 18 2

Private Hospital 13 5

Clinic

Hospital-based 8 3

Free-standing 24 4

RHU 19 3

Lying-in 12

RHU extension 21

TOTAL 17 3

Table 4.29b: Average years of practice, by municipality

Municipality / City Years of practice Years of specialty training

Tagum City 7 2

Compostela 14 8

Laak 15

Mabini 13 2

Maco 27 4

Maragusan 18 2

Mawab 22 3

Monkayo 18 3

Montevista 14 4

Nabunturan 19 3

New Bataan 18 3

Pantukan 17 2

TOTAL 17 3


Tables 4.29a and 4.29b show the average years of practice and specialty training by type of facility and municipality, respectively.

PhilHealth accreditation

Table 4.30a shows the incidence of accreditation of physicians across facilities and municipalities.

Less than half of the sample physicians were PhilHealth-accredited. Physicians in public hospitals had higher accreditation rates than those in private hospitals.

Table 4.30b shows the accreditation rate across municipalities. With the exception of Mabini where all practitioners were accredited, Tagum City recorded the highest accreditation rate.

Table 4.30a: PhilHealth accreditation, by facility type

Facility TypePhilHealth accreditation

TotalAccredited %

Public Hospital

Regional 6 86 7

District 9 75 12

Municipal 4 67 6

Private Hospital 4 31 13

Clinic

Hospital-based 1 50 2

Free-standing 2 12 17

RHU 14 42 33

Lying-in 2 67 3

RHU extension 0 0 1

TOTAL 42 45 94


Table 4.30b: PhilHealth accreditation, by municipality

Municipality / CityPhilHealth accreditation

TotalAccredited %

Tagum City 7 78 9

Compostela 7 54 13

Laak 1 17 6

Mabini 2 100 2

Maco 0 0 7

Maragusan 6 60 10

Mawab 4 67 6

Monkayo 1 17 6

Montevista 4 50 8

Nabunturan 5 45 11

New Bataan 0 0 4

Pantukan 5 42 12

TOTAL 42 45 94

Patient case load and mix

On average, most outpatient consultations were done in municipal hospitals (735.7 average visits per month), followed by the Davao Regional Hospital in Tagum City (444.3 average visits per month).

Table 4.32 presents the average outpatient cases by municipality. Most of the outpatient cases came from sick child and other miscellaneous cases.

Table 4.33 presents mean inpatient cases administered by type of facility. Regional hospital physicians had the highest average inpatient cases per month. District hospital doctors ranked next.

Table 4.34 shows the average case load of a physician per municipality. As expected, doctors in Tagum City would get more cases, as the Davao Regional Hospital is located there.


Table 4.31a: Average outpatient visits per month, by facility (hospitals)

Facility TypePublic Hospital Private

HospitalRegional District Municipal

Outpatient cases 444.3 234.9 735.7 178.3

Child immunization 76.9 9.3 0.0 0.8

Outpatient sick child 179.4 121.4 326.3 101.3

Normal prenatal care 23.1 20.8 26.7 7.2

High-risk prenatal care 8.6 26.0 8.0 2.8

FP counseling 0.0 8.5 26.7 0.7

Non-scalpel vasectomy 0.0 0.0 0.0 0.0

IUD insertion 0.4 0.7 0.0 0.0

Postpartum check-ups 10.7 14.2 44.0 2.5

Other OP cases 30.9 26.7 304.0 63.2

Table 4.31b: Average outpatient visits per month, by facility (clinics and RHUs)

Facility TypeClinic

Hospital-based

Free-standing

RHULying-

inRHU

extension

Outpatient cases 5.5 215.9 199.5 50.0 281.0

Child immunization 0.0 8.6 59.0 6.7 101.0

Outpatient sick child 1.0 93.3 50.5 0.0 9.0

Normal prenatal care 2.0 7.7 19.8 22.7 0.0

High-risk prenatal care 0.5 2.7 10.1 2.0 0.0

FP counseling 1.0 6.5 10.1 8.7 3.0

Non-scalpel vasectomy 0.0 0.0 0.4 0.0 0.0

IUD insertion 0.0 2.3 1.6 2.0 0.0

Postpartum check-ups 1.0 6.1 8.2 6.7 16.0

Other OP cases 0.0 101.1 39.6 1.3 0.0


Table 4.32: Average outpatient cases, by municipality

Municipality / CityOutpatient

casesChild

immunizationOutpatient sick child

Normal prenatal

care

Tagum City 346.8 59.8 139.8 18.4

Compostela 178.0 19.1 90.7 19.1

Laak 124.0 20.8 44.2 7.2

Mabini 351.5 66.0 180.0 45.0

Maco 172.4 12.0 47.9 10.1

Maragusan 520.0 21.9 195.0 24.7

Mawab 253.3 42.2 92.0 14.7

Monkayo 201.7 30.3 68.2 23.8

Montevista 199.8 13.5 76.8 15.3

Nabunturan 213.8 18.0 74.4 6.1

New Bataan 267.5 90.8 65.0 12.5

Pantukan 193.3 37.8 105.4 16.3

TOTAL 248.5 30.8 98.5 16.3

Table 4.33: Average inpatient cases, by facility type

Facility TypeInpatient

casesSick

neonatesInpatient sick child

Normal delivery

Public Hospital

Regional 228.6 31.9 130.7 29.3

District 208.9 21.2 105.3 25.1

Municipal 86.3 1.7 53.2 19.3

Private Hospital 86.1 0.7 36.6 1.3

Clinic

Hospital-based 0.0 0.0 0.0 0.0

Free-standing 11.3 1.9 6.2 0.1

RHU 9.8 0.0 5.8 0.7

Lying-in 11.0 0.3 0.3 10.0

RHU extension 0.0 0.0 0.0 0.0

TOTAL 66.9 5.7 34.8 7.5


High-risk prenatal

care

FP counseling

Non-scalpel vasectomy

IUD insertion

Post-partum check-ups

Other OP cases

6.8 0.2 0.0 0.3 8.6 24.0

4.2 4.2 0.0 0.1 3.9 36.8

3.5 1.0 0.0 0.0 8.7 38.7

17.0 0.0 0.0 2.0 0.5 41.0

2.4 4.0 0.0 0.3 7.4 88.3

10.3 24.3 0.0 0.0 31.0 214.5

14.5 3.5 0.0 0.0 4.8 81.7

11.0 20.7 0.3 7.0 6.7 33.7

27.3 11.3 1.3 2.6 10.5 27.8

1.1 3.2 0.0 1.1 4.7 91.5

12.3 16.5 0.0 0.8 8.5 70.3

10.6 6.4 0.0 1.8 15.0 12.5

9.0 8.0 0.1 1.2 10.2 65.7

CS deliveryOther

deliveryMaternal ICU

Abortion/ miscarriages

Other IP cases

3.1 1.9 0.4 12.1 37.4

1.8 3.2 0.0 9.8 38.8

0.0 0.2 0.0 2.5 9.5

0.0 0.0 0.0 0.2 27.5

0.0 0.0 0.0 0.0 0.0

0.0 0.0 0.0 0.1 3.0

0.0 0.0 0.0 1.9 1.3

0.0 0.0 0.3 0.0 0.3

0.0 0.0 0.0 0.0 0.0

0.5 0.6 0.0 3.1 13.0


Table 4.34: Average inpatient case load, by municipality

Municipality / CityInpatient

casesSick

neonatesInpatient sick child

Normal delivery

Tagum City 177.8 24.8 101.7 22.8

Compostela 43.1 0.6 12.3 1.3

Laak 41.7 1.7 19.2 15.0

Mabini 0.0 0.0 0.0 0.0

Maco 4.7 0.0 2.6 0.4

Maragusan 58.8 0.0 39.6 4.6

Mawab 75.8 4.7 41.0 0.8

Monkayo 6.7 0.7 0.7 0.3

Montevista 142.0 2.0 71.9 22.3

Nabunturan 20.9 0.2 10.0 2.4

New Bataan 0.0 0.0 0.0 0.0

Pantukan 116.8 19.8 59.0 10.3

TOTAL 66.9 5.7 34.8 7.5


CS deliveryOther

deliveryMaternal ICU

Abortion/ miscarriages

Other IP cases

2.4 1.4 0.3 9.4 29.1

0.0 0.0 0.0 0.0 7.4

0.0 0.0 0.0 0.3 5.5

0.0 0.0 0.0 0.0 0.0

0.0 0.0 0.0 0.0 1.7

0.0 0.1 0.0 7.7 6.8

0.0 0.0 0.0 0.0 29.3

0.0 0.0 0.0 0.3 4.7

2.8 4.8 0.0 7.8 24.8

0.0 0.0 0.1 0.2 6.1

0.0 0.0 0.0 0.0 0.0

0.0 0.0 0.0 4.6 23.1

0.5 0.6 0.0 3.1 13.0


Table 4.35: Average number of hours allocated by provider, by municipality

Municipality / City

Clinic practice hoursHospital

administration

Research and

trainingClinic

practiceInpatient

casesOutpatient

cases

Tagum City 76 58 13 0 3


Laak 36 12 24 2 0

Mabini 40 0 32 8 0

Maco 39 3 35 5 2

Maragusan 42 9 33 3 8

Mawab 45 16 25 3 2

Monkayo 42 6 35 2 5


Nabunturan 46 8 35 2 2

New Bataan 27 0 27 5 0

Pantukan 36 12 22 5 0

TOTAL 45 15 28 3 2

Practice time allocation

Table 4.35 shows the average number of hours per week allotted by a provider in clinic practice, hospital administration, and research and training.

Bulk of a typical physician’s time in all municipalities was spent in clinical practice, most of which were outpatient consultations in nature. A very small portion of their time was allotted to research, training and facility administration.


Income distribution

Table 4.36 shows average monthly income of health providers across facility types. While much of a provider’s income came from public hospitals, there were some doctors who earned more from their private practice. Providers from free-standing clinics earned more from private practice and non-medical practice.

Table 4.37 shows the average monthly income distribution of providers across municipalities.

Table 4.36: Income distribution of health service providers, by facility type, in PhP

Facility TypeTotal

Income

Source

This facility

Other facility

Private practice

Non-medical practice

Profit sharing

with hospital

Public Hospital

Regional 14,807 12,735 0 948 95 171

District 24,218 14,200 1,064 1,455 7,227 291

Municipal 20,796 16,572 2,000 0 1,167 1,047

Private Hospital 39,037 7,677 5,500 18,043 8,551 417

Clinic

Hospital-based 25,500 11,000 11,500 0 0 3,000

Free-standing 65,069 4,259 8,059 23,069 22,389 5,882

RHU 21,794 19,996 456 455 735 0

Lying-in 23,760 6,333 6,093 4,667 6,667 0

RHU extension 8,000 8,000 0 0 0 0

TOTAL 31,806 13,181 3,076 7,177 6,701 1,323


Table 4.37: Income distribution of health service providers, by municipality, in PhP

Municipality / City

Total Income

Source

This facility

Other facility

Private practice

Non-medical practice

Profit sharing

with hospital

Tagum City 17,183 12,350 2,556 737 74 800

Compostela 30,340 8,558 4,370 9,626 8,474 0

Laak 23,547 21,500 0 0 1,667 380

Mabini 30,100 25,600 3,500 0 1,000 0

Maco 43,438 10,152 3,286 18,857 9,857 0

Maragusan 15,129 12,597 1,400 0 725 400

Mawab 37,092 10,592 3,167 15,000 5,833 2,500

Monkayo 52,420 10,000 600 3,987 27,833 0

Montevista 39,690 20,290 1,150 2,250 15,625 400

Nabunturan 46,922 10,487 10,298 17,501 4,545 8,182

New Bataan 23,388 16,300 0 438 6,653 0

Pantukan 26,164 14,527 1,682 7,273 1,864 0

TOTAL 31,806 13,181 3,076 7,177 6,701 1,323

Vignette scores

The vignettes administered after the health provider survey were designed to capture the capacity of physicians, nurses, and midwives in handling antenatal care, delivery, neonatal care, and diarrhea cases.

Tables 4.38 to 4.40 show the average percentage scores of providers by facility type, municipality, and provider.

Physicians fared better in treating diarrhea, but scored low in antenatal, delivery, and post-delivery care.

Table 4.40 presents average vignette scores by physician specialization. Respondents performed better in the diarrhea vignette than in antenatal, delivery, and postpartum care.


Tabl

e 4.

38: A

vera

ge v

igne

tte

scor

es, b

y fa

cilit

y ty

pe

Faci

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Typ

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pr

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Acu

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diar

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w

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re

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ion

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25.0

20.1

20.6

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.7.

Dis

tric

t22

.816

.018

.816

.617

.725

.841

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Highlights of Health Facilities Survey

Since the sample contained a relatively small number of facilities for each type, especially for hospitals and clinics, the summary statistics shall be disaggregated according to location (i.e.,Tagum City vs. non-Tagum City facility).

Hospital survey

General information

This section contains the distribution of hospitals surveyed in Compostela Valley.

For the following subsections, all Compostela Valley facilities were combined and the Davao Regional Hospital in Tagum City (non-Compostela Valley facility) was excluded.

Table 4.41: Distribution of hospitals across Compostela Valley (including Davao Regional Hospital)

Municipality / City

Public Hospital Private Hospital

TotalRegional District Municipal


Laak 0 0 1 0 1

Maco 0 0 0 1 1

Maragusan 0 0 1 0 1

Mawab 0 0 0 2 2


Nabunturan 0 0 0 1 1

Pantukan 0 1 0 0 1

Tagum City 1 0 0 0 1

TOTAL 1 2 2 7 12



Table 4.42 shows the number of hospitals with PhilHealth accreditation.

All public hospitals across Compostela Valley plus the Davao Regional Hospital in Tagum City have PhilHealth accreditation. Three of the seven private hospitals were not accredited.

Table 4.43 tracks accredited hospitals by municipality.

Table 4.42: PhilHealth accreditation, by facility type

Facility TypePhilHealth-accredited

Not accredited Total

Public

Non-Compostela Valley 1 0 1

Compostela Valley 4 0 4

Private Hospital 4 3 7

TOTAL 9 3 12

Table 4.43: PhilHealth accreditation, by municipality

Municipality / CityPhilHealth-accredited

Not accredited Total

Compostela 1 2 3

Laak 1 0 1

Maco 0 1 1

Maragusan 1 0 1

Mawab 2 0 2

Montevista 1 0 1

Nabunturan 1 0 1

Pantukan 1 0 1

Tagum City 1 0 1

TOTAL 9 3 12


Bed capacity

Table 4.44 summarizes average bed capacity distributed by facility type.

The average number of beds used in public hospitals exceeded the average number of DOH-accredited beds. In private hospitals, the figure was lower than the DOH-accredited number of beds.

Table 4.45 shows the average number of beds by municipality. The deficiency in bed capacity was largely due to the excess demand for hospital beds at the Davao Regional Hospital in Tagum City.

Table 4.44: Average bed capacity, by facility type

Facility Type DOH-accredited beds Actual used

Public

Compostela Valley 18 20

Davao Regional Hospital 200 337

Private 17 9

TOTAL 33 40

Table 4.45: Average bed capacity, by municipality

Municipality / City DOH-accredited beds Actual used

Compostela 20 10

Laak 10 15

Maco 12 0

Maragusan 10 15

Mawab 14 9

Montevista 25 37

Nabunturan 20 12

Pantukan 25 14

Tagum City 200 337

TOTAL 33 40


Staffing Table 4.46 shows the average number of health professionals stationed in the hospitals.

The health providers, particularly the physicians, were segregated between residents and consultants.

Table 4.46: Average number of health care providers present, by type of facility

Staff

Public HospitalPrivate

HospitalTotalCompostela

ValleyDavao Regional

Hospital

Residents

OB-Gyn n/a 10.0 n/a 0.8

Anesthesiologist n/a 8.0 n/a 0.7

GP/Family physician n/a 4.0 0.6 0.7

Pediatrician n/a 10.0 n/a 0.8

Internal medicine specialist n/a 10.0 n/a 0.8

Surgeon n/a 9.0 n/a 0.8

Others n/a n/a n/a 0.0

Consultants

OB-Gyn 0.8 4.0 0.1 0.7

Anesthesiologist 0.3 3.0 n/a 0.3

GP/Family physician 3.5 3.0 2.0 2.6

Pediatrician 0.5 7.0 n/a 0.8

Internal medicine specialist 0.5 8.0 0.3 1.0

Surgeon 0.5 9.0 0.4 1.2

Others 0.0 n/a n/a n/a

Nurse 5.3 98.0 4.0 12.3

Midwife 4.3 n/a 0.7 1.8

Nursing aides 2.3 63.0 1.7 7.0

Pharmacist 1.8 7.0 0.3 1.3

Medical Technologist 1.0 18.0 0.9 2.3

Nutritionist/Dietician 1.0 1.0 0.3 0.6


Case load and mix

The next set of tables show the hospitals’ average case load.

Davao Regional Hospital received more outpatient cases on average than hospitals in Compostela Valley (both private and public). Most of the cases were for ill-baby/sick child check-ups and prenatal care.

For inpatient cases, Davao Regional Hospital scored the highest average inpatient cases.

OB-Gyn, pediatric, and internal medicine cases recorded the highest average inpatient admissions for all facility types.

Table 4.47: Average outpatient case load and mix

Type of Case




Hospital

OP Consultations 1,000 5,319 168 874

Normal PNC check-ups 3 615 1 53

High-risk PNC check-ups 2 106 0 9

PPC check-ups 1 351 0 30

Well-baby/child/Immunization check-ups

0 259 0 22

Ill child/sick baby check-ups

246 1,171 67 218

Family planning consultations

3 0 0 1

STI consultations 0 0 0 0

HIV/AIDS consultations 0 0 0 0

TB DOTS 0 15 0 1


Table 4.48: Average inpatient case load and mix

Type of Case




Hospital

IP admissions 401 2,457 84 388

OB-Gyn 20 756 0 70

NSVDs 19 445 0 44

CesareanSection 0 131 0 11

Bilateral Tubal Ligation 0 55 0 5

MICU 0 3 0 0

Pediatrics 80 709 23 99

Neonates 11 332 0 31

Age < 12 37 166 6 30

Age 12 - 60 months 28 154 16 32

Respiratory tract infection

39 205 11 36

Diarrhea/dehydration 27 75 6 19

Severe malnutrition 0 1 0 0

Fever/other infections 14 128 6 19

Anemia 0 1 0 0

NICU 0 69 0 6

Internal medicine 301 530 52 175

TB 0 20 0 2

Surgery 0 384 0 32

Appendectomy 0 64 0 5


Lab services

Table 4.49 shows the percentage of Compostela Valley hospitals with laboratory services.

The column for Davao Regional Hospital refers to the availability of the lab service.

Table 4.49: Availability of laboratory services

Laboratory Service




Hospital

Hematology

CBC 0.04 Yes 0.05 10

Blood typing 0.06 No 0.05 8

PTT/PT n/a Yes 0.25 2

Blood chemistry

Electrolytes n/a Yes 0.50 2

Liver function tests n/a Yes 0 1

Oral glucose challenge n/a Yes 0 1

Serum creatine 0.20 Yes 0.60 5

Serum glucose test 0.29 Yes 0.57 7

Immunology

Hepa B titers n/a Yes 0.5 2

VDRL/RPR n/a Yes 0 1

HIV ELISA test n/a Yes 0 1

PPD n/a No n/a 0

Microbiology

Gram stain 0.50 Yes 0.25 4

KOH smear 0.67 Yes n/a 3

AFB smear 0.80 Yes n/a 5

AFB culture 1 No n/a 1


Laboratory Service




Hospital

Bacterial culture n/a Yes n/a 1

Vaginal wet mount n/a No n/a 0

Urine culture n/a Yes n/a 1

Microscopy

Fecalysis 0.40 Yes 0.50 10

Urinalysis 0.75 Yes n/a 4

Dipstick albumin 0.75 Yes n/a 4

Pregnancy test 0.4 Yes 0.50 10

Surgical pathology

Pap smear 0.50 Yes n/a 2

Surgical pathology n/a Yes n/a 1

Equipment Tables 4.50 to 4.53 present the average number of equipment available in hospitals.

Table 4.50 shows the average number of equipment present in the emergency room.

Table 4.51 shows the average number of equipment found in a consultation room.

Table 4.52 summarizes the number of equipment found in the delivery room.

Table 4.53 shows the average number of equipment in a typical operating room in Compostela Valley facilities.


Table 4.50: Average number of equipment present, emergency room

Equipment, emergency room




Hospital

Examination Tables 2.0 5.0 1.7 2.1

Wheelchair 2.8 6.0 1.1 2.1

Oxygen source 2.3 13.0 1.6 2.8

BP apparatus 2.0 4.0 1.3 1.8

Adult Laryngoscope 1.0 14.0 0.7 1.9

Adult Ambu bag 1.3 4.0 1.0 1.3

IV stands 2.0 25.0 1.3 3.5

Stretchers 1.8 25.0 0.7 3.1

Curtains/Dividers 2.3 8.0 0.4 1.7

Defibrillator 0.0 1.0 0.0 0.1

Stethoscope 2.8 4.0 2.3 2.6

PediaLaryngoscope 0.8 3.0 0.6 0.8

PediaAmbu Bag 1.0 4.0 1.0 1.3

Incubator 0.0 0.0 0.0 0.0

Table 4.51: Average number of equipment present, consultation room

Equipment, consultation room




Hospital

Examination table 0.8 3.0 68.1 40.3

Vaginal speculum 5.5 12.0 69.6 43.4

BP apparatus 0.8 2.0 68.1 40.2

Thermometer 2.3 0.0 68.3 40.6

IUD insertion kits 0.3 5.0 68.0 40.2

Weighing scale 1.0 1.0 68.1 40.2

Watch clock 0.5 2.0 68.1 40.1

Gestational age calendar 0.8 2.0 68.1 40.2

Curtains/dividers 0.0 1.0 68.1 39.8


Equipment, consultation room




Hospital

Gooseneck lamps 1.3 3.0 68.4 40.6

Adult stethoscope 0.5 2.0 68.6 40.3

Pedia stethoscope 0.5 0.0 68.1 39.9

Vasectomy kits 0.0 1.0 67.9 39.7

Height scale 0.8 1.0 68.0 40.0

Measuring tape 1.0 2.0 68.4 40.4

Table 4.52: Average number of equipment present, delivery room

Equipment, delivery room




Hospital

Delivery tables 1.5 8.0 1.2 2.0

Cardiac monitor 0.0 1.0 0.0 0.1

Suction machine 1.5 4.0 0.8 1.4

Oxygen source 1.5 8.0 0.6 1.7

Wheelchairs 0.5 0.0 0.2 0.3

Curtains/dividers 1.0 0.0 0.4 0.6

Curettageset 0.8 4.0 1.0 1.2

Bassinets 0.8 2.0 1.0 1.0

Pediaambubag 0.5 1.0 0.6 0.6

Pedia stethoscope 0.8 0.0 0.8 0.7

Thermometer 1.5 4.0 1.8 1.9

Anesthesia machines 0.0 1.0 0.0 0.1

Adult ambubag 0.3 2.0 0.4 0.5

Stretchers 0.3 6.0 0.0 0.7

Gooseneck lamps 1.3 6.0 1.4 1.8

Normal spontaneous vaginal delivery kit

2.8 0.0 1.4 1.8

Cervical inspection set 1.8 8.0 0.0 1.5

Forceps kit 0.0 2.0 0.0 0.2

Pediatric laryngoscope 0.3 2.0 0.4 0.5

Suturing sets/kits 1.0 0.0 1.0 0.9


Table 4.53: Average number of equipment present, operating room

Equipment, delivery room




Hospital

OR table with overhead lamp

2.0 1.0 . 1.8

Cardiac monitor 0.0 1.0 . 0.3

Laryngoscope adult 0.7 3.0 . 1.3

IV stands 2.3 2.0 . 2.3

Gooseneck lamps 1.0 1.0 . 1.0

BTL kits 1.3 6.0 . 2.5

Appendectomy kits 0.3 13.0 . 3.5

Adult stethoscope 1.0 1.0 . 1.0

Neonatal ambubag 0.0 1.0 . 0.3

Newborn suction 0.7 1.0 . 0.8

Instrument stand with tray 1.3 2.0 . 1.5

D and C sets 0.7 4.0 . 1.5

Minor surgery sets 0.0 13.0 . 3.3

Anesthesia machine 1.0 1.0 . 1.0

Ambubag adult 0.7 2.0 . 1.0

Suction machines 1.0 2.0 . 1.3

Oxygen source 1.7 3.0 . 2.0

C-section kits 1.0 4.0 . 1.8

Explore lap kit 1.3 13.0 . 4.3

Pedia stethoscope 0.3 0.0 . 0.3

BP apparatus 1.0 2.0 . 1.3

Pediatric laryngoscope 0.3 2.0 . 0.8

Radian warmer 0.0 2.0 . 0.5

Instrument trolley 2.3 2.0 . 2.3

Laparotomy and Cesaran sets

0.3 4.0 . 1.3

Episiotomy repair sets 0.3 5.0 . 1.5


Hospital charges

Table 4.54 shows the average service charge of hospitals.

The low average charge for all other facilities except Davao Regional Hospital may be due to averaging, although this figure still appears too high for a public hospital.

Table 4.55 shows the disaggregation of hospital charges by municipality.

Table 4.54: Average hospital charge, by facility type, in PhP

Facility Type Room Charge

Procedure Fees

Outpatient Consultation

Fees

Diagnostics Fees

Other Procedure

Fees

Public

Compostela Valley 172 1,613 56 135 136

Davao Regional Hospital 1,750 8,625 50 1,000 230

Private 426 3,950 130 126 64

TOTAL 477 3,483 93 217 110

Table 4.55: Average hospital charge, by municipality, in PhP

Facility Type Room Charge

Procedure Fees

Outpatient Consultation

Fees

Diagnostics Fees

Other Procedure

Fees

Compostela 417 5,500 117 170 38

Laak 100 1,350 50 120 60

Maco 0 0 200 0 0

Maragusan 265 500 63 140 275

Mawab 446 2,500 115 30

Montevista 600 63 150 180

Nabunturan 840 6,250 100 175 215

Pantukan 150 4,000 50 130 30

Tagum City 1,750 8,625 50 1,000 230

TOTAL 477 3,483 93 217 110


Hospital expenditures

Table 4.56 summarizes the expenditures of hospitals by setting.

Davao Regional Hospital spent more on personnel than on MOOE and capital expenses, while other public hospitals in Compostela Valley spent more on MOOE than on staff expenses.

Table 4.57 disaggregates expenditures by municipality.

Among Compostela Valley hospitals, only the hospitals in Pantukan spent more than a million pesos for all personnel, MOOE, and capital expenses.

Table 4.56: Average hospital expenditures, by facility type (in million pesos)

Facility TypePersonnel Expense

MOOEOther

expenses

Public

Compostela Valley 1.5 2.4 1.2

Davao Regional Hospital 81.9 43.8 8.6

Private 1.1 1.1 0.4

TOTAL 9.4 5.9 1.8

Table 4.57: Average hospital expenditures, by municipality (in million pesos)


MOOEOther

expenses


Laak 0.29 2.14 1.09

Maco

Maragusan 0.01 1.97 0.20



MOOEOther

expenses

Mawab 0.41 0.66 0.29



Pantukan 5.35 3.18 3.26

Tagum City 81.90 43.80 8.60

TOTAL 9.37 5.89 1.83

Clinics survey

General information

The following sections present highlights of the private clinics survey.

The only hospital-based clinic is in Davao Regional Hospital in Tagum City. The rest are free-standing clinics distributed across Compostela Valley municipalities.

Table 4.58: Distribution of clinics across municipalities

MunicipalityType of Clinic

TotalHospital-based Free-standing

Tagum City 1 0 1

Compostela 0 1 1

Maco 0 4 4

Mawab 0 1 1

Monkayo 0 2 2

Montevista 0 1 1

Nabunturan 0 4 4

New Bataan 0 1 1

Pantukan 0 2 2

TOTAL 1 16 17


Staffing Table 4.59 shows the proportion of health professionals distributed across the sample clinics.

Most of the health professionals were located in free-standing clinics.

Table 4.59: Distribution of health providers

Clinic StaffClinic

TotalTagum City Compostela Valley

Physicians 19% 81% 27

OB-Gyn 33% 67% 3

Gen. Practitioner 7% 93% 15

Pediatrician 50% 50% 2

Internal Medicine Specialist 25% 75% 4

Surgeon 33% 67% 3

Registered Nurse 13% 88% 8

Registered Midwife 20% 80% 5

Medical Technologist 50% 50% 2

Nutritionist/Dietician 100% 0% 1

Case load and mix

Table 4.60 shows the average outpatient case loads for clinics.

The only hospital-based clinic in Tagum City was separated, and entry values are counts of outpatient cases.


Table 4.60: Average outpatient case load and mix

CasesClinic


Total OP visits 139 253 246

Prenatal care 92 23 27

Postpartum care 25 13 14

Ill-baby/sick child consultations 2 109 102

Immunization/well-baby/well-child 0 5 5

Family Planning Consults 0 8 7

TB DOTS 0 6 6

Lab services

Table 4.61 shows the count of facilities with laboratory services.

Only one facility in Compostela Valley offered the AFB smear test. Only the hospital-based clinic in Tagum City offered TV/abdominal ultrasound services. Nonetheless, most of the clinics offered essential laboratory services.

Table 4.61: Count of available lab services

Lab ServiceClinic


Pap smear No 3 3

Urinalysis Yes 4 5

AFB Smear No 1 1

Stool exam Yes 4 5

Blood typing Yes 2 3

Pregnancy Test Yes 7 8

CBC Yes 3 4

TV/Abdominal Ultrasound Yes 0 1

Blood chemistry Yes 2 3

Bacterial Gram Staining No 2 2


Equipment Table 4.62 summarizes the average number of equipment available.

Entries for Tagum City represent actual counts of equipment in the facility, while the Compostela Valley column represents the average across municipalities.

Table 4.62: Equipment present

EquipmentClinic


Examination table 10 2 3

Writing surface 10 3 3

Refrigerator/cold box 2 1 1

Light source 10 5 5

Watch or clock with second hand 1 2 2

Tables for equipment 10 3 3

Blood pressure cuff 2 2 2

Examination gloves 10 71 67

Sterile gloves 10 22 21

Stethoscope, adult 2 2 2

Stethoscope, fetal 1 1 1

Thermometer 2 3 3

Vaginal specula 2 2 2

Measuring tape 1 1 1

Gestational age calculator 2 2 2

Drape/blanket 10 6 7

Needles and syringes 100 54 57

Autoclave/boiler/steamer 1 1 1


Facility charge

Table 4.63 shows the average service charge of clinics.

Table 4.63: Facility charge, by type of service, in PhP

FeesClinic


GP consultation charges 150 147 147

Specialist charges 150 102 106

Immunization

TT . 90 90

BCG . 500 500

OPV . 300 300

DPT . 1,200 1,200

Hepa B . 275 275

Measles . 500 500

AFB Smear . . .

X-ray 165 180 173

Ultrasound 600 . 600

NSV charges . . .

Newborn screening . 150 150

Facility expenditure

Table 4.64 summarizes the average facility staff, maintenance, and capital expense by municipality in 2007.

As in the hospital survey, the expenditures were grouped into personnel expense, MOOE, and capital expense. The hospital-based clinic in Tagum City only reported maintenance expense, as personnel and capital expenses may be included in the hospital’s overall expenses.


Table 4.64: Average facility expenditure, 2007 (in million pesos)

FeesClinic


Tagum City 0.03


Maco 0.06 0.25 0.08

Mawab 0.28 0.81

Monkayo 0.11 0.33 0.06

Montevista 0.36 0.71


New Bataan 0.02 0.05 0.02

Pantukan * 0.15 0.01

Total 0.12 0.24 0.03* Less than P10,000

Birthing home/ lying-in survey

General in-formation

The FHB Baseline Survey covered only two birthing home/lying-in facilities in the municipalities of Compostela and Nabunturan.

Only the birthing home facility in Nabunturan had PhilHealth accreditation. No physician was present in both facilities; only midwives and nurses were available.

Each of the lying-in clinics in Compostela and Nabunturan had DOH accreditation as 2-bed facilities but only one was actually used in Compostela, and none in Nabunturan.


Table 4.65: Distribution of medical staff

StaffMunicipality

TotalCompostela Nabunturan

Midwife 2 1 3

Nurse 1 0 1

Table 4.66: Bed capacity of birthing homes/lying-in

Municipality DOH-accredited Actual used

Compostela 2 1

Nabunturan 2 0

TOTAL 4 1

Case load and mix

Table 4.67 shows the distribution of cases between Compostela and Nabunturan.

The birthing home/lying-in facility in Compostela received more outpatient cases than that in Nabunturan. The Nabunturan facility only catered to prenatal check-ups and family planning consultations.

Table 4.67: Distribution of outpatient cases

CasesMunicipality


OP visits 66% 34% 122

Prenatal check-ups 66% 34% 53

Postpartum check-ups 100% 0% 10

Immunization/well-baby consults 100% 0% 20

Family planning consults 38% 62% 39


Equipment Table 4.68 presents the distribution of equipment in facilities in Compostela and Nabunturan.

Most of the equipment listed were available in both facilities.

Table 4.68: Distribution of medical equipment

EquipmentMunicipality


Examination table 25% 75% 4

Writing surface 60% 40% 5

Refrigerator/cold box 100% 0% 1

Light source 50% 50% 4

Watch/clock with second hand 50% 50% 4

Equipment table 33% 67% 3

BP cuff 80% 20% 5

Examination gloves 88% 13% 800

Sterile gloves 89% 11% 168

Adult ambubag 0% 100% 1

Adult stethoscope 80% 20% 5

Fetal stethoscope 100% 0% 4

Thermometer 50% 50% 4

Vaginal specula 40% 60% 5

Measuring tape 67% 33% 6

Gestational age calculator 67% 33% 3

Drape/blanket 92% 8% 26

Needles/syringe 60% 40% 250

Autoclave/boiler/steamer 50% 50% 2

Neonatal ambubag 0% 100% 1

Oxygen source 50% 50% 2


EquipmentMunicipality


Vacuum extractor n/a n/a 0

Blanket to wrap newborn 93% 7% 43

Two cloths/drape 86% 14% 14

Episiotomy scissors 50% 50% 6

Scissors for cutting umbilical cord 71% 29% 7

Needle holder 71% 29% 7

Suture scissors 60% 40% 5

Suture 83% 17% 29

IV catheters 0% 100% 12

Obstetric forceps 75% 25% 8

Newborn scale 50% 50% 2

Two blankets for drying newborn 95% 5% 42

Cord ties/clamps 95% 5% 105

Kelly clamps 88% 13% 16

Suction apparatus 50% 50% 4

Dissecting forceps 50% 50% 8

Protective gowns 50% 50% 4

IV tubings 88% 12% 41

Suture needles 83% 17% 29

Facility charge

Table 4.69 shows average facility charges in Compostela and Nabunturan.

The highest charge went to delivery service (PhP 3,500). Most of the fees hovered around PhP 75-250, exept for urinalysis (PhP 35).


Table 4.69: Average service charge, by municipality, in PhP

ServicesMunicipality


Normal delivery 3,500 3,500 3,500

Consultation fee 70 50 60

Immunization

TT 75 50 63

BCG 75 . 75

Measles 75 . 75

Hepa B 75 . 75

Supplements

Iron with folate 4 . 4

Vitamin A 100,000 IU . . .

Vitamin A 200,000 IU . . .

Room and board

Private room . . .

Semi-private room . . .

Pay ward . . .

Charity ward . . .

CBC 80 . 80

Ultrasound . . .

Urinalysis 35 . 35

OCPS 142 25 84

Condom 17 6 12

DMPA 45 200 123

IUD . 250 250

Newborn screening . . .



Table 4.70 presents the average personnel, maintenance and operating, and capital expense of each of the lying-in facilities in Compostela and Nabunturan.

These expenses were computed as those in the hospital and clinics survey. Most of the expenses were medical staff salaries.

No capital expense was paid for in Compostela.

Table 4.70: Average facility expenditures, in PhP

MunicipalityPersonnel Expense

MOOECapital

Expense

Compostela 135,000 69,600 0

Nabunturan 108,627 65,472 47,996

TOTAL 121,813 67,536 23,998

RHUs

General information

The FHB Baseline Survey covered 12 rural health units.

Each of the municipality in Compostela Valley had its own rural health center. Nabunturan had one satellite unit.


Table 4.71 shows that only seven of the 11 RHUs had PhilHealth accreditation. The RHU satellite unit in Nabunturan was not accredited.


Table 4.71: PhilHealth accreditation

Facility TypePhilHealth-accredited

Not accredited

Total

RHU 7 4 11

RHU satellite 0 1 1

TOTAL 7 5 12

Staffing All RHUs had the listed health professionals except for an internal medicine specialist.

Table 4.72: Distribution of health providers

Staff RHU Satellite Total

Physicians 100% 0% 13

OB-Gyn 100% 0% 1

GP/Family medicine 100% 0% 9

Pediatrician 100% 0% 1

Internal medicine n/a n/a n/a

Surgeon 100% 0% 1

Registered nurse 100% 0% 14

Registered midwife 98% 2% 84

Med tech 100% 0% 16

Nutritionist/dietician 100% 0% 4

Case load and mix

Table 4.73 shows the average case load and mix per type of outpatient case. Most of the patients visited the facilities for immunization/well-baby consultations.


Table 4.73: Average case load and mix, RHUs

CasesRHU type

TotalRHU Satellite

OP visits 410 281 399

Prenatal check-ups 66 42 64

Postpartum check-ups 36 16 35

Ill-baby/sick child consults 48 9 45

Immunization/well-baby consults 133 101 131

Family planning consults 87 78 86

TB DOTS 14 8 14

Lab services

Table 4.74 shows the number of RHUs with lab services listed below. The RHU satellite unit only offered Pap smear services . No RHU offered ultrasound services.

Table 4.74: Number of RHUs with laboratory services

Lab serviceRHU type

TotalRHU Satellite

Pap smear 8 1 9

Urinalysis 11 0 11

AFB smear 11 0 11

Stool 11 0 11

Blood type 10 0 10

Pregnancy test 11 0 11

CBC 10 0 10

Ultrasound 0 0 0

Blood chemistry 4 0 4

Bacterial Gram Staining 3 0 3


Equipment Table 4.75 presents the average number of equipment available in the RHUs.

Table 4.75: Average number of equipment present

Equipment RHU Satellite Total

Examination table 3.1 1.0 2.9

Writing surface 10.7 5.0 10.3

Refrigerator/cold box 3.1 1.0 2.9

Light source 6.4 8.0 6.5

Watch or clock with second hand 3.3 2.0 3.2

Tables for equipment 4.5 3.0 4.4

Blood pressure cuff 3.5 1.0 3.3

Examination gloves 170.0 16.0 157.2

Sterile gloves 191.8 1.0 175.9

Stethoscope, adult 4.7 12.0 5.3

Stethoscope, fetal 0.1 0.0 0.1

Thermometer 5.8 2.0 5.5

Vaginal specula 19.8 5.0 18.6

Measuring tape 4.5 1.0 4.2

Gestational age calculator 2.6 0.0 2.4

Drape/blanket 14.6 6.0 13.9

Needles and syringes 545.0 0.0 499.6

Autoclave/boiler/steamer 2.7 1.0 2.6


Facility charge

Table 4.76 enumerates each RHU’s average charge on a particular service. The satellite RHU only charged for FP and OB service. Service charges for each RHU ranged from PhP 1 to PhP 50 (for non-scalpel vasectomy).

Table 4.76: Facility charge, by type of service, in PhP

Charges RHU Satellite Total

Consultation fee 8.55 * 7.83

FP and OB services 4.55 20.00 5.83

Immunization

TT 0.91 * 0.83

BCG 0.91 * 0.83

OPV 0.91 * 0.83

DPT 0.91 * 0.83

Hepa B 0.91 * 0.83

Measles 0.91 * 0.83

AFB smear 14.55 * 13.33

Non-scalpel vasectomy 50.00 * 45.45

Newborn screening * * **zero value


The following two tables summarize expenses of Compostela Valley RHUs.

All RHUs spent more than a million pesos for personnel expense, but less than a million for maintenance and capital expenses.

Table 4.78 disaggregates the expenditures by municipality.


Table 4.77: Average facility expenditure (in million pesos)

Expenses RHU Satellite Total

Personnel expense 4.08 * 3.74

MOOE 0.99 * 0.91

Capital expense 0.34 0.01 0.31*no value

Table 4.78: Average facility expenditure, by municipality (in million pesos)

MunicipalityPersonnel Expense

MOOECapital

Expense

Compostela 3.60 2.19 **

Laak 2.72 1.63 0.01

Mabini 3.65 1.11 0.01

Maco 6.23 1.47 0.13

Maragusan 4.87 0.87 2.27

Mawab 3.26 0.35 0.14

Monkayo 4.75 0.83 0.18



New Bataan 4.09 0.43 0.01

Pantukan 3.94 0.80 0.87

TOTAL 3.74 0.91 0.31**Value less than 10,000


Highlights of the Patient Exit Survey

In this section, the socio-economic characteristics and satisfaction of inpatients and outpatients admitted in facilities included in the facilities survey are discussed.

Outpatient survey

General information

Table 4.79 presents the distribution of outpatients by type.

The cases covered were maternal and childcare. Majority of the cases were child care-related.

Table 4.80 summarizes the distribution of outpatients by type of facility. The regional hospital refers to the Davao Regional Hospital in Tagum City.

Table 4.81 shows the distribution by wealth quintiles of outpatients who visited either public or private facilities.

Wealth quintiles were computed using patients’ asset ownership.

Most of the poorer outpatients chose to visit a public facility (23 of the 166 outpatients). Richer patients chose to visit private facilities (22 of 166).


Table 4.79: General characteristics

Characteristics Maternal Child Total

Sex

Male . 67 67

Female 49 50 99

Municipality

Compostela 3 20 23

Laak 2 6 8

Mabini 1 2 3

Maco 5 6 11

Maragusan 2 9 11

Mawab 7 11 18

Monkayo 4 5 9

Montevista 5 7 12

Nabunturan 7 22 29

New Bataan 1 5 6

Pantukan 3 13 16

Tagum City 9 11 20

TOTAL 49 117 166


Table 4.80: General characteristics: Facility visited for consultation

Facility Maternal Child Total

Public Facility 28 51 79

Private Facility 21 66 87

Total 49 117 166

Facility Type

Public

Regional hospital 1 3 4

District hospital 4 6 10

Municipal hospital 1 10 11

Community hospital 1 0 1

Private hospital 4 11 15

Clinics



RHU 21 32 53

Total 49 117 166

TOTAL 49 117 166

Table 4.81: Distribution of outpatients by wealth quintiles

Wealth Index Quintiles

Public Private Total

1 23 12 35

2 18 14 32

3 15 19 34

4 12 20 32

5 11 22 33

TOTAL 79 87 166


Household expenditure

Table 4.82 shows the average household outpatient expenditure for the past 12 months.

Those who visited private facilities spent more annually than those who went to public facilities.

Table 4.83 shows average household expenditure by wealth quintiles. Those in the higher wealth quintiles spent more annually than those in lower wealth quintiles.

Table 4.82: Average household expenditures, by municipality, in PhP

Municipality Public Private Total

Compostela 4,167 5,529 35

Laak 3,063 32

Mabini 6,767 34

Maco 1,950 4,857 32

Maragusan 4,215 33

Mawab 4,532 3,352 166

Monkayo 9,533 5,417

Montevista 3,816 3,250

Nabunturan 6,855 4,991

New Bataan 3,167 5,500

Pantukan 3,550 3,813

Tagum City 8,500 9,145

TOTAL 4,676 5,643


Table 4.83: Average household expenditure, by wealth quintile, in PhP


Public Private

1 2,006 3,083

2 4,107 3,540

3 6,100 4,812

4 5,658 6,070

5 8,177 8,705

TOTAL 4,676 5,643

Reason for visit

Table 4.84 presents the cross-tabulation of reasons for visit and the health service providers visited.

In most cases, patients visited general physicians more often than specialists.

Table 4.85 summarizes the percentage of physicians/specialists visited according to wealth index. Patients from higher wealth quintiles tended to visit specialists rather than general practitioners. Those in lower wealth quintiles were more likely to visit GPs.


Table 4.84: Patient’s reason for visit

Reason for visit GPFamily

physicianOB-Gyn

Pediatrician Others Total

Prenatal check-up and other maternal care

46% 4% 26% 0% 24% 46

Pneumonia and other respiratory tract infection

75% 10% 1% 12% 1% 81

Diarrhea and other intestinal tract infection

75% 8% 0% 17% 0% 12

Immunization 58% 0% 0% 0% 42% 12

Other cases 79% 7% 7% 0% 7% 14

Total 66% 7% 8% 7% 11% 165

Table 4.85: Physician types visited by wealth quintile

Wealth Index

QuintilesGP

Family physician

OB-Gyn Pediatrician Others Total

1 74% 6% 14% 3% 3% 35

2 75% 6% 3% 0% 16% 32

3 74% 3% 6% 6% 12% 34

4 68% 10% 6% 6% 10% 31

5 39% 12% 12% 21% 15% 33

TOTAL 66% 7% 8% 7% 11% 165


Consultation cost

Table 4.86 shows average consultation costs, which also covered travel time to the facility and the transportation cost.

Patients typically had longer travel times and spent more to visit a public hospital than a private facility.

While private hospitals were more accessible to patients, they charged more on average than public facilities. This also applied to clinics and RHUs, as patients paid less for a consultation (PhP 19) in an RHU.

In Table 4.87, public and private facilities are aggregated and outpatient visits per municipality are summarized.

Consultations in private facilities cost more than in public facilities, although transportation costs going to public facilities were higher compared to those incurred in going to private facilities.

Table 4.88 shows the average consultation costs by patient type (child or maternal). Consultation costs in private facilities were higher than those in public facilities.

Table 4.89 shows average consultation costs by wealth quintiles. Relatively wealthier patients tended to spend more than the poor in both public and private facilities.


Table 4.86: Average consultation cost, by type of facility

Facility TypeTravel time (minutes)


Consultation cost (in PhP)

Public

Regional hospital 35 96 344

District hospital 25 41 55

Municipal hospital 23 76 55

Community hospital 15 20 0

Private hospital 12 19 421

Clinics



RHU 10 18 19

TOTAL 17 44 181

Table 4.87: Average consultation cost, by type of municipality

Municipality

Public Private

Travel Time

(minutes)

Transpor-tation cost

(in PhP)

Consul-tation

cost (in PhP)

Travel Time

(minutes)


(in PhP)

Consul-tation

cost (in PhP)

Compostela 4 7 54 10 16 269

Laak 29 96 38

Mabini 9 14 30

Maco 8 9 0 7 15 212

Maragusan 10 16 42

Mawab 7 13 0 12 20 246

Monkayo 5 36 10 5 11 141

Montevista 28 40 38 18 15 25

Nabunturan 13 34 62 29 44 414

New Bataan 4 11 17 4 27 503

Pantukan 16 24 33 10 13 197

Tagum City 45 124 358 39 179 407


Table 4.88: Average consultation costs, by patient type

Patient type Public Private

Maternal

Time of travel (minutes) 13 26

Transportation cost (in PhP) 31 124

Consultation cost (in PhP) 37 360

Child




Both Maternal and Child




Table 4.89: Average consultation costs, by wealth index

Wealth Index Quintile

Public Private

Travel Time

(minutes)


(in PhP

Consul-tation

cost (in PhP)

Travel Time

(minutes)


(in PhP

Consul-tation

cost (in PhP)

1 19 46 32 24 120 336

2 11 23 29 15 20 193

3 11 26 57 16 33 340

4 16 19 22 22 38 261

5 14 43 104 22 72 361


Patient’s capacity to pay

This section summarizes patients’ capacity to pay, disaggregated by sources of payment for health services. Most of the patients shelled out their own money to pay for health services. A portion of payments came from loans.

Table 4.91 summarizes patients’ capacity to pay by wealth index.

Those in higher wealth quintiles tended to shell out more from their own income compared to those in lower wealth quintiles. Those in the first wealth quintile took out more loans than those in higher quintiles.

Table 4.90: Capacity to pay (average household), in PhP

Facility Type

Ow

n in

com

e so

urce

Loan

s

Sale

of

prop

erty

Tran

sfer

do

nati

ons

Phil

Hea

lth

insu

ranc

e

Priv

ate

insu

ranc

e

Oth

er

insu

ranc

e

Oth

er

sour

ces

Public

Regional hospital 474 0 0 0 0 0 0 0

District hospital 178 0 0 0 0 0 0 0

Municipal hospital 306 0 0 0 0 0 0 0

Community hospital 25 0 0 0 0 0 0 0

Private hospital 520 33 0 0 0 0 0 0

Clinics

Hospital-based 429 0 0 0 0 0 0 0

Free-standing 353 35 0 0 0 0 0 0

RHU 91 1 0 0 2 0 0 0

TOTAL 273 18 0 0 1 0 0 0


Table 4.91: Capacity to pay, by wealth quintiles, in PhP


Ow

n in

com

e so

urce

Loan

s

Sale

of

prop

-er

ty

Tran

sfer

do

nati

ons

Phil

Hea

lth

insu

ranc

e

Priv

ate

insu

ranc

e

Oth

er

insu

ranc

e

Oth

er

sour

ces

1 262 63 0 0 0 0 0 0

2 209 0 0 0 0 0 0 0

3 261 20 0 0 4 0 0 0

4 263 2 0 0 0 0 0 0

5 369 0 0 0 0 0 0 0

TOTAL 273 18 0 0 1 0 0 0

Patient satisfaction

The next set of tables present average patient satisfaction scores, which covered items on general satisfaction, technical quality, interpersonal manner, communication, financial aspect, time spent with doctor, and accessibility and convenience.

Scores ranged from 1 to 5, 1 being the least satisfactory and 5 the most satisfactory.

Table 4.92 shows average satisfaction scores by type of facility. Scores for all facilities ranged between 3 and 4. Davao Regional Hospital had the highest satisfaction score among patients. Free-standing clinics scored 4, while RHUs scored 3.8.

Table 4.93 shows the average patient satisfaction scores by municipality and facility setting. Private facilities in the municipalities of Compostela, Maco, Montevista, Nabunturan, and Pantukan scored higher than public facilities.


Table 4.92: Average patient satisfaction scores, by facility type

Facility Type Patient Satisfaction Score

Public

Regional hospital 4.1

District hospital 3.7

Municipal hospital 4.0

Community hospital 3.7

Private hospital 4.0

Clinics

Hospital-based 2.9

Free-standing 4.0

RHU 3.8

TOTAL 3.9

Table 4.93: Average patient satisfaction scores, by municipality

MunicipalityPatient satisfaction score

Public Private

Compostela 3.9 4.0

Laak 3.8

Mabini 3.9

Maco 3.8 4.0

Maragusan 3.9

Mawab 3.9 3.5

Monkayo 3.8 3.9

Montevista 3.7 4.1

Nabunturan 3.5 4.0

New Bataan 3.4 3.3

Pantukan 3.8 4.0

Tagum City 4.2 4.2

TOTAL 3.8 4.0


Tables 4.94 to 4.96 show average patients’ scores by components.

Table 4.95 shows disaggregation of component scores by municipality.

The highest level of general satisfaction can be found in the outpatient clinics at the Davao Regional Hospital.

Table 4.96 summarizes the component satisfaction scores by patient type.

Table 4.94: Average patient satisfaction component scores, by facility type

Facility Type

Gen

eral

sa

tisf

acti

on

Tech

nica

l qu

alit

y

Inte

rper

sona

l m

anne

r

Com

mun

icat

ion

Fina

ncia

l asp

ect

Tim

e sp

ent

wit

h do

ctor

Acc

essi

bili

ty a

nd

conv

enie

nce

Public

Regional hospital 4.4 4.4 4.0 4.3 4.0 3.6 4.0

District hospital 3.6 3.6 4.0 4.1 4.0 3.6 3.6

Municipal hospital 3.8 4.1 4.2 4.1 4.0 3.8 4.0

Community hospital 4.0 4.0 4.5 4.0 3.0 3.0 3.5

Private hospital 4.0 4.2 4.2 4.1 3.6 3.6 4.0

Clinics

Hospital-based 2.3 2.8 3.8 3.7 2.0 3.0 2.8

Free-standing 4.1 4.1 4.2 4.1 3.7 3.9 3.9

RHU 3.7 3.7 4.0 4.1 4.4 3.6 3.3

TOTAL 3.9 4.0 4.1 4.1 3.9 3.7 3.7


Table 4.95: Average patient satisfaction component scores, by municipality

MunicipalityG

ener

al

sati

sfac

tion

Tech

nica

l qu

alit

y

Inte

rper

sona

l m

anne

r

Com

mun

icat

ion

Fina

ncia

l asp

ect

Tim

e sp

ent

wit

h do

ctor

Acc

essi

bili

ty a

nd

conv

enie

nce

Compostela 4.1 4.1 4.1 4.0 4.1 3.5 3.8

Laak 3.6 4.0 4.1 3.9 4.0 3.6 3.6

Mabini 3.7 3.8 4.3 4.2 5.0 4.0 3.0

Maco 3.9 4.0 4.0 4.1 4.0 3.6 3.9

Maragusan 3.9 3.7 4.3 4.1 4.2 3.5 3.8

Mawab 3.4 3.8 4.2 4.2 3.9 3.6 3.5

Monkayo 4.1 3.9 4.0 4.0 3.9 3.6 3.6

Montevista 3.8 3.8 4.2 4.0 4.0 3.8 3.7

Nabunturan 3.9 3.9 4.1 4.0 3.7 3.9 3.6

New Bataan 2.8 3.4 4.3 4.1 4.1 3.8 2.3

Pantukan 3.8 3.9 4.0 4.1 4.1 3.9 3.8

Tagum City 4.4 4.4 4.2 4.4 3.4 4.0 4.3

TOTAL 3.9 4.0 4.1 4.1 3.9 3.7 3.7

Table 4.96: Average patient satisfaction component scores, by patient type

Components Maternal Child Total

General satisfaction 3.8 3.9 3.9

Technical quality 4.0 4.0 4.0

Interpersonal manner 4.1 4.1 4.1

Communication 4.1 4.1 4.1

Financial aspect 3.8 4.0 3.9

Time spent with doctor 3.7 3.8 3.7

Accessibility and convenience 3.8 3.7 3.7


Inpatient survey

General information

The inpatient exit survey covered 61 patients with maternal, neonatal, and pediatric care cases.

Table 4.97 summarizes the number of patients covered by category.

Table 4.97: General characteristics, inpatients

CategoriesAdult,

maternalNeonates Pediatric Total

Sex

Male . 0 19 19

Female 23 1 18 42

Facility type

Public

Regional hospital 3 1 2 6

District hospital 4 0 4 8

Municipal hospital 6 0 5 11

Private hospital 4 0 26 30

Lying-in/birthing home 6 0 0 6

Setting

Public facility 13 1 11 25

Private facility 10 0 26 36

Municipality

Compostela 2 0 14 16

Laak 2 0 2 4

Maragusan 4 0 3 7


CategoriesAdult,

maternalNeonates Pediatric Total

Mawab 3 0 9 12

Montevista 2 0 2 4

Nabunturan 5 0 3 8

Pantukan 2 0 2 4

Tagum City 3 1 2 6

TOTAL 23 1 37 61

Average length of confinement

The following tables present average length of confinement (in days) grouped by patient type, facility type, municipality, and wealth index quintiles.

Table 4.98 shows the average length of confinement by type of patient. Neonatal cases had a longer average length of stay in a public facility compared to other cases.

Those confined at the Davao Regional Hospital had a longer average confinement length compared to other hospital types. Confinement periods in private hospitals were shorter.

Table 4.100 shows the average length of stay in Compostela Valley hospitals and DRH by municipality of residence.

Table 4.101 presents the average length of stay by wealth index.

Those in the 4th wealth quintile tended to stay longer on average in a public facility than in a private facility. Those in the lowest wealth quintile tended to stay a day longer in a public facility.


Table 4.98: Average length of confinement, by case

Inpatient type Public facility Private facility

Adult, maternal 2.8 2.1

Neonates 8.0

Pediatrics 3.1 2.5

TOTAL 3.1 2.4

Table 4.99: Average length of confinement, by facility type

Facility type Average days of confinement

Public





Lying-in/birthing home 2.2

TOTAL 2.7

Table 4.100: Average length of stay, by municipality

Municipality Public facility Private facility

Compostela 2.6

Laak 3.3

Maragusan 2.4

Mawab 2.4

Montevista 2.0

Nabunturan 2.0

Pantukan 2.3

Tagum City 5.2

TOTAL 3.1 2.4


Table 4.101: Average length of stay, by wealth quintile

Wealth Index Quintiles Public facility Private facility

1 3.1 2.0

2 2.8 2.0

3 2.6 2.0

4 6.0 2.8

5 2.5 2.5

TOTAL 3.1 2.4

Household expenditure

Table 4.102 shows the average household expenditure of inpatients for the past 12 months.

Table 4.103 shows the average household expenditure by wealth index.

Those confined in a public facility belonging in the 5th wealth index spent more: at PhP 15,200 on average. This amount is miuch larger than the annual spending of those confined in a private facility, who belonged to the same wealth index, at PhP 5,375.

Table 4.102: Average household expenditures, by municipality, in PhP

Municipality Public facility Private facility

Compostela 4,063

Laak 2,450

Maragusan 4,715

Mawab 4,009

Montevista 8,738

Nabunturan 3,138

Pantukan 1,925

Tagum City 5,508

TOTAL 4,740 3,839


Table 4.103: Average household expenditure, by wealth index quintile, in PhP

Wealth Index Quintiles Public facility Private facility

1 2,690 3,500

2 4,200 2,579

3 5,504 2,943

4 5,750 4,207

5 15,200 5,375

TOTAL 4,740 3,839

Reason for confinement

Table 4.104 shows the distribution of inpatient cases and their attending health professionals. A GP handled 43 percent of all obstetrics cases and 73 percent of all pediatric cases. OB-Gyns only attended to 14 percent of obstetric cases.

In almost all wealth quintiles, as Table 4.105 shows, most of the inpatients belonging in the 2nd wealth quintile were attended to and handled by GPs or family physicians. Those who belonged to a higher wealth quintile were most likely attended by specialists.

Table 4.104: Reason of confinement with attending specialist

Reason for confinement

GPFamily

physicianOB-Gyn

Pedia-trician

Midwife Internist Total

Internist 0% 0% 0% 0% 100% 0% 2

ANC 43% 24% 14% 0% 19% 0% 21

Obstetrics 0% 0% 0% 100% 0% 0% 1

Neonates 73% 8% 0% 5% 0% 14% 37

Pediatrics 59% 13% 5% 5% 10% 8% 61

TOTAL 59% 13% 5% 5% 10% 8% 61


Table 4.105: Attending specialists, by wealth index quintile


GPFamily

physicianOB-Gyn

Pedia-trician

Midwife Internist Total

1 38% 46% 8% 8% 0% 0% 13

2 67% 8% 8% 0% 0% 17% 12

3 75% 8% 0% 0% 17% 0% 12

4 64% 0% 0% 14% 14% 7% 14

5 50% 0% 10% 0% 20% 20% 10

TOTAL 59% 13% 5% 5% 10% 8% 61

Cost of confinement and other costs

Table 4.106 presents the average miscellaneous costs (transportation expenses and travel time) incurred by inpatients during confinement.

Inpatients spent more travel time going to public facilities compared to private facilities, and it was more costlier for inpatients on average to travel to a public facility than to a private one.

Table 4.107 shows miscellaneous costs incurred by inpatients and sorted by cases. Maternal and neonatal cases in a public facility were associated with increased travel time as well as transportation cost.

Tables 4.108 and 4.109 shows the average hospital expenditures of inpatients, classified by type of case and wealth index. The hospital charge for maternal cases was higher in public facilities than in private facilities. Charges for neonatal cases in private hospitals were not given.

Table 4.109 shows the average hospital charge by wealth index. In-hospital charges in a private facility for those belonging to the lowest wealth quintile were higher on average (PhP 4,140) than for wealthier inpatients (PhP 2,690).


Table 4.106: Average miscellaneous costs of confinement, by municipality

MunicipalityPublic Private

Travel Time (minutes)




Compostela 9 156

Laak 6 101

Maragusan 24 102

Mawab 19 103

Montevista 38 129

Nabunturan 24 75

Pantukan 14 59

Tagum City 102 501

TOTAL 40 195 16 121

Table 4.107: Average miscellaneous costs , by patient type

Inpatient typePublic Private





Adult, maternal 37 222 21 77

Neonates 30 250

Pediatrics 45 158 14 137

TOTAL 40 195 16 121

Table 4.108: Average hospital charges, by type of patient, in PhP

Inpatient type

Public facility Private facility

Room charge

Charge IN

hospital

Charge OUTSIDE hospital

Room charge

Charge IN

hospital


Adult, maternal 515 4,092 356 250 3,497 295

Neonates 3,200 8,000 0

Pediatrics 580 1,698 260 500 1,974 200

TOTAL 651 3,195 300 430 2,397 226


Table 4.109: Average hospital charges, by wealth index, in PhP


Public facility Private facility

Room charge

Charge IN

hospital


Room charge

Charge IN

hospital


1 508 3,134 293 300 4,140 500

2 620 3,856 450 325 1,923 263

3 460 1,927 381 337 2,116 302

4 2,000 5,425 0 542 2,536 225

5 700 3,176 135 466 2,690 93

TOTAL 651 3,195 300 430 2,397 226

Average capacity to pay

Table 4.110 presents inpatients’ average capacity to pay, classified by their source of payment.

Those confined in private facilities tended to make more out-of-pocket payments than those confined in public ones, who had to borrow or sell their property.

These public and private facilities are further disaggregated in Table 4.111.

After classifying these payment sources by wealth quintiles, one could see that those who were relatively wealthier tended to shell out more of their income to pay for the services; poorer inpatients tended to borrow, sell their property, or rely on PhilHealth insurance to pay for their hospitalization.


Table 4.110: Average capacity to pay, by facility setting, in PhP

Facility setting

Ow

n in

com

e so

urce

Loan

s

Sale

of

prop

erty

Tran

sfer

do

nati

ons

Phil

Hea

lth

insu

ranc

e

Priv

ate

insu

ranc

e

Oth

er

insu

ranc

e

Oth

er

sour

ces

Public facility 2,095 1,092 448 370 291 0 0 0

Private facility 2,353 160 0 0 584 0 0 0

TOTAL 2,247 542 184 152 464 0 0 0

Table 4.111: Average capacity to pay, by facility type, in PhP

Facility type

Ow

n in

com

e so

urce

Loan

s

Sale

of

prop

erty

Tran

sfer

do

nati

ons

Phil

Hea

lth

insu

ranc

e

Priv

ate

insu

ranc

e

Oth

er

insu

ranc

e

Oth

er

sour

ces

Public

Regional hospital

2,571 4,333 1,868 1,327 0 0 0 0

District hospital

1,777 38 0 163 0 0 0 0

Municipal hospital

2,066 91 0 0 662 0 0 0

Private hospital 2,250 76 0 0 550 0 0 0

Lying-in/birthing home

2,865 583 0 0 756 0 0 0

TOTAL 2,247 542 184 152 464 0 0 0


Table 4.112: Average capacity to pay, by wealth index quintiles, in PhP


Ow

n in

com

e so

urce

Loan

s

Sale

of

prop

erty

Tran

sfer

do

nati

ons

Phil

Hea

lth

insu

ranc

e

Priv

ate

insu

ranc

e

Oth

er

insu

ranc

e

Oth

er

sour

ces

1 1,889 1,331 386 138 408 0 0 0

2 1,744 606 516 0 508 0 0 0

3 2,275 83 0 0 347 0 0 0

4 2,906 536 0 354 396 0 0 0

5 2,359 0 0 251 721 0 0 0

TOTAL 2,247 542 184 152 464 0 0 0

Outcome of confinement

The following set of tables shows the distribution of inpatients and the outcomes of their confinement.

More inpatients claimed feeling better and fully recovered when discharged from a private facility (59.4 percent) than when discharged from a public one. More inpatients report not feeling fully recovered (41.4 percent) when discharged from public facilities.

These figures are further disaggregated in Table 4.114.

Table 4.115 shows the distribution of patients by outcome by municipality.


Table 4.113: Outcome of confinement, by facility setting

Outcome of Confinement Public facility Private facility Total

Discharged fully recovered 40.6% 59.4% 32

Discharged feeling better but not fully recovered

41.4% 58.6% 29

TOTAL 41.0% 59.0% 61

Table 4.114: Outcome of confinement, by facility type

Facility type

Outcome

TotalDischarged fully recovered

Discharged feeling better but not

fully recovered

Public

Regional hospital 50% 50% 6

District hospital 50% 50% 8

Municipal hospital 55% 45% 11

Private hospital 53% 47% 30

Lying-in/birthing home 50% 50% 6

TOTAL 52% 48% 61

Table 4.115: Outcome of confinement, by municipality

Municipality

Outcome

TotalDischarged fully recovered

Discharged feeling better but not

fully recovered

Compostela 69% 31% 16

Laak 25% 75% 4

Maragusan 71% 29% 7

Mawab 25% 75% 12

Montevista 75% 25% 4

Nabunturan 63% 38% 8

Pantukan 25% 75% 4

Tagum City 50% 50% 6

TOTAL 52% 48% 61


Patient satisfaction

Table 4.116 shows the average patient satisfaction score per facility.

Patient satisfaction scores ranged from “1” as the lowest score and “5” as the highest. Satisfaction was lowest in the regional hospital.

Table 4.117 presents average patient satisfaction scores disaggregated by municipality.

There was minimal variation in patient satisfaction scores when Davao Regional Hospital was excluded. Patients in lying-in/birthing homes reported the highest average patient satisfaction score.

Table 4.118 shows average satisfaction scores by type of patient.

Parents/guardians of neonates reported noticeably lower patient satisfaction scores compared to those with maternal and child cases.

Table 4.119 shows average patient satisfaction scores by components: general satisfaction, technical quality, interpersonal manner, communication, financial aspect, time spent with doctor, and accessibility and convenience.

Table 4.120 shows disaggregation of average patient satisfaction component scores by municipality.

Average component scores were highest for communication and lowest for the financial aspect of patient satisfaction.

Average patient satisfaction scores can also be disaggregated by type of patient case, as shown in Table 4.121.


Table 4.116: Patient satisfaction scores, by facility type

Facility Type Patient Satisfaction Score

Public





Lying-in/birthing home 4.4

TOTAL 3.7

Table 4.117: Average patient satisfaction scores, by municipality

Facility NamePatient satisfaction score

Public Private

Montevista District Hospital 3.3

Pantukan District Hospital 3.8

Laak Municipal Hospital 3.8

Maragusan Municipal Hospital 3.8

Davao Regional Hospital 3.0

Dr. Julio Layug Jr. Medical Clinic 3.7

Mawab Medical Clinic and Hospital 4.0

Nabunturan Doctors' Hospital 3.9

St. James Hospital and Medical Clinic 3.8

Nabunturan Well Family Midwife Clinic 4.4 3.3

Compostela Valley Hospital 3.8

Flordeliz Medical Clinic and Hospital 2.9

Family Care and Maternity Clinic 4.3


Table 4.118: Patient satisfaction, by type of patient

Inpatient typePatient satisfaction score

Public Private

Adult, maternal 3.6 4.2

Neonates 2.9

Pediatrics 3.5 3.7

TOTAL 3.5 3.8

Table 4.119: Patient satisfaction component scores, by facility type

Facility Type

Gen

eral

sa

tisf

acti

on

Tech

nica

l qu

alit

y

Inte

rper

sona

l m

anne

r

Com

mun

icat

ion

Fina

ncia

l asp

ect

Tim

e sp

ent

wit

h do

ctor

Acc

essi

bili

ty a

nd

conv

enie

nce

Public

Regional hospital 3.5 3.7 2.7 3.2 1.6 2.2 3.5

District hospital 3.5 3.5 3.6 4.1 3.3 3.2 3.8

Municipal hospital 3.6 3.8 4.0 4.0 3.5 4.0 3.7

Private hospital 3.8 3.8 3.8 4.1 3.2 3.5 3.7

Lying-in/birthing home 4.3 4.3 4.6 4.5 4.3 4.5 4.3

TOTAL 3.7 3.8 3.8 4.0 3.2 3.5 3.8


Table 4.120: Patient satisfaction component scores, by municipality

Facility Name

Gen

eral

sa

tisf

acti

on

Tech

nica

l qu

alit

y

Inte

rper

sona

l m

anne

r

Com

mun

icat

ion

Fina

ncia

l asp

ect

Tim

e sp

ent

wit

h do

ctor

Acc

essi

bili

ty a

nd

conv

enie

nce

Montevista District Hospital 3.3 3.1 3.3 4.4 3.0 3.1 3.0

Pantukan District Hospital 3.8 3.8 4.0 3.8 3.5 3.3 4.1

Laak Municipal Hospital 3.5 3.9 4.0 3.1 3.8 4.1 3.9

Maragusan Municipal Hospital 3.6 3.8 4.1 4.1 3.4 3.9 3.5

Davao Regional Hospital 3.5 3.7 2.7 3.2 1.6 2.2 3.5

Dr. Julio Layug Jr. Medical Clinic 4.0 3.5 4.0 3.5 3.5 3.5 4.0

Mawab Medical Clinic and Hospital 4.0 4.2 4.1 4.0 3.1 4.0 4.0

Nabunturan Doctors' Hospital 3.9 4.0 4.0 4.3 2.9 3.6 4.1

St. James Hospital and Medical Clinic 3.9 4.0 3.8 4.1 3.8 3.0 3.7

Nabunturan Well Family Midwife Clinic 4.5 4.0 4.8 4.4 4.4 4.8 4.4

Compostela Valley Hospital 4.0 3.9 3.8 4.0 3.9 3.3 3.7

Flordeliz Medical Clinic and Hospital 2.5 2.8 3.0 4.3 2.0 3.4 2.7

Family Care and Maternity Clinic 4.0 4.8 4.3 4.8 4.0 4.0 4.1

TOTAL 3.7 3.8 3.8 4.0 3.2 3.5 3.7

Table 4.121: Patient satisfaction component scores, by type of patient

Inpatient type

Gen

eral

sa

tisf

acti

on

Tech

nica

l qu

alit

y

Inte

rper

sona

l m

anne

r

Com

mun

icat

ion

Fina

ncia

l asp

ect

Tim

e sp

ent

wit

h do

ctor

Acc

essi

bili

ty a

nd

conv

enie

nce

Adult, maternal 3.8 4.0 4.0 4.2 3.4 3.7 3.9

Neonates 2.5 3.0 2.5 4.0 2.0 2.0 3.8

Pediatrics 3.7 3.7 3.7 3.9 3.1 3.4 3.6

TOTAL 3.7 3.8 3.8 4.0 3.2 3.5 3.8

372

About the Authors

Aleli KRAFT is a consultant at the UPecon-HPDP and an associate professor at the U.P. School of Economics.

Jhiedon FLORENTINO is a consultant at the UPecon-HPDP.

Julio M. GALVEZ is a research assistant at the UPecon-HPDP.

Orville SOLON is Chief of Party of UPecon-HPDP.

Carlos Antonio TAN Jr. is a consultant at the UPecon-HPDP.

Rhodora TIONGSON is a program associate at the UPecon-HPDP.

The Family Health Book - UPecon Foundation

Documents

Transcript of The Family Health Book - UPecon Foundation