philippine policies on maternal and newborn health

8/11/2019 Philippine Policies on Maternal and Newborn Health

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P L C P D P O L I C Y R I E F

Philippine Policies on Maternal,Newborn,

and Child Health and Nutrition:

Towards Achieving

Carlos O. Tulali

Introduction

n the Philippines, 3.4 million pregnancies occur every year, half are unintended, one-thirdof which end in abortions.1An estimated 11 mothers die of pregnancy-related causesevery day, most of these deaths could have been avoided in a properly functioning

health care delivery system. Among the leading direct causes of maternal deaths in thecountry are: post-partum hemorrhage, hypertensive disorders of pregnancy, abortion-related complications and obstructed labor. Beyond the glaring data of mortality lies ahuge toll of ill health and disability due to pregnancy-related complications and infant andchild deaths and deepening poverty in families where a mother has died. It is estimated

that for every maternal death there is at least 20 to 30 other women who suffer from seriouscomplications, some of which are life-long. Maternal health conditions are the leadingcauses of burden of disease among women.

Based on the State of the Worlds Children2009 report of the United Nations ChildrensFund (UNICEF), the Philippines is among 68countries, which contributed to 97 percentof maternal, neonatal, and child healthdeaths worldwide.2Statistics also show that

almost half of the deaths of Filipino childrenunder five years old is within the first 28 daysof life3According to UNICEF, complicationsin childbirth are brought by hemorrhage,sepsis, hypertension and abortive outcomes,which are actually preventable.4

Due to these reasons, monitoring andevaluation (M&E) system in health programsplay a crucial role in addressing the issue

of maternal, newborn and child healthand nutrition (MNCHN) for the Philippinesto achieve Millennium Development Goals4 (Reduce child mortality) and 5 (Improvematernal health). This paper identifiesand discusses currently available data

used to monitor the potential and actualeffects of Philippine government policieson maternal, newborn and child healthand nutrition (MNCHN) status. In addition,recommendations will be made on howto better meet the data needs for timelyanalyses of the effects of policy on Filipinomothers and their children. The paper alsoidentifies critical gaps in MNCHN services andsuggests a set of priorities for action to extend

Expanding choices, uplifting lives through responsive population and human development


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MDGs 4 and 5

I

egislation


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Philippine Policies on Maternal, Newborn, and Child Health and Nutrition: Towards Achieving MDGs 4 and 5

and strengthen them. The aim of this paperis to provide access to, and understandingof, this information to help legislators,policymakers, and health professionals to planeffective MNCHN programs and mobilize

additional resources to improve the lives ofFilipino mothers, newborns, and children.

Maternal, Newborn, and Child Health andNutrition in the Philippines

The quality of care that both mother andnewborn receive during pregnancy, atdelivery, and in the early postnatal periodis essential to ensuring women remain

healthy and that children get a strong start.5Many stillbirths and newborn deaths couldbe averted if more women were in goodhealth, well-nourished, and receiving qualitycare during pregnancy, labor, and delivery,and if both mother and newborn receivedappropriate care in the postpartum period.6

Most recent government surveys reveal thefollowing state of MNCHN in the Philippines:

1.Fertility Trends- The current fertilityrate, according to the NationalDemographic Health Survey (NDHS)2008 preliminary results, is at 3.3.7TheNDHS 2008 also reports that fertilitylevels in the Philippines declinedgradually in the last 15 years. The

declines in the fertility rates of womenages 25 to 34 have continued to bemore noticeable. The fertility rates ofwomen ages 15-19 and 45-49 haveremained almost unchanged in the last

15 years while the rate of birth remainshigher among women aged 25 to 29.

2.Maternal Mortality Trends -Accordingto the 2006 Family Planning Survey(FPS), the maternal mortality ratio forthe seven-year period prior to thesurvey was 162 deaths per 100,000births.8This implies a slight decline fromthe level of about 172 estimated fromthe 1998 NDHS. However, because of

the 95 percent confidence intervalsaround the point estimates of the twosurveys, the apparent decline cannotbe considered statistically significant.The 2008 NDHS did not collectmaternal mortality data.

3. Infant and Child Mortality Trends

- Preliminary results of the 2008 NDHSshow that there has been a declinein under-five mortality rate in 15years, from 54 deaths per 1,000 livebirths during the period 1988-1992 to34 deaths per 1,000 live births in theperiod 2003-2007. The infant mortalityrate has declined, from 34 deaths per1,000 live births to 25 deaths per 1,000live births.9

Box 1. Facts on maternal; and neonatal health in the Philippines:

------

160 women for every 100,000 births die.Roughly over 11 women die every day.7 out of 10 deaths occur at child birth or within a day after delivery.4 out of 10 deaths are due to complications and widespread infectionsFor every death, 40 more women get sick.8 out of 10 births in rural areas are delivered outside a health facility.

Source: UNICEF Philippines website, http://www.unicef.org/philippines/8889.html


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Philippine Policies on Maternal, Newborn, and Child Health and Nutrition: Towards Achieving MDGs 4 and 5| PLCPD POLICY RIEF

4.Immunization of Children- The 2008NDHS preliminary report shows thatoverall, 80 percent of children ages12-23 months have received all ofthe recommended vaccinations.

Immunization coverage is generallyhigh for each type of vaccine: 94percent of children have received theBCG vaccination, 93 percent havereceived the first DPT dose, and 92percent have received the first poliodose. Coverage against measles is 84percent. Only 6 percent of childrenhave not received any immunization,a decrease from 8 percent of childrennot immunized in 2003.

5.Nutritional Status of Infant and Children- The 6thNational Nutrition Survey2008 initial results show that amongchildren under age five, 27.6 percentare underweight and 1.4 percentare overweight. Among pregnantand lactating women, 26.6 percentand 11.7 percent, respectively, areunderweight. The prevalence ofanemia among 6 months to below1 year, and 1 year and 11 monthsold children, is at 66 percent and 53percent, respectively. The prevalenceof anemia among pregnant andlactating women is at 43.9 percentand 42.2 percent, respectively.10

The 2008 NDHS results show that 8percent of infants under two monthsold are not breastfed. Furthermore,

only 34 percent of infants under 6months old are being exclusivelybreastfed, most are mixed fed withother milk or plain water or givencomplementary feeding. By age 6-9months, only 63 percent of infantsare being breastfed with 58 percentreceiving complementary food. Eightypercent of households (mothers)claim they are aware of iodizedsalt, but only 38 percent actually

use iodized salt. The proportion ofhouseholds whose salt tested positivefor iodine is 56.4 percent.

6.Childhood Illness- Acute respiratory

illness (ARI), malaria, and dehydrationfrom diarrhea are the major causesof childhood mortality. In the 2008NDHS, mothers were asked whethereach child under age five hadexperienced cough with short, rapidbreathing (symptoms of ARI), fever(symptom of malaria), or diarrheain the two weeks prior to the surveyand the treatment given to thosewho experienced the symptom. The

survey results show that treatment wassought from a health facility or healthprovider for 50 percent of childrenwith symptoms of ARI in the two weeksbefore the survey. The survey resultsalso show that treatment was soughtfor 34 percent of children under agefive who are reported to have haddiarrhea in the two weeks prior to thesurvey, and 47 percent were givensolutions prepared from packetsof oral rehydration salts (ORS).Fifty-nine percent of children withdiarrhea were given oral rehydrationtherapy (ORT), which includessolution prepared from ORS andrecommended homemade fluids.


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Global Mandates on Maternal, Newborn,and Child Health and Nutrition

The Philippines, together with the rest of theother nations, is a signatory to international

conventions which recognize these rightssuch as the International Covenant onEconomic, Social and Cultural Rights in1976, the Convention on the Elimination of

All Forms of Discrimination Against Women(CEDAW) in 1979, the Convention onthe Rights of the Child (CRC) in 1989, theInternational Conference on Populationand Development (ICPD) in 1994, theBeijing Declaration, Platform of Actionduring the Fourth World Conference on

Women (WCW) in 1995, and the MillenniumDevelopment Goals in 2000, among others.Most of these international conventionswere ratified by the Philippine Congress/Senate and, therefore, the country isbound to implement and report progress inachieving them.

International Conference on Population andDevelopment

Access to reproductive health (RH) servicesis a human right. This is explicitly stated inthe 1994 ICPD Programme of Action (PoA)of which the Philippine Government is asignatory to both. Against this background,the ICPD, through the PoA marked thewillingness of the Philippine government,international community, and civil societyto integrated SRHR concerns into alleconomic and social activities. The PoA

of the 1994 ICPD, for example, calls ongovernments and international donoragencies to expand and transform existingprograms, and to offer services that arecomprehensive, integrated, universallyaccessible, and delivered in a mannerconsistent with health and rights objectives.

If maternal and neonatal mortality is to bereduced, a comprehensive program andstrong political commitment are needed.

Effective advocacy to attract governmentsattention and to mobilize resources is veryimportant. Consistent with the principlesof the 1994 ICPD, MDGs, and the UNsrights-based approach, three evidence-

based approaches to maternal andneonatal mortality reduction have beenrecommended by UN agencies (i.e. WHO,UNICEF and the UNFPA) to address or avoidthe delays in service delivery:

1. All women must have accessto reproductive health services,including contraception to determinethe number and spacing of theirchildren;

2. Antenatal care, all deliveries, andpost partum care must be attendedby skilled birth attendant withtimely access to quality emergencyobstetric and newborn care, whenneeded; and

3. All mothers and newborns mustbenefit postpartum visits.


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Millennium Development Goals (MDGs)

The Philippines has committed to fully supportthe Millennium Development Goals (MDGs)

along with 191 other UN member stateswhen it signed the Millennium Declarationin 2000, particularly on improved maternaland neonatal health by tracking progresson reducing maternal and child mortalities.The Goals include reducing under-fivemortality by two thirds (Goal 4) and reducingmaternal mortality ratio by three quarters(Goal 5) between 1990 and 2015.11In 2005,the UN General Assembly highlighted furtherthe need to incorporate the attainment of

universal access to reproductive health (RH)by 2015 under MDG 5.

Partnership for Maternal, Newborn, andChild Health

On September 12, 2005, the globalPartnership on Maternal, Newborn, andChild Health (PMNCH) was officiallylaunched. The PMNCH is an international

alliance of some 280 governments,donors, NGOs, health care professionals,academics, and multilateral agencies.Its mission is to support the global healthcommunity to work successfully towards

achieving MDGs 4 and 5 by advocatingfor national, regional, and global politicalcommitments, and by raising funds toreduce maternal and child mortality. Itenhances partners interactions and usestheir comparative advantages to: (1) buildconsensus on and promote evidence-based, high-impact interventions, anddeliver them through harmonization; (2)contribute to raising US$30 billion (for 2009-2015) to improve maternal, newborn,

and child health through advocacy;and (3) track partners commitmentsand measurement of progress foraccountability.12

Global Consensus for Maternal, Newborn,and Child Health

A new global Consensus for Maternal,Newborn, and Child Health, setting out fivekey action steps to save the lives of morethan 10 million women and children by2015, was launched on September 23, 2009at a high-level event at the United Nations.The Consensus, strongly endorsed by theGroup of Eight (G8) at its meeting in Italyin July, was agreed this year by a broadrange of governments, NGOs, internationalhealth agencies, and individuals, throughthe PMNCH, and formally launched by Dr.Margaret Chan, Director-General of the

World Health Organization (WHO).13The UNevent, attended by several heads of state,heads of government, and other dignitaries,reflected the united political will of theinternational community.

Political will is in fact the first of five pillarsof the global Consensus, which liststhe priority actions that are needed toaccelerate progress on the MDGs formaternal and child health. They are: (1)


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political leadershipand community

engagement; (2) aquality package ofevidence-based

interventions,delivered througheffective healthsystems; (3) theremoval of barriersto access, with

services ideally beingfree at point of use for

all women and children;(4) skilled and motivated

health workers, in the right place at the right

time; and (5) accountability for results.14

Legal Bases

1987 Philippine Constitution.

The Philippine constitution has mandatedthe state to provide a comprehensive andaccessible healthcare program to everycitizen. The constitution also prohibits anydiscrimination due to religion and beliefs.The State has the responsibility to provideinformation, assistance, and access to alltypes of FP methods. Thus, the government isexpected to develop policies including healthprograms based on these general principles.

Under the 1987 Constitution Article 13, Sec.11: The State shall adopt an integratedand comprehensive approach to health

development which shall endeavor tomake essential goods, health, and othersocial services available to all peopleat affordable cost. Moreover, Sec 14states that the State shall protect workingwomen by providing safe and healthfulworking conditions, taking into accounttheir maternal functions, and such facilitiesand opportunities that will enhance theirwelfare and enable them to realize their fullpotential in the service of the nation.

Though not directly specifying the stateduty on maternal and child health, the 1987Philippine Constitution clearly mandatesthe government to promote it by fulfillingits mandate on the health of the people

in general. Section 15 of Article II expressesthis states duty: The state shall protect andpromote the right to health of the people andinstill health consciousness among them.15

It is only in the 1987 Philippine Constitutionwhere health was enshrined as afundamental right of all Filipinos, particularlythe poor. In the 1973 Constitution, it was onlyincluded as part of the social services. In the1935 Constitution, there was no mention of it.

1991 Local Government Code

With the passage of the 1991 LocalGovernment Code (LGC), health servicesdelivery was devolved to the LGUs.Corresponding to the new powers andfunctions of the different structures of thehealth sector are the new responsibilitiesthat each LGU should assume. Thisassumption of new powers, functions, andresponsibilities (to be discussed later in theinstitutional analysis) entails an institutionalrestructuring of the DOH as the main nationalagency responsible for overseeing healthservices delivery, financing, regulation,and governance of the health sector. The1991 LGC mandates DOH to continueto formulate policies, standards, andregulations, as well as provide tertiary care intertiary hospitals and special hospitals, while

the LGUs are responsible for the primary andsecondary cases in the hospitals and someof the general tertiary hospitals, which areprovided by the provincial hospitals16

Complementing the new functionality ofthe LGUs are the local health boards (LHBs).These are special bodies that exist in all levelsof LGUs, except in the barangays. An LHB iscomposed of the local chief executive (i.e.,governor for the provincial health board,


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city mayor for the city, andmunicipal mayor for themunicipality) as chair;local health officer(i.e., provincial, city, or

municipal health officer)as vice-chairperson; thecommittee chair on healthof every local legislativebodysangguniang

panlalawigan(provincialboard),sangguniang

panlunsod(city board), andsangguniang bayan(municipalboard), a representative from the privatesector or NGO involved in health services,

and a DOH representative (provincial, city, ormunicipality). The main function of the LHB isto formulate policies on budget allocationsand act as advisory committee for thesanggunian.

Magna Carta of Women (RA 9710)

On August 15, 2009, Philippine PresidentGloria Macapagal-Arroyo signed Republic

Act 9710, also known as the Magna Carta ofWomen, which is a comprehensive womenshuman rights law that seeks to eliminatediscrimination against women by recognizing,protecting, fulfilling, and promoting the rightsof Filipino women, especially those in themarginalized sectors. All rights in the PhilippineConstitution and those rights recognizedunder international instruments duly signedand ratified by the Philippines, in consonancewith Philippine laws, shall be rights of women

under the Magna Carta of Women. Theserights shall be enjoyed without discriminationsince the law prohibits discrimination againstwomen, whether done by public and privateentities or individuals.

Features of the law include:

1.Comprehensive health services andhealth information and education

covering all stages of a womans

life cycle, and which addressesthe major causes of womens

mortality and morbidity,including access to amongothers, maternal care,

responsible, ethical, legal,safe and effective methodsof family planning, andencouraging healthy lifestyle

activities to prevent diseases;2. Leave benefitsof two

(2) months with full pay basedon gross monthly compensation,

for women employees who undergosurgery caused by gynecologicaldisorders, provided that they have

rendered continuous aggregateemployment service of at least six (6)months for the last twelve (12) months;

3.Equal rights in all matters relating tomarriage and family relations.The Statshall ensure the same rights of womenand men to: enter into and leavemarriages, freely choose a spouse,decide on the number and spacingof their children, enjoy personal rightsincluding the choice of a profession,own, acquire, and administer theirproperty, and acquire, change, orretain their nationality. It also states ththe betrothal and marriage of a childshall have no legal effect.

4.Review amendment or repeal of lawsthat are discriminatory to women.

5.Mandate access to information andservicespertaining to womens health.

There are several other national lawsand issuances that support maternal andchild health interventions and services inparticular, and public health affectingmaternal and child health in general.

Among these are:

- Newborn Screening Law (RA 9288);- An Act Increasing Maternity Benefits

in Favor of Women Workers in thePrivate Sector (RA 7322);


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- Magna Carta of Public Health Workers(RA 7305);

- Barangay Health Workers Benefitsand Incentives Act of 1995 (RA 7883);

- The Paternity Leave Act of 1995 (RA

8187); and- Philippine Midwifery Act of 1992 (RA7392).

Other MNCHN-related governmentissuances are:

- maternal package for normalspontaneous vaginal delivery in non-hospital facilities (PhilHealth CircularNo. 6);

- supplemental guide for

Garantisadong Pambata(DOHCircular 265-A);

- setting standard labeling forbreastmilk substitutes, infant formula,other milk products, foods andbeverages (DOH Circular 2008-0006);

- Bright Child Program (EO 286); and- national commitment forBakuna

and Una sa Sanggol at Ina(EO 663).

Government Policies and Programs

Integrated Maternal, Neonatal, and ChildHealth and Nutrition Strategy

The health of mothers and children wereplaced at the center of health sector

reform, consistent withthe advocacy that

all women have

the right to safeand qualityemergencyobstetricservices(EmOC)to preventmaternaland newborn

deaths, andachieve the

MDG target to cut maternal and childdeaths by 2015.

With pregnancy and childbirth posingserious risks to Filipino mothers and their

newborn, the country recognizes the needto accelerate the reduction in maternal andchild mortality. In response to this need, theDepartment of Health (DOH) has initiatedkey health reforms for the rapid reductionof maternal and neonatal mortality throughthe DOH Administrative Order (AO) No.2008-0029 on Implementing Health Reformsfor Rapid Reduction of Maternal andNeonatal Mortality.17This mandates theimplementation of anIntegrated Maternal,

Neonatal and Child Health and NutritionStrategywithin the framework of the F1. Itadopts a unified strategic framework formaternal and newborn health that is linkedwith child survival strategies, maximizing thedelivery of service packages, and ensuringa continuum of care across the life cyclestages. Under this strategy, all pregnanciesare considered at-risk. Likewise, it takesinto consideration the three major pillars inreducing maternal mortality and morbidity,namely, emergency obstetric care, skilledbirth attendants and family planning.

AO 2008-0029, issued on September 9,2008, outlines specific actions for nationaland local health systems to systematicallyaddress health risks with the end goal ofrapidly reducing maternal and neonataldeaths. It states that the strategy shallguide the development, implementation,

and evaluation of various programs aimedat women, mothers and children, with theultimate goal of rapidly reducing maternaland neonatal mortality in the country.18Itaims to address service delivery, regulation,financing, and governance of the Philippineshealth system. The integrated MNCHNstrategy, implemented in all provincesand cities, is aimed to meet the followingreproductive health (RH) indicators by 2010:

- increase CPR to 60 percent;


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- increase theproportion of

pregnantwomen havingat least four

antenatalcare visits to80 percent;- increaseskilled birth

attendanceand facility-based

births to 80 percent;and

- increase percentage of fully-immunized children to 95 percent.

On September 18, 2009 the PhilippinesDepartment of Health (DOH) announcedthat the three United Nations (UN) agencies- UNFPA, UNICEF, and WHO - have joinedforces and resources to undertake a jointprogram on rapidly reducing maternal andneonatal deaths in the country and meetthe MDGs. The new project, with the supportof the Australian Agency for InternationalDevelopment (AusAID) is divided into twosignificant phases: the Transition period(2009-2011), which will cover the provincesof Eastern Samar, Ifugao, Lanao del Sur,Maguindanao, North Cotabato, andSaranggani, and the urban poor areasin Tacloban, General Santos, Taguig,Navotas, Paraaque and Makati; and theFull Operationalization Period covering theyears 2011-2016.19

On December 7, 2009, the DOH releaseda new Administrative Order on the subjectAdopting New Policies and Protocol onEssential Newborn Care (ENC), which detailsspecific policies and principles to follow forall health care providers involved in newbornhealth care.20Consistent with AO 2008-0029, the newly-released AO will providekey behaviors and appropriately-timedinterventions to make the post-natal period fornewborns safer. It is also seen to help pave the

way for a globally accepted, and evidence-based essential newborn care health system.

Womens Health and Safe MotherhoodProject

As a measure to accelerate efforts onMMR reduction, the Philippine governmenthas adopted Womens Health and SafeMotherhood as its flagship program underthe sector-wide F1 for Health with thehelp of other stakeholders such as theWorld Bank, ADB, EU/GTZ, JICA, USAID,WHO, UNICEF, and UNFPA. The SecondWomens Health and Safe MotherhoodProject (WHSMP2) will contribute to the

national goal of improving womenshealth by: Demonstrating in selected sitesa sustainable, cost-effective model ofdelivering health services that increasesaccess of disadvantaged women toacceptable and high quality reproductivehealth services and enables them to safelyattain their desired spacing and numberof children. The main objectives of theWHSMP2 in the Philippines are the following:

1. To increase the access ofdisadvantaged women ofreproductive age to acceptable,high quality, and cost-effectivereproductive health services andenable them to safely attain theirdesired spacing and number ofchildren; and

2. To assist in the development andimplementation of sustainableand replicable systems within the

framework of the Health Sector ReformAgenda for financing and delivery ofreproductive health services.

Family planning

A national mandated priority public healthprogram to attain the countrys nationalhealth development: a health interventionprogram and an important tool for theimprovement of the health and welfare of


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mothers, children, and other members of thefamily. It also provides information and servicesfor the couples of reproductive age to plantheir family according to their beliefs andcircumstances through legally and medically

acceptable family planning (FP) methods.

Philippine National Strategic Framework forPlan Development for Children, 2000-2025(Child 21)

The health sectors contribution to thePhilippine National Development Plan forChildren defines the vision for children by2025, formulates cost-effective interventions,and outlines a budget that will reflect

contributions of different national and localgovernment units, the private sector, NGOs,and international organizations. It serves as aframework for local government units (LGUs)in the formulation of their development plans.Childrens Health 2025, a subdocument ofChild 21, realizes that health is a critical andfundamental element in childrens welfare.

The vision of Child 21 has been concretizedthrough the formulation of the NationalPlan of Action for Children for the period2005-2010, aimed at reducing disparitiesin development indicators for children.Subsequently, there will be a National Planof Action 2011-2015 (Catching up with theMillennium Development Goals); a NationalPlan of Action 2016-2020 (Sustaining thegains); and a National Plan of Action 2021-2025 (Achieving the Child 21 vision).

Early Childhood Care and DevelopmentProgram

Republic Act 8980, known as the EarlyChildhood Care and Development (ECCD)

Act of 2000, defines the ECCD System asthe full range of health, nutrition, earlyeducation, and social services programsthat provide for the basic holistic needsof young children from birth to age six (6),to promote their optimum growth and

development. It encourages the activeinvolvement of parents and communities.The implementation of this system shall bethe responsibility of the national government,LGUs, NGOs, and private organizations.

The rearing of a child is a traditional roleof mothers. With the enactment andimplementation of this law, raising a child isno longer solely the responsibility of mothers.The community, the national and localgovernments, and other institutions are nowobliged to assist in providing for the basicholistic needs of young children. ECCDprograms include: child care programs;parent effectiveness seminars; childminding centers; family day care services;

parent-child development programs; andkindergartens in public schools.

Promotion of Breastfeeding program /Mother and Baby Friendly Hospital Initiative

Realizing optimal maternal and child healthnutrition is the ultimate concern of thePromotion of Breastfeeding Program. Thus,exclusive breastfeeding in the first four tosix months after birth is encouraged as wellas enforcement of legal mandates. TheMother and Baby Friendly Hospital Initiative(MBFHI) is the main strategy to transform allhospitals with maternity and newborn servicesinto facilities which fully protect, promote,and support breastfeeding and rooming-inpractices. The legal mandate to this initiativeare the RA 7600 (The Rooming-In andBreastfeeding Act of 1992) and the ExecutiveOrder 51 of 1986 (The

Milk Code). Nationalassistancein terms offinancialsupport forthis strategyended in2000, thusLGUs wereadvocated topromote and


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sustain this initiative. To sustain this initiative,the field health personnel has to provideantenatal assistance and breastfeedingcounseling to pregnant and lactating mothersas well as to the breastfeeding support

groups in the community; there should alsobe continuous orientation and re-orientation/updates to newly hired and old personnel,respectively, in support of this initiative.

Food Fortification program

The Food Fortification program is thegovernments response to the growingmicronutrient malnutrition, which havebeen prevalent in the Philippines for thepast several years. Food Fortification is theaddition ofSangkap Pinoyor micronutrientssuch as Vitamin A, Iron and/or Iodine to food,whether or not they are normally containedin the food, for the purpose of preventing orcorrecting a demonstrated deficiency withone or more nutrients in the population orspecific population groups. Micronutrientsare vitamins and minerals required by thebody in very small quantities. These are

essential in maintaining a strong, healthy,and active body; sharp mind; and forwomen to bear healthy children.

Expanded Program on Immunization

Children who are not fully immunized aremore susceptible to common childhood

diseases. The Expanded Program onImmunization is one of the DOH Programsthat has already been institutionalizedand adopted by all LGUs in the region. Itsobjective is to reduce infant mortality and

morbidity through decreasing the prevalenceof six immunizable diseases (TB, diphtheria,pertussis, tetanus, polio and measles).

Government Financing for MNCHN

Health care financing system refers tovarious structures, methods, processes andprocedures in which financial resourcesare made available to fund health sectoractivities, and how it is used on the deliveryof health services. The purpose of healthfinancing is to make funding available,to set the right financial incentives forproviders, as well as ensure that allindividuals have access to effective publichealth and personal health care.21Poorwomen, their children, and families usepublic-funded maternal and child health(MCH) services worldwide. However, with

the decline in public-funded health servicesand the growing role of private-financedsystems, poor women and their childrenare at risk of falling through the cracks ofbusiness-driven health systems.22

Based on the 2003 Philippine NationalHealth Accounts (PNHA) estimates,

Box 2. State of Health Care Financing in the Philippines

Current health financing: Total health expenditures only 3% of GNP 59% from out-of-pocket payments 16% from national budget (DOH and ODA) 13% from LGU budgets 11% from PhilHealth

We are not spending enough on health 3% of Phil GNP vs. WHO 5% of GNP standard


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the Philippine national governmentexpenditures for preventive and publichealth services went to programs forprevention of communicable diseases(34%) and non-communicable diseases

(23%), and maternal and child health (9%).Similarly, expenditures of foreign-assistedprojects mostly paid for programs forprevention of communicable diseases (32%)and non-communicable diseases (23%),and maternal and child health (22%).23

The recent increases in the Philippinesnational health budget (approximately100% in 2008 and an additional 30%increase in 2009) are changing the way

that the Department of Health (DOH)makes fiscal transfers to regions and localgovernments. Starting in October 2008the DOH moved away from input-basedallotments in favor of performance basedblock grants. The RHR Department issupporting a rapid assessment of two ofthese performance based grants: grants to

fund reproductive healthcommodities; and

womens healthteams. Results willbe used by thegovernmentas it plansto increasesubstantiallythe use ofperformance

based fundingmodalities for

reproductive health as well as other priorityhealth programs.

PhilHealth

The Philippine Health Insurance Corporation(PhilHealth) is the government agencyresponsible for managing the NationalHealth Insurance Program (NHIP). Assuch, it is a major source of financinghealth services through its various benefitpackages including the maternal carepackage for normal deliveries and the newborn screening package.

PhilHealth provides a viable source for

financing FP and maternal and childhealth services and products. The rangeof PhilHealth benefit packages includea maternity care package for normaldeliveries that includes the first cycle of oralcontraceptives, the first dose of injectablecontraceptive postpartum, and the firstdose of BCG for the infant. Philhealthalso covers IUD insertion and voluntarysterilization. PhilHealth benefit packagesalso include a newborn care packagethat covers the cost of newborn screening.However, utilization of these benefitpackages remains low. Furthermore, theissues on accreditation and reimbursementstill need to be addressed.

FOURmula One for Health and MNCHN

In 2005, under national leadership of theDOH, based on a deeper understanding of

Box 3. Health Insurance Coverage

The Philippines2008 National Demographic and Health Survey (NDHS)

included a module of questions concerning health care utilization and costs.Based on the NDHS 2008 results, only 42 percent of Filipinos are covered bysome form of health insurance.

Source: National Statistics Office (NSO), and ICF Macro, 2009. National Demographic and Health

Survey 2008. Calverton, Maryland: NSO and ICF Macro.


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the requirements of implementation, andcoordinated support from developmentpartners, the Government formulated anew health reform implementation strategy,known as FOURmula Onefor Health

(F1). The strategy organizes the reforms intofour implementation components, namely:Health Financing, Health Sector Regulation,Health Service Delivery (covering bothpublic health and hospital reforms), andHealth Sector Governance in Health(covering DOHs internal managementand its sector coordination and leadershiprole, of stewardship over the whole healthsystem). The new implementation strategyemphasizes the role of PhilHealths national

social insurance program as the main leverto effect desired changes and outcomesin all four implementation components atnational and local levels.

The objective of financing reforms underF1 is to secure more, better, and sustainedinvestments in health to provide equity andimprove health outcomes, especially forthe poor.24Mobilizing additional resourcesfor health will entail increasing revenuegeneration capacities of health agencieswithout compromising access by the poor.This may include revenues from user feesand charges for personal health careand regulatory services, and rationalizeduse of real property assets belonging togovernment health agencies.

F1 specified clear targets and identifiedpriority projects and activities of the DOH

for the medium and long term, emphasizingthe needs to focus attention toward theattainment of the MDGs and the NationalObjectives for Health (NOH) for 2005-2010.

Monitoring and Evaluation

Government commitments to maternaland child health can be monitored usingfinancial indicators and policy approvals.

Investment in maternal health programscan be tracked by measuring inputs (suchas midwifery training), outputs (such as thenumber of midwives posted) and processes(such as the uptake of skilled delivery

care).25These indicators are necessary forplanning, implementing and monitoringinitiatives to improve maternal health.

The F1 strategy coordinates health reformmore closely with public expendituremanagement and governance reform,including public procurement reform,and measures to increase transparencyand accountability in public expendituremanagement. Reform implementation

planning has been integrated with theformulation of a medium term HealthSector Expenditure Framework, and theannual budget process. A performancemonitoring framework for DOH, PHIC, andconvergence provinces, will link budgetingand resource allocation to outputs andintermediate results.

The DOH budget for family planning and

maternal and child health has significantlyincreased in the last two years. While theDOH does not have a specific line itemfor procurement of contraceptives, theGeneral Appropriations Act of 2008 has anearmark in the DOH budget P180 million tothe DOH for operational costs associatedwith providing contraceptive services;P30 million for the routine functions ofDOH in support of FP and,through congressional

initiative, anotherP150 million to besub-allocatedto LGUs forpurchasing RHcommoditiesand conductingFP seminars.26The GAA of2008 againhad an earmark


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in the DOH budget of P2billion for contraceptivesand related training,promotional andother costs. P1.2

billion of this earmarkis for contraceptivesand downloaded tothe LGUs to facilitateLGU procurement ofcontraceptives. Theguidelines for operationalizingthis financing mechanism, whilealready developed, have yet to be fullyunderstood by DOH staff and have yet tobe uniformly applied across regions, with

the exemption of ARMM where guidelinesmay have to be adjusted to respond torealities in the region.

Monitoring at the Local Level

Since 1991, DOH has also had to dealwith the implementation of the LocalGovernment Code, which devolvedresponsibility for the provision of social

services, including health and familyplanning, to local government units (LGUs).LGUs are subdivided into 81 provinces,136 cities, 1,495 municipalities and 42,008barangays as of December 31, 2008.27The LGUs are grouped into seventeen(17) regions based on their geographicallocations.

Provinces and cities are responsiblefor planning, overall coordination of

population/family planning/maternaland child health (MCH) activities, and forfamily planning services provided throughprovincial and city hospitals. Municipalitiesare responsible for delivery of familyplanning/MCH services through a networkof clinics and outreach services. Nearlyall provinces and cities have a PopulationOffice and a Health Office and staffresponsible for planning and monitoringof family planning-related activities. These

offices are also responsible forcoordinating the efforts of

NGOs to ensure the broadestpossible coverage forservices and to facilitate

information transfer to thelocal and national MIS.The DOH has retainedresponsibility for overall

monitoring and evaluationof local programs, projects,

facilities, setting of standards,and for technical support services

such as logistics, training, IEC, andinformation systems.

At the local level, a number of LGUs havebudgets for FP and maternal and childhealth, including the procurement ofcontraceptives and essential maternaland child health drugs and supplies. Thismakes the LGU a significant market forprivate sector products. However, issuesaround procurement and willingness ofsuppliers to serve the LGU market still needto be addressed. Equally important is the

availability of private sector providers inthe community. While these are available,there is very little appreciation of the role ofprivate sector in the delivery of basic publichealth services. Hence, the private sectoris rarely tapped for family planning andmaternal and child health services and localenvironments for private sector practiceare not always favorable. Local policies formobilizing the private sector in the delivery ofpublic health still need to be developed and

regulating systems are not strong.

Based on the monitoring of 87 municipalitiesand 41 independent cities conducted bythe United States Agency for International

Aid and Development (USAID), and theUniversity of the Philippines School ofEconomics, the total amount releasedby the DOH to LGUs, as of May 15, 2009amounted to P90,131,728.94 or 60.09percent of the P150 million DOH budget


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sub-allocated to LGUs under the GAA2008 for purchase of RH commoditiesand conduct of FP seminars. Seventyseven percent of the municipalities and63 percent of the cities that have been

monitored have already accessed thefunds.28

Policy Gaps

Low government expenditures for health

In 2005, the Philippines total healthexpenditure went up by 9.4 percent, fromP165.3 billion in 2004 to P180.8 billion in 2005.

However, the share of health expenditureto GDP was lower at 3.3 percent in 2005compared to 3.4 percent in 2004. It isstill below the 5 percent standard set bythe WHO for developing countries.29TheWHO database showed total per capitaexpenditure on health in the Philippines wasat $177 from 20002004. This is relatively lowby comparison to neighboring countries likeMalaysia ($355) and Thailand ($257).30

With increasing costs of health care,aggressive marketing of social healthinsurance, and growth of HMOs, healthfinancing has become a major concernto ensure optimal mobilization of financialresources for health care. Health financingis one of the major programs under the F1Framework that aims to acquire better andsustained health investments and provideequitable services and improve health

outcomes especially for the poor.31

Lack of a comprehensive newborn healthprogram

Instead of a comprehensive newbornhealth program, various interventions areembedded in maternal or child healthprograms. The scattered efforts weaken thepotential political will and fiscal dedicationneeded for adequate implementation,

monitoring andevaluation.32All theabove factors havecreated large gapsin maternal and

newborn health. Forexample, antenatalcare is limited, withlow rates of tetanustoxoid immunizationand iron and iodinesupplementation,with virtually no folic acidsupplementation. As a result, alarge number of babies, including lowbirth weight infants, are at higher risk for

morbidity and mortality. Coupled with thisare low exclusive breastfeeding rates andpoor feeding practices contributing to highneonatal, infant, and under-five mortalityrates.

Lack of a national reproductive health law

In the Philippines, the passage of a nationallaw to address the RH care needs of

women still remains a major challenge. Thedevolution of health services, alongside thepresent administrations policy of leavingthe responsibility of providing RH services toLGUs, resulted to major disparities in accessto RH services. While some LGUs alreadyhave their own RH ordinances, there wererecorded cases of local public healthfacilities denying women of information andservices on the full range of contraceptivemethods in other LGUs.

Government promotes natural familyplanning only

The Philippine constitution has mandatedthe state to provide a comprehensive andaccessible healthcare program to everycitizen. The constitution also prohibits anydiscrimination due to religion and beliefs. Theseparation between the church and stateis mandated as well. There are many non-


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Catholics the state must also serve. The Statehas the responsibility to provide information,assistance, and access to all types of FPmethods. Thus, the government is expectedto develop policies including health

programs based on these general principles.

The government violates the constitutionwhen it promotes and emphasizes particularprograms that are discriminatory to certaingroups either because of religious or politicalbeliefs. The governments promotion of thenatural family planning (NFP) method overthe other methods available to our people isa de facto violation of our constitution in thisregard. This policy is obviously designed to

please the Roman Catholic church.

Policy Options and Recommendations:

Strengthen monitoring system at nationaland local levels

At the national level, policies and plansconcerning maternal, infant, and childmortality outcomes should be monitored,including legislation and reforms, policies,and programs that promote healthypregnancy, contraceptive services, andgender-based violence prevention. Equallyimportant are indicators of stakeholderparticipation in determining and monitoringprogress, which includes their role incommunication, organization, training,

supervision, planning,local and social

management,emergencynetworks andreferral systems,and budgetappropriations.

Nationalmonitoring

systems should,therefore, include:

- Advocating with national and localauthorities the importance of havingsystems for regular maternal, infant,and child mortality monitoring;

- Selection of indicators and

procedures, by consensus;- Design and implementation of localand national maternal, infant, andchild mortality monitoring plans; and

- Performance audits and maternal,infant, and child mortality monitoringprocesses.

Monitoring at the local level providesinformation for planning and improvinginterventions, and for building consensus

among stakeholders: service providers,policymakers, women, communityleaders, and local authorities. Localmonitoring should include indicatorsof access to quality obstetric care, aswell as socioeconomic determinantsof risk of maternal deaths, such ashealth infrastructure, institutional andsocial responsibilities, levels of localgovernment commitment, and communityparticipation.

The monitoring of maternal, infant, and childdeath is the responsibility of health workersand community members who shouldrepresent different sectors and groups (age,sex, and ethnicity) to ensure the participationof the populations most affected bymaternal, infant, and child deaths.

These stakeholders should organize

committees that provide immediateinformation and actions for interventions tolocal authorities and program managers atthe local, district, and health center levels.Monitoring committees play an importantrole in:

- Strengthening the information systemsby involving community organizations;

- Selecting priority areas forintervention;

- Strengthening administrative


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structures and resources forintervention implementation; and

- Introducing complementary methodsof analysis such as qualitativeresearch.

Increase investment for maternal and childhealth facilities and personnel

Essential to the MNCHN strategy arefacilities that can provide basic emergencyobstetric and neonatal care (BEmONC).These facilities operate on a 24-hour basis,and are accessible within 30 minutes oftravel, equipped with communication andtransportation systems for referrals. Every

BEmONC facility should have a physician,nurse, and midwife. Also essential to theMNCHN strategy are the comprehensiveemergency obstetric and neonatal care(CEmONC) facilities which are accessiblewithin one hour travel time, operationalon a 24-hour basis, and capable to carryout emergency responses. A CEmONCfacility should be staffed with at leastone obstetrician/surgeon, pediatrician,anesthesiologist, six nurses, medicaltechnologist, and six midwives.33

Part of the additional investment needed toreach MDGs 4 and 5 should be allocatedto recruit, train, equip, and deploy morehealth workers. Targets should be set forexpanding the number of trained andproperly equipped health workers in thecountry, particularly to meet the needsof the poorest and most marginalized

communities.

On midwives, nurses and doctors:- Upgrade skills of midwives, nurses and

doctors for BEONC, BEmONC andCEmONC

- Mandates for midwives- Develop as team of professionals- Midwives at basic level- Midwives, nurses and doctors at

BEmONC and CEmONC

On TBAs andcommunity healthworkers:

- Definingroles and

incentivesin womenshealth team

- Training TBAsas professionalmidwives

- Regulating TBApractices

The World Bank estimated that a total ofthree US dollars per person a year can

provide basic family planning, maternal,and neonatal health care to women indeveloping countries.34The services wouldinclude:

- Routine maternal care for allpregnancies, including a skilledattendant (midwife or doctor) at birth;

- Medical training for traditional birthingattendants might be one way to helpprovide this service;

- Emergency treatment ofcomplications during pregnancy,delivery, and after birth;

- Postpartum family planning and basicneonatal care;

- Educating women and theircommunities about the importance ofmaternal health care, and accordingwomen the social status to makehealth care decisions and seekmedical attention;

- Any form of education, even 6 yearsworth of education for girls candrastically improve overall maternalhealth;35

- Research on social and psychologicalfactors affecting maternal health; and

- Development of better interventions(and evaluations of interventions) forcomplex problems (e.g., behavioral,social, biological, cultural) arising inmarginalized communities.


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Expand PhilHealths enrollment coverage

The NHIP should be further strengthenedby expanding enrollment coverage,improving benefits and leveraging

payments on quality of care. As the leadimplementer of the health financing reformcomponent, PhilHealth

needs to recognize thatchanges in enrollment,

benefits, and providerpayments need to bewell orchestrated tobecome effective.Moreover, PhilHealthhas to recognize that

it operates in localmarkets and would

have to continueengaging partners at

that level.

Involve health care professionalsand their organizations

Health care professionals and theirorganizations have central roles to playin the partnership for promoting MNCHN.These organizations represent highly trainedprofessionals (physicians, nurses, midwives,and pharmacists) with the following rules:

- They serve in all sectors: public,private, and non-governmental;

- They provide informed leadership inMNCHN, and constitute the core ofhealth care for mothers, newborns,and children at national and local

levels;- They also have vital roles to play in theeducation and training of all levels ofhealth care personnel.

Stronger involvement of males in MNCHNissues and services

Although Filipino men become visiblein MNCHN issues, their roles often areperipheral. MNCHN advocates should

seek the activeinvolvement ofmen in findingsolutions tothe following

problems inthe country:(a) endinggenderinequities;(b) promotingadequate childspacing intervals;and (c) reducing thelevels of teenage pregnancy.

Promote public-private partnerships

In an increasingly business-driven healthcare environment, public health advocatesface the major challenge of how tointegrate health programs with population-based social, economic, psychosocial,and environmental services. To integratethese services, MNCHN advocates shouldemphasize the role of public-privatepartnerships at local, national, andinternational levels in addressing MNCHNissues. The ultimate goal of the partnershipis to harness scarce public and privateresources and to coordinate the use of suchresources to meet the needs of MNCHNclients.36A public-private partnershipcan only be considered a success if itleads to measurable improvements inthe health status of defined MCNCHNtarget populations. NGOs, multinational

corporations, professional associations,and community-based organizations willbecome essential participants in thesepartnerships.

Pass a national reproductive health law

Couples have the right to information andaccess to the right contraceptive methodat the right time and at the right place.Furthermore, it is estimated that there are


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3.1 million pregnancies in the Philippinesevery year, half of which are unplanned,with one third ending in abortions. Thepassage of a RH national law seeks tobring down cases of maternal deaths by

allowing better access to services on RHand FP, making FP commodities affordable,and providing information and educationto women and couples on pregnancyand family planning. Strategies to reducehigh levels of newborn mortality should belinked to policies and strategies in relatedfields, such as reproductive health, safemotherhood, child survival, and earlychildhood development, and incorporatedin national health plans.

Conclusion

The health of women and their newbornsand children are inextricably entwined.Neonatal deaths are frequently the resultof poor maternal health, inadequatecare during pregnancy, inappropriatemanagement of complications duringpregnancy and delivery, poor hygieneduring delivery and the first critical hoursafter birth, and lack of newborn care.Several factors such as womens statusin society, their nutritional status at thetime of conception, early childbearing,frequent and closely spaced pregnancies,and harmful practices are deeply rootedin the cultural fabric of societies andinteract in ways that are not always clearlyunderstood.37

Government must be committed tosupport health programs of health-systemadministration at the national and locallevels. Reductions in maternal, newborn,and child mortality are needed at the LGUlevel to achieve the ambitious MDG ofreducing maternal and child mortality bythree quarters and two-thirds, respectively,by 2015.

The issue of thesustainability ofexisting MNCHNprogramcommitments must

also be addressed.Enshrining nationalcommitments ina legal frameworkcan provide thenecessary continuity insupport of scaling up thecontinuum of care beyondthe political lifespan of its initialchampions. Development of maternal,newborn, and child health approaches

should take place within a national policyframework (e.g. through a reproductivehealth law). This longer-term politicalagenda requires partnerships betweengovernment, civil society organizations, anddevelopment agencies to maintain thepolitical momentum, overcome resistanceto change, and mobilize resources. A wellfunctioning health system also requiresaccountability mechanisms and checksand balances. Finally, sustained investmentin both time and resources is requiredover many years to steadily take MNCHNprograms to scale.


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Endnotes1

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Darroch JE, Singh S, Bal H, Cabigon JV, Meeting womens

contraceptive needs in the Philippines, Issues in Brief, Alan

Guttmacher Institute 2009;1:1-8.

United Nations Childrens Fund. The State of the Worlds

Children 2009, New York: UNICEF, December 2008.UN urges DoH to probe why 11 mothers die due to pregnancy

or childbirth, UNICEF Philippines, 11 May 2009. Available at

http://www.unicef.org/philippines/8891_10641.html;

Senate of the Philippines, Accelerate efforts on maternaland newborn deaths prevention thru research Angara,

23 February 2009. Available at http://www.senate.gov.

ph/press_release/2009/0223_angara1.asp.

Anne Tinker et al., A Continuum of Care to Save NewbornLives, The Lancet Neonatal Survival Series, No. 3 (March 2005).Anne Tinker, Safe Motherhood is a Vital Social and EconomicInvestment (paper delivered at Technical Consultation on

Safe Motherhood, Colombo, Sri Lanka, Oct. 18-23, 1997).

National Statistics Office (Philippines), 2008 NationalDemographic and Health Survey, Preliminary Report.

http://www.census.gov.ph/data/pressrelease/2007/

pr0718tx.html.http://www.census.gov.ph/data/pressrelease/2009/

pr0930tx.html.Food and Nutrition Research Institute, 6th National NutritionSurvey Results. Available at http://www.fnri.dost.gov.ph/files/fnri%20files/nns/6thnns.pdf.

International Monetary Fund (IMF), Organization for EconomicCo-operation and Development (OECD), United Nations (UN)and World Bank Group (WBG), 2000 A Better World for All:

Progress towards the International Development Goals (2000).The Partnership for Maternal, Newborn, and Child Health

(PMNCH) website, http://www.pmnch.org/..

The Partnership for Maternal, Newborn, and Child Health, New Global Consensus on maternal, Newborn and Child Health to save

10 million lives, 23 September 2009 Available at http://www.familycareintl.org/UserFiles/File/PMNCH_pressrelease_final.pdf.Ibid.1987 Constitution of the Republic of the Philippines.

The Local Government Code of the Philippines (Republic ActNo. 7160).

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25

26

27

28

29

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31

32

33

34

35

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http://home.doh.gov.ph/ao/ao2008-0029.pdf

http://www.doh.gov.ph/files/ao2008-0029.pdf.

http://www.doh.gov.ph/node/2423.

http://www.doh.gov.ph/node/2506;

Department of Health, National Objectives for Health2005-2010 (Manila: DOH, 2005).

Akukwe C., Maternal and child health services in the twe

century: critical issues, challenges, and opportunities, Health Ca

Women International, 07399332, Oct/Nov2000, Vol. 21, IIbid.

http://www2.doh.gov.ph/f1primer/F1-Page.htm#pg6a;

Wardlaw T and Maine D, Process indicators for materna

mortality programmes, in Reproductive Health Matters.Safe Motherhood Initiatives: Critical Issues, Oxford:

Blackwell, 1999:24-30.

Darroch JE, Singh S, Bal H, Cabigon JV, Meeting women

contraceptive needs in the Philippines, Issues in Brief, A

Guttmacher Institute 2009;1:1-8..Department of the Interior and Local Government (DILG)

website, http://www.dilg.gov.ph.

Libo-on, D. Family planning budget for 2007 and 2008:What has happened? Research paper submitted and to b

published by PLCPD. (May 2009).

World Health Organization, The World Health Report

2006: working together for health (Geneva: WHO, 2006)World Health Organization,, National Health Accounts,

World Health Statistics, 2006.

http://www.doh.gov.ph/fourmulaone/primer.

Basics Support for Institutionalizing Child Survival Projec

(BASICSII), Newborn Health in the Philippines: A Situation Analy

published by the BASICS II for the United States Agency

International Development: Arlington, Virginia, June 2004Ibid.

http://www.globalhealth.org/view_top.php3?id=225.

UNICEF website, http://www.unicef.org/;

Akukwe, C. The growing influence of non government organizain international health: Challenges and opportunities. JourRoyalSociety of Health, 1998, 118, 107-115.

Neonatal and Perinatal Mortality: Country, Regional andGlobal Estimates, WHO 2006.

PEOPLE COUNTPLCPD POLICY BRIEF March 2010

A publication of the Philippine Legislators Committeeon Population and Development Foundation, Inc. (PLCPD)

with support from the United Nations Population Fund (UNFPA).

2/F AVECSS Building, #90 Kamias Road. cor. K-J Street, East Kamias, Quezon City, 1102

Tel. nos.: (+632)925-1800 (+632)436-2373E-mail: [email protected]: http://www.plcpd.org.ph

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