Executive Summary

The Bulacan Province-wide Investment Plan for Health (PIPH), was formulated by the different local health units, LGU officials and key health personnel of the Provincial Government of Bulacan [PGB]. The PIPH embodied the PGB’s 5-year investment and commitment to promote the general well being and health of all its constituents, particularly the poor and marginalized, by ensuring accessibility, affordability and availability of quality health care services that will lead constituents and their families into productive, self-reliant and self-managing communities.

Under the Fourmula 1(F1) framework, the PIPH will be the key tool in establishing multi-sectoral partnership leading to better health outcomes, more responsive health systems, and more equitable health care financing leading to client satisfaction. The PIPH also seeks to contribute towards the achievement of the Philippine Government’s Millennium Development Goals of reducing child mortality, improving women’s reproductive health, combating HIV/AIDS/STD/STI, malaria and other preventable diseases, and in ensuring environmental sustainability for generations to come. The PIPH will serve as a channel in the implementation of much-needed health reforms in the various levels of governance.

Under the guidance and supervision of the PHO, with the assistance of the DOH CHD 3, various assessment and planning workshops, or Municipal/City Investment Plan for Health, were conducted with the different LGUs in the four [4] congressional districts of the province. LGU participants were composed of the Sangguniang Bayan Committee on Health chairperson, Municipal/City Health Officer [MHO/CHO], Municipal/City Budget Officer [M/CBO], Municipal/City Planning and Development Coordinator [M/CPDO], Public Health Nurse [PHN], Rural Health Midwife [RHM], and Barangay Health Worker [BHW]. Senior officers and staff from the PHO, CHD 3 and HealthGov facilitated these activities.

Various workshops were also conducted at the level of the province. Workshops were attended by the members of the Sangguniang Panlalawigan Committee on Health, Department Heads of the Provincial Government, namely the Provincial Administrator, the Provincial Treasurer, the Provincial Budget Officer, the Provincial Planning and Development Officer [PPDO] as well as the different Chiefs of Hospital/Hospital Administrators. NGO partners implementing health programs and projects in the province were also invited. In the workshops, LGU participants identified and analyzed the gaps in health service delivery performance using the F1/HSR framework. The participants utilized the results of the previously conducted SDIR that became very useful in coming up with a sound situational analysis. Taking into consideration the list of programs, projects and activities [PPA] that the DOH provided, the participants zeroed in on identifying the critical interventions and its corresponding cost and sources of funds. A financial plan for each municipality on how to generate and mobilize resources was drafted by the participants.

Chapter 1 of the PIPH briefly introduces the processes involved in the crafting of the PIPH. Chapter 2 is a concise description of the Province of Bulacan, its historical and cultural

beginnings, the physical characteristics of the province, basic data on the political administrative divisions, demography, infrastructure and utilities. Chapter 3 and Chapter 4 describe in detail the health situation in the province and the performance gaps and deficiencies in the public health sector viz-a-viz the different health programs being delivered, to wit: Disease-Free Zone Initiatives, Intensified Disease Prevention and Control, Emerging and Re-emerging Infection Prevention and Control Services, Child Health, Maternal Health, Healthy Lifestyles and Management of Health Risks, Surveillance and Epidemic Management Systems, Disaster Preparedness and Response System, Health Promotions and Advocacy, and Health Facilities Development Program. The remaining three [3] pillars of Health Regulation, Financing and Governance were also discussed showing the need for a proactive regulatory environment for health and health-related services, more investments to health and more responsive governance structures and systems for health delivery.

Chapter 5 discusses the overall health strategies and interventions to be implemented to respond to the performance gaps and deficiencies discussed in detail in Chapters 3 and 4. For the plan period covering 2010-2013, the Provincial Government of Bulacan shall pursue the strategies of increasing public and private investments for health programs and projects, strengthening local health systems to deliver quality health care services, improving the quality and quantity of its health service providers, intensification of health promotion activities leading to good health-seeking behavior, and increased collaboration and partnership with the private health sector.

Strategies and interventions for the different PPAs are further fleshed out in Chapter 6 describing the critical targets, detailed activities and outcomes. Chapter 7 discusses the critical investments needed for the implementation of the 5-year PIPH. The total cost of investments from 2009 to 2013 amounts to Php 2,926,054,176. This is the projected amount of investments that the Province of Bulacan has generate in order to achieve the public health sector goals of better health outcomes, more responsive health system and equitable health care financing. Of the full amount of investments allotted, 1% shall be spent for the implementation of disease free zone initiatives, 2% for intensified disease control programs, 41% for management of child health, 3% for maternal health, 17% for healthy lifestyle and management of health risks, <1% for strengthening the surveillance and epidemic management system, 1% for disaster management and 2% for health promotion. A big chunk of the budget shall be devoted to health facilities development to include facility upgrading for hospital and public health services with 31% of the total cost of investments. Health regulation, governance and financing have 1% each.

Chapter 8 shows the sources of financing and financing timetable is discussed in Chapter 9. Chapter 10 discusses the overall structure for the management and implementation of the PIPH.

C hap te r 1 :I n t r oduc t i on

The Provincial Government of Bulacan [PGB] aims to promote the general well being and health of all its constituents, particularly the poor and marginalized, by ensuring accessibility, affordability and availability of quality health care services that will lead and individuals and their families into productive, self-reliant and self-managing communities.

To attain better health outcomes, the PGB shall undertake critical strategic thrusts focusing on increasing investments to public health programs and projects, ensuring quality service and accessibility of health care facilities, expanding PHIC’s coverage for indigent families and the non-poor, among others.

The PGB commits itself to the Health Sector Reform Agenda of the Government of the Philippines and adheres to FourMula One as a framework in improving the delivery of health services with focus on strengthening health-related systems, financing, regulation and governance.

Under the F1 framework, the Provincial Investment Plan for Health [PIPH] shall be the key tool in establishing multi-sectoral partnership leading to better health outcomes, more responsive health systems and client satisfaction. The PIPH shall serve as a channel in the implementation of much-needed health reforms in the various levels of governance.

The Making of the PIPH

While health program assessments were done every semester by the PHO and at the ground level and remedial measures taken to fill in the gaps and deficiencies in health service delivery, problems still persist. Taking into account the service delivery implementation review (SDIR), the series of commodity service delivery (CSR+) assessment, review and consolidation spearhead by PHO with the assistance of HealthGov and other cooperating agencies of USAID have become an eye opener to health leaders that despite efforts on improving health status in the province, gaps still prevail in the implementation of the programs and as well as to the level of frontline implementors. It is in this context that Gov. Jonjon Mendoza directed the PHO to initiate a comprehensive review of the province’s public health sector performance vis-à-vis client satisfaction, capacity of health care providers, areas that need critical investments among others that will lead to better health outcomes, with the technical assistance package of the HealthGov and other partners.

A separate consultative-meeting was conducted by the PGB with the LCEs to discuss the need for a strategic investment plan for health for the province. Past assessment results of the Service Delivery Implementation Review conducted by the public health sector were presented showing the high and low performances of each municipality in various priority public health programs.

The PGB pointed out the importance of crafting a comprehensive plan outlining the critical investments to accelerate service delivery performance and achieve the desired health outcomes for better quality of life. Under the leadership of Gov. Mendoza, the different municipal and city mayors agreed and concurred on the need to undertake comprehensive review of health program implementation at the ground.

Under the guidance and supervision of the PHO, with the assistance of the DOH CHD 3, various assessment and planning workshops, or Municipal/City Investment Plan for Health, were conducted with the different LGUs in the four [4] congressional districts of the province. LGU participants were composed of the Sangguniang Bayan on Health, Municipal/City Health Officer [MHO/CHO], Municipal Budget Officer [M/CBO], Municipal/City Planning and Development Coordinator [M/CPDO], Public Health Nurse [PHN], Rural Health Midwife [RHM], and Barangay Health Worker [BHW]. Senior officers and staff from the PHO, CHD 3 and HealthGov facilitated these activities.

Various workshops were also conducted at the level of the province. Workshops were attended by the Sangguniang Panlalawigan for Health, Department Heads of the Provincial Government, namely the Provincial Administrator, the Provincial Treasurer, the Provincial Budget Officer, the Provincial Planning and Development Officer [PPDO] as well as the different Chiefs of Hospital and their Hospital Administrators. NGO partners implementing health programs and projects in the province were also invited. In the workshops, LGU participants identified and analyzed the gaps in health service delivery performance using the F1/HSR framework. The participants utilized the results of the previously conducted SDIR that became very useful in coming up with a sound situational analysis. Taking into consideration the list of programs, projects and activities [PPA] that the DOH provided, the participants zeroed in on identifying the critical interventions and its corresponding cost and sources of funds. A financial plan for each municipality on how to generate and mobilize resources was drafted by the participants.

The following months were devoted to the writing and packaging of the MIPH plan document. To assist the municipalities in the write-up, the Provincial Health Office with the assistance of the DOH CHD 3 and other cooperating agencies conducted writeshop seminars. The PHO walked-through the participants on the major parts of the plan document, utilizing the annotated outline suggested by the technical assistance providers. After the workshops, the LGUs were able to formulate and develop their draft Municipal Investment Plan for Health and submitted them to the Provincial Health Office for review, assessment, integration and consolidation. The different department heads likewise coordinated for the development of the plan together with the technical assistance from CHD and HealthGov in order to come-up with the Provincial Investment Plan for Health for the province of Bulacan.

The PIPH still will undergo further appraisal by CHD, approval from the local chief executives and legislative councils, by the PGB, prior to submission to DOH for the Joint Appraisal Committee [JAC] Review.

C hap te r 2 :T he P rov ince o f B u l acan

One tradition says that Bulacan came from the word “bulak” or cotton. More than two hundred years ago before the coming of the Spaniards, Chinese merchants documented the planting of cotton in the province. Cotton fibers were woven into clothing materials by primitive looms. Another interpretation says the name Bulacan originated from “burak”, the clay used for pottery found along the Calumpit riverbanks. Shards from several archeological diggings revealed that pottery making in Bulacan existed as far as the Neolithic Age.

Twelfth-century Chinese documents already marveled at the bounty with which nature blessed Bulacan. Early friar chroniclers were so enamored by the abundance of the province’s flora that they described it as the “Garden of Luzon”. A mountain range nurtures its forests thick with hardwood, Rivers fertilize abundant fields famous for producing rice, sugarcane, melons, okra, bananas and papayas. Manila Bay meets her waterways to produce brackish waters necessary for fishponds producing milkfish, prawns, beds of oysters and crabs.

Bulacan prides itself for its strategic location of being almost equidistant with the northern and southern parts of Luzon. At the same time, it is adjacent to the highly urbanized National Capital Region (NCR) or Metro Manila thus earning the moniker of “northern gateway to Manila”.

It is in Bulacan where the national trunk line road, Philippine-Japan Friendship Highway, forks in the Cagayan Valley Region in the northeast and towards the rest of North Luzon in the north and northwest. Such accessibility is a key factor that prompted private investors to develop several industrial estates in the province. It has also become an important link between the large and consolidated consumer market in Manila and the resource-rich provinces of North Luzon.

Bulacan prides itself for its rich historical heritage. In 1899, the historic Barasoain Church in Malolos City is the birthplace of the First Constitutional Democracy in Asia. Bulacan is also the cradle of the nation's noble heroes, of great men and women; among them: Marcelo H. del Pilar—"The Great Propagandist," and General Gregorio del Pilar"—The Hero of Tirad Pass."

Bulacan is also home to many of the country's greatest artists, with a good number elevated as National Artists; among them: the legendary poet Francisco "Baltazar" Balagtas, the musician Nicanor Abelardo, and the nationalist sculptor Guillermo Tolentino.

Today, Bulacan is among the most progressive provinces in the Philippines. Its people—the Bulakeño [or Bulakenyo]—are highly educated, enterprising and industrious.

Bulacan is well-known for the following industries: Marble and Marbleized Limestone, Jewelry, Pyrotechnics, Leather, Aquaculture, Meat and Meat Products [poultry and swine], Garments, Furniture, High-Value Crops, and Sweets and Native Delicacies, and a wide variety of high-quality native products.

Dubbed as the "Northern Gateway from Manila," Bulacan is indeed an ideal investment destination owing largely to the following factors: Strategic Location; Highly Productive Human Resources; Abundant Natural Resources; Well-Developed Infrastructure Support; Reasonable Cost for Doing Business; Effective Government and Private Sector Partnership for Investments; Favorable Peace and Order Situation; and Attractive Investments Incentives.

Bulacan has fast become an ideal tourist destination, owing to its vital role in Philippine history, and its rich heritage in culture and the arts. The province is popularly known for its historical sites; nostalgic old houses and churches; idyllic ecological attractions; religious attractions; colorful and enchanting festivals; swimming and various themed attractions; and a wide selection of elegant native crafts and sumptuous delicacies. It is also home to numerous resorts, hotels, restaurants, and other recreational facilities.

Physical Environment

The province of Bulacan like the rest of Central Luzon or Region 3 provinces, falls under Type 1 climate, i.e., two pronounced seasons; generally dry from December to April and wet from May to November. The main atmospheric systems controlling rainfall in the area are the southwest monsoon from June to September and northeast monsoon from December to February. The Inter-Tropical Convergence Zone (ITCZ) and Local Thermal Convection also contribute significantly to the total annual rainfall especially during summer. Heavy rainfall is usually experienced during the months of July, August and September. Relative humidity averages about 27.58%, which indicates dry air conditions throughout the year. The province has three ecosystems, coastal, lowland and upland.

The agricultural area consists of ninety-four thousand one and 25/100 hectares (94,001.24 has.) or 35.81% of the total land area while the grassland area consists of fifty-nine thousand three hundred twenty five hectares (59,325 has.) or 22.60% of the total land area. This shows that the province is mostly suitable for agriculture may it be mixed farming, diversified crops, irrigated rice paddy and agro-forestry.

Forestland composed of seventy-four thousand two hundred eighty seven and 50/100 hectares (74,287.50 has.) or 28.30% of the entire province. The built-up area consists of fourteen thousand six hundred forty seven and 50/100 hectares (14,647.50) or 5.58% of the total land area. It is made up of residential, commercial, institutional, industrial and open space. Fishpond area composed of sixteen thousand nine hundred eighty three and 75/100 hectares (16,983.75 has.) or 6.47% of the province while the body of water consists of three thousand two hundred fifty five hectares or 1.24 percent of the province.

The province’s total land area indicates that its topography ranges from level to rugged terrain. The western portion of Bulacan for instance has been classified in the Landscape Map as belonging to the lowland category with an approximate coverage of close to 50% of the provincial land area. On the other hand, the eastern part of the province covers those areas that are hilly to mountainous. This is where the province interfaces with the southeastern part of Luzon. In the middle of these two major landforms are the piedmont landscapes, which have elevation of about 50-100 meters above sea level (masl). A little over one half of Bulacan’s overall land area have been classified as having slope less than 8% or those considered as having level to gently sloping terrain and this is found on the western part of Bulacan.

Administrative/Political Boundaries

Bulacan has four congressional districts and 21 municipalities and 3 component cities with an aggregate of 569 barangays. Bulacan has a total land area of 262,500 hectares or roughly 14% of the total area of Central Luzon. The total land area is unevenly distributed among the 24 municipalities/cities where Doña Remedios Trinidad is considered as the biggest municipality having a total land area of about 93,298 hectares or almost 36% of the provincial land total while Obando has the smallest area with only 1,458 hectares or 0.56% of the entire province.

Congressional Districts BarangaysLand Area

Hectares %First DistrictBulacan, Calumpit, Hagonoy, Malolos City, Paombong and Pulilan

153 39,092 14.89

Second DistrictBalagtas, Baliuag, Bocaue, Bustos, Guiguinto, Pandi and Plaridel

124 23,974 9.13

Third DistrictAngat, Doña Remedios Trinidad, San Ildefonso, San Miguel and San Rafael

155 168,535 64.21

Fourth DistrictMarilao, Meycauayan City, Obando, San Jose Del Monte City and Santa Maria

136 30,899 11.77

Demography

Bulacan holds the distinction of being the fastest growing province in the region. During the 1990-1995 period, Bulacan’s population grew by 3.46% annually, much higher as compared to the region’s coverage of about 2.27% per year. Although this figure is much lower than what the province had in 1990, it is still too high as compared to national and/or Asian standards. At present, Bulacan’s total population is about 2,234,088 [2007 Bulacan Socio-Economic Profile, 2nd Edition]. This is 11% higher than the projected population of the province in the 1995 census. The population growth rate increased to 4.98% by year 2000. The continued increase in the province population in the past 15 years may not be attributed to natural increase. It is more a result of the influx of migrants from various points of origin as several relocation sites were opened in the municipalities adjacent to Metro Manila. In addition, Bulacan has become a receiver of population from the northern provinces. If the trend will continue in the next six years, Bulacan is expected to have a total a larger population.

In 2000, the province had an average of 850.00 persons per square kilometer (ppskm). This is more or less 25% higher than 1995 figure of 679.79 ppskm. Two factors have contributed to the increasing pressure of development on the province, namely its proximity to Metro Manila makes it a prime target for urban development and secondly, its being a major urban center.

Infrastructure Facilities and Utilities

Roads and Transportation. Based on the road map of the province it can be seen that inter-provincial travel is adequately provided by a network of about 313 kilometers of national roads such as the North Luzon Expressway (NLE), Manila North Road (MNR) and the Phililippine-Japan Friendship Highway.

Complementing this are: (1) the availability of transport services provided by several bus companies with terminals in six municipalities; (2) 352 kilometers of provincial roads; (3) availability of inter-town transport services provided by jeepneys; and (4) availability of tricycles for intra-municipality travel.

Considering road density and number of registered vehicles in the province, its indicators of 1.06 km. per sg.km. of land is better compared to standards. However it can be observed that the intra-province travel time has become unnecessarily long primarily because of the following factors: (a) big volume of traffic; (b) capacities of existing major roads have been overtaken by increases in traffic volume especially along the MNR and of the NLE.

It may be advanced that road-related issues are localized. Another example is the road network condition in the northeastern section of the province. Compounding the low road density is the unpaved conditions of a considerable length of roads in the area. This may have caused the slow pace of development in agriculture production areas and tourism sites.

The ongoing project on the revitalization of the North Rail railways system is welcome relief to improve traffic loads of the province’s road network. Once operational, there will be a considerable reduction of traffic volume on the province’s major roads. The downside, however, is the need to improve intra-municipality mobility.

Water transport has not been given emphasis in the province. Its proximity to the Manila Port System may have contributed to a focus on developing a fish port system in the province’s five coastal municipalities.

Utilities. Provision of utilities in the province is presently adequate. Twenty-one (21) water districts and seventeen (17) rural waterworks associations are providing water requirements for a majority of households in the province. About 7,412 unserved by water districts, especially those in rural areas were provided with potable water through the provincial government’s Rural Waterworks and Sanitation Program. However, more rural households can be served should water from Angat Dam be made available for local use.

The Manila Electric Company (MERALCO) provides electricity to about 99% of all households in the province. Only the municipality of Doña Remedios Trinidad has very low electricity coverage.

The province is fortunate to host the Angat Hydroelectric Plant operated by the National Power Corporation (NAPOCOR). Using water from Angat River, this power plant has a generating capacity of 228 megawatts. The power is fed into the Luzon grid.

Five major service carriers throughout the province adequately provide telecommunications. Twenty-three (23) out of 24 municipalities have been provided with a total of 78,264 telephone lines as of the end of 2000. In addition, all commercial telecommunication companies are operating cellular sites in the province.

Labor Force and Employment

The Province of Bulacan recorded the highest employment figure in the region for the period of five years. In 1995, Bulacan had 668,755 employed who are engaged in various income generating activities. As compared with its 1990 employment scenario, the province in 1995 grew by 41% also the highest percentage increase among the six provinces of Central Luzon. Based on the National Statistics projection, by the year 2007, Bulacan will almost double its employment figure to 1,315,978 or an increase of 647,223. The provinces of Bataan and Nueva Ecija would follow it, as their employment figure would increase by 88% and 87%, respectively, in the next ten years. 2007 socio economic data shows that employment rate is pegged at 92.2%, which are 3.64% higher than that of the region and 2.71 higher than that of the country.

The province’s total working age population was estimated at 1,315,000. With a labor participation rate of 64.7 percent, the total labor force was pegged at 844,335 in 2000. Employment rate of the province registered at 92.2 percent.

The service sector has been accommodating most of the increase in the labor force. At present, the service sector accounted for 57 percent or 440,000 of the labor force. This trend in the service sector stems from the fact that the province has been recipient of hundreds of thousands of migrants from various parts of the country. Although this poses a major issue, but to the business sector this kind of situation represents business opportunities.

The manufacturing sector also plays a vital role in the overall economy of the province. It is the second leading economic activity registering some 238,000 individuals with employment in the various sub-sectors of this particular activity. This number represents at least 30 percent of the total employment in Bulacan for 2000 making it the second leading sector in providing employment opportunities to Bulakeños.

Agriculture is the third leading sector in terms of the total number of employed individuals. In 2000, this sector posted a total employment of 101,000 or 13% of the total employment in Bulacan.

C hap te r 3 :Hea l th S i tua t i on

The Bulacan Provincial Health Office under the Provincial Government of Bulacan is mandated to deliver affordable, accessible health services to the constituents of the province of Bulacan irregardless of race and religion giving priority to its less fortunate residents. In a devolved environment and as a result of the re-organization of the provincial government, health service falls into two [2] service components, the Hospital Services and the Public Health Service.

The Hospital Services is tasked to provide diagnostic, therapeutic, rehabilitation and health promotion. The province runs six [6] district hospitals to include a specialty hospital catering to pregnant mothers and children and the Bulacan Medical Center formerly the Bulacan Provincial Hospital. There are two [2] community hospitals under the management of the Norzagaray and Bustos LGUs. Provincial government hospitals operate with a total authorized bed capacity of 295 beds.

It was the decision of the Bulacan provincial government to separate the Hospital Services from the Public Health Service whose goal is the promotion, prevention, early detection and treatment and rehabilitation of preventable diseases. In line with the thrusts of the National Government, it is tasked to implement the National Tuberculosis Program, Expanded Program of Immunization, Nutrition Program, Family Planning, Population Management Program, Healthy Lifestyle, Integrated Maternal and Child Health, Control of Acute Respiratory Infection, HIV/AIDS/STD/STI Control, Environmental Health and Sanitation, Malaria Control Program, Dengue Control Program, Leprosy Control Program, Primary Health Care, Dental Health Program, Disability Health Program, Mental Health, Sentrong Sigla Movement, Provincial Epidemiology and Surveillance, and Field Health Service Information System.

Bulacan has a total projected population of 2,921,947 in 2008 with total estimated households of 660,237 and an average household size of 4. San Jose Del Monte City has the biggest in terms of population while Doña Remedios Trinidad has the smallest.

A total of 64,551 births were recorded in 2008, giving the province a crude birth rate of 22.09 per 1,000 population. In the same year, 10,904 deaths were reported, resulting to a crude death rate of 3.73 per 1,000 population. There were 305 infant deaths and 7 child deaths, with infant and child mortality rates of 4.72 and 0.11 per 1,000 live births, respectively. The maternal mortality ratio is 7.43 per 10,000 live births, with a total number of deaths of 48. All these deaths [infant, neonatal and maternal] are low compared to the national standards [IMR: 17 deaths/1,000 live births; NMR: 10 deaths/1,000 live births; MMR: 90 deaths/100,000 live births]. Compared to the previous year of 2007, there was an increased in the neonatal and maternal deaths. [Refer to Table 1. Bulacan Vital Health Indices, 2007-2008.]

Table 1. Bulacan Vital Health Indices, 2007–2008Indicators 2007 Rate 2008 Rate

Population 2,826,926 2,921,974Births 66,123 23.39% 64,551 22.09%Deaths 10,283 3.64% 10,904 3.73%Infant Deaths 331 5.01% 305 4.72%Neonatal Deaths 1 0.02% 7 0.11%Maternal Deaths 34 2.25% 48 7.43%Source: FHSIS

Seven of the 10 leading causes of morbidity are communicable diseases that are preventable and easily manageable. Acute respiratory infection ranked first followed by the diseases of the heart, diarrheas, bronchitis, influenza, urinary tract infections, infected wounds, allergy/skin diseases, arthritis and pneumonias. [Refer to Table 2. Ten Leading Causes of Morbidity in Bulacan, 2008 compared to 2007 and Table 3. Ten Leading Causes of Mortality in Bulacan, 2008 compared to 2007.]

Table 2. Ten Leading Causes of Morbidity in Bulacan, 2008 compared to 2007Cause 2007 SMR* Cause 2008 SMR*

Acute Respiratory Infection 53,546 1,894 Acute Respiratory Infection 184,995 6,331Diarrheas 22,743 804 Diseases of the Heart 27,999 958Diseases of the Heart 16,413 581 Diarrheas 21,620 739Bronchitis 11,208 396 Bronchitis 14,158 484Pneumonias 10,264 363 Influenza 13,046 446Dog Bites 5,492 194 Urinary Tract Infections 12,193 417Influenza 4,065 144 Infected Wounds 10,151 347TB Respiratory 3,891 138 Allergy/Skin Diseases 7,883 269Infected Wounds 2,752 97 Arthritis 5,683 194Urinary Tract Infections 2,289 81 Pneumonias 4,983 170SMR*: Specific Morbidity Rate per 100,000 populationSource: FHSIS

Table 3. Ten Leading Causes of Mortality in Bulacan, 2008 compared to 2007Cause 2007 SMR* Cause 2008 SMR*

Heart Diseases 2,981 105.45% Heart Diseases 1,897 64.30%Cancer, all forms 987 34.91% C.V.A. 1,365 46.71%C.V.A. 901 31.87% Cancer, all forms 1,167 39.93%Pneumonias 629 22.25% Pneumonias 737 25.22%Accidents, all forms 457 16.16% Tuberculosis 369 12.62%Diabetes Mellitus 427 15.10% Diabetes Mellitus 357 12.21%Tuberculosis 367 12.98% Accidents, all forms 281 9.61%COPD 286 10.12% COPD 272 9.30%Kidney Diseases [Renal Failure] 210 7.43% Kidney Diseases [Kidney Failure] 174 5.95%Septicemia/Sepsis 125 4.42% Septicemia/Sepsis 131 4.48%

SMR*: Specific Morbidity Rate per 100,000 populationSource: FHSIS

The province is confronted with a double burden of disease, as reflected in the leading causes of mortality. Six [6] of the causes were due to healthy lifestyle (communicable) while the rest of the leading causes are communicable.

In 2008, there were 10,904 registered deaths. For the past several years, heart diseases has been the number one cause of deaths followed by cerebrovascular accident [CVA], cancer [all forms], pneumonias, tuberculosis, diabetes mellitus, accidents [all forms], chronic obstructive pulmonary disease [COPD], kidney diseases [kidney failure], and septicemia/sepsis.

HEALTH SERVICE DELIVERY

1. Disease-Free Zone Initiatives

1.A. Filariasis Elimination Services

The province is not endemic to Filariasis disease. But the possibility of transient cases are not remote due to the high volume of Visayans going to Bulacan to visit relatives. Surveillance of possible cases is still included as preventive measure. At present, there are no Filariasis cases in the province of Bulacan.

1.B. Schistosomiasis Elimination Services

Likewise, the province is not endemic to schistosomiasis. The same reason for surveillance is implemented in the province for prevention and control. There are no Schistosomiasis cases in the province of Bulacan.

1.C. Rabies Elimination Services

For 2008, Bulacan registered a total of 8,584 animal bites and six [6] cases of human rabies. San Jose del Monte City registered 3,854, Malolos City with 944, Hagonoy with 601 and Marilao with 521 animal bite cases [Table 4. Animal Bite Cases, 2008].

The province of Bulacan has established animal bite centers to initially assess and provide treatment to animal bite cases referred to PGB. These centers are located at the Bulacan Provincial Hospital in Malolos City, Sapang Palay District Hospital in San Jose del Monte City, Emilio G. Perez District Hospital in Hagonoy, Gregorio del Pilar District Hospital in Bulacan and RMMM Hospital in Santa Maria. If vaccination was needed, the centers provided the initial doses of active immunization vaccine. Human rabies cases are immediately referred to San Lazaro Hospital in Manila City.

Table 4. Animal Bite Cases, 2008

Municipality/CityStatus of Rabies Control Program

Human Rabies CasesAnimal BiteCases Seen

GivenImmunization

Angat 20 8

Balagtas 158 58

Baliuag 318 277

Bocaue 108 35

Bulacan 282 91

Bustos 85 44

Calumpit 281 94

Doña Remedios Trinidad 4 2

Guiguinto 223 86

Hagonoy 601 266

Malolos City 944 346 1

Marilao 521 290 1

Meycauayan City 21 14 1

Table 4. Animal Bite Cases, 2008

Municipality/CityStatus of Rabies Control Program

Human Rabies CasesAnimal BiteCases Seen

GivenImmunization

Norzagaray 17 6

Obando 11 10

Pandi 96 27

Paombong 129 25

Plaridel 226 80 1

Pulilan 186 66

San Ildefonso 62 24

San Jose del Monte City 3,854 1,751 1

San Miguel 271 141

San Rafael 59 24

Santa Maria 107 48 1

Total 8,584 3,813 6

Animal bite cases in the province were primarily due to the neglect of owners to vaccinate their pets with anti-rabies. Moreover, stray dogs continue to proliferate in the streets. More than twenty [20] LGUs have no mechanism to register pet dogs. Due to limited funds, there were inadequate free vaccines for anti-rabies. LGUs did not have adequate resources to impound stray dogs, making children, the youth and old alike vulnerable to dog bites.

The PHO is working hand in hand with the Provincial Agriculture Office [PAO] that has the mandate for dog immunization and has the resources for dog vaccines for immunization. Dog immunization is done by the PAO in coordination with the Municipal Agriculture Offices [MAOs]. These offices also handle health promotion in terms of responsible pet ownership at the level of the community.

LGUs lacked the resources and manpower to enforce existing ordinances on the vaccination of pet dogs in their respective areas. Also, most public health personnel were not trained on Animal Bite Treatment and Management. There was also the problem of delayed management of animal bite cases in 19 municipalities/cities where there is no dog bite center. This could have been managed if there was a strong referral system between the public health sector and the private hospitals and at the district level/inter-local health zone.

Due to the lack of knowledge of the public on rabies, poor families resorted to “tawak” for the treatment and management of rabies. The limited supply and/or expensive anti-rabies vaccines for pre- and post-exposure exacerbated this. Only when symptoms become critical that families sent the victims to the bite centers, making treatment difficult.

1.D. Leprosy Elimination Services

The WHO has set the goal of eliminating leprosy as a public health menace by year 2000, which means reducing the Leprosy Prevalence Rate [PR] to less than 1/10,000 population.

In 2008, Bulacan has registered 13 patients afflicted with leprosy located in the municipalities of Angat, Balagtas, Baliuag, Bocaue, Guiguinto, Marilao, San Miguel and

Santa Maria [refer to figure below]. With a population of 2,921,974, leprosy PR is 0.04/10,000 population. While the number of cases is considered low compared to the other provinces in Region III, there is a need to conduct active case finding in the 24 municipalities/cities. Training on leprosy detection, treatment and management needs to be provided to health workers and volunteers at the community levels for case finding. [Refer to figure below.]

The poor health seeking behavior of patients and their families, lack of awareness on the signs and symptoms of the disease and mode of transmission, social stigma associated with the disease, individual preferences for consultation and limited financial resources contributed to the prevalence of leprosy in the affected municipalities/cities of Bulacan.

Treatment for leprosy cases is at no expense on the part of the patient. Drugs and medicines for leprosy cases are provided free by the DOH and are available at the health centers for the whole duration of the treatment course.

1.E. Malaria Control Services

For several years, four [4] municipalities and one [1] city of the province are endemic to malaria. Malaria is seen in the 15 barangays in the four [4] municipalities of Doña Remedios Trinidad, San Miguel, Norzagaray, San Ildefonso and San Jose del Monte City [Table 5. Malaria Cases in Bulacan, 2008], afflicting the poor upland dwellers and settlers.

Table 5. Malaria Cases in Bulacan, 2008Municipality/City Barangay

Doña Remedios Trinidad 1. Kabayunan2. Kalawakan3. Camatching4. Sapang Bulak 5. Talbak

Norzagaray 6. San Lorenzo 7. San Mateo

San Jose del Monte City 8. Kaybanban9. Paradise III10. San Isidro 11. San Roque

San Miguel 12. Biak na Bato13. Malibay [MEPA]

Table 5. Malaria Cases in Bulacan, 2008Municipality/City Barangay

14. Sibul [MEPA]San Ildefonso 15. Barangay Akle [MEPA]

Malarious B classification refers to more than or equal to 2% slide positivity rate; medium and unstable transmission in the last five [5] years; topography that is mountainous, forested, less developed, and with forest fringes; and characterized by mobile population, with indigenous communities and poor housing conditions. MEPA refers to slide positivity rate of less than or equal to 1% or below, low and unstable transmission and better topography and population movements, socio-economic and housing conditions than malarious B category.

The Annual Parasite Incidence in 2008 is 30.7 per 100,0000 population, with 30 confirmed cases out of the 766 clinically diagnosed patients. Morbidity rate of malaria was 26.2/100,000 population. Only 96 of the confirmed and clinically diagnosed cases were given treatment due to lack of anti-malaria drugs at the RHUs. In addition, malaria control program is not devolved yet to the LGUs. [Refer to figure.]

The occurrence of malaria cases in these areas was primarily due to the lack of information of community residents and health personnel on malaria transmission, prevention and treatment. Also, upland human settlements make it difficult for patients with malaria symptoms to seek attention from medical facilities. More often than not, malaria cases are found among the indigenous peoples belonging to the Dumagat and Aeta tribes. Due to the nomadic character of these tribes, health care providers find it difficult to identify suspects, modes of transmission and control of the vector because of their mobility, culture and practices. Adding up to new malaria cases are “imported” cases from neighboring endemic provinces of Neva Ecija and Zambales. Many cases came from shipyard workers in Zambales.

There is only one [1] medical technologist, out of the five [5] endemic areas, was trained in malaria microscopy. There is a need therefore to identify, train and deploy community health workers to far–flung areas, carrying with them rapid diagnostic test [RDT] kits, collecting smear samples from asymptomatic patients.Vector control materials, e.g., mosquito bed nets and insecticides, are far from the reach of the affected communities. Most often, malaria patients are poor and rarely can afford to

purchase untreated mosquito nets, much more treat these with insecticides. Malaria control to be successful in the province must implement the twin strategy of vector control and active case detection and treatment at the local level.

Malaria drugs are provided for by the DOH through the CHD 3. Led by the Bulacan provincial government in partnership with the concerned LGUs, steps must be taken to ensure the availability of anti-malaria drugs to endemic areas through centralized procurement and distribution; promotional activities on the effective and regular use of insecticide-treated bed nets must be conducted in the endemic areas; and the continuous promotion of early diagnosis, management and referral of malaria cases.

2. Intensified Disease Prevention and Control

It has been proven that most communicable diseases can be prevented and controlled, or even eradicated successfully by appropriate strategies and technologies such as immunization, improved sanitation and personal hygiene, better nutrition, early treatment and steady supply of antibiotics made available at the community or at first level health facilities.

Improving the quality of public health work, patient care and disease surveillance, and providing adequate and efficient resource allocation are the elements required in the elimination of communicable diseases, such as the vaccine-preventable diseases, leprosy, malaria, filariasis and even tuberculosis [TB]. Parallel activities need to be aggressively pursued in the areas of disease surveillance [such as avian and swine flu virus, dengue, etc.] and health promotion.

With the deterioration of the global environment and the imminent health threats posed by global warming, the public health sector can also focus its attention and shift its limited resources towards the prevention and control of emerging diseases.

2.A Tuberculosis Control Services

For a decade, the province of Bulacan has not been spared from the debilitating disease called tuberculosis. It has remained as one of the ten [10] leading causes of mortality for the last five [5] years. Despite the rigid implementation of the National TB Control Program with the end goal of reducing mortality and morbidity due to the killer disease, TB continues to plague a sizeable segment of the provincial population. In recent years, with foreign assistance [JICA and TB Linc], effective case finding, disease management with Directly Observed Treatment Short Course [DOTS] strategy have made inroads in the prevention and control of the disease.

The control of TB, an airborne infection, is achieved mainly by rendering infectious smear-positive cases noninfectious soon after diagnosis is made and by curing as many TB cases

identified. These measures reduce disease transmission and minimize the physiological and socio-economic impact of TB on the patient, his immediate family and community.

With a population of 2,921,974 in 2008, TB ranks 5th as the leading cause of mortality and 8th as the leading cause of morbidity. Since 2000 DOTS have been fully implemented in the province’s 57 RHUs. However, provincial performance on case detection rate [CDR] is 63% against the national target of 70% and cure rate of 80% in 2007 compared to national target of 85%. [Refer to figures below.]

2008 data shows that ten [10] out of the 24 municipalities/cities have reached the national standard of CDR of 70%. They are Balagtas, Baliuag, Bocaue, Bulacan, Norzagaray, Obando, Plaridel, San Miguel, Doña Remedios Trinidad and San Jose del Monte City. While six [6] have reached the national standard of TB Cure Rate of 85%. They are Balagtas, Bulacan, Meycauayan City, Pulilan, Santa Maria and San Jose del Monte City [Table 6. Bulacan 3. Bulacan TB Case Detection Rate and Cure Rate, 2004-2008].

Table 6. Bulacan TB Case Detection Rate and Cure Rate, 2004–2008

Municipality/CityTB Case Detection Rate [CDR] TB Cure Rate

2004 2005 2006 2007 2008 2004 2005 2006 2007ANGAT 59.0% 51.0% 61.0% 55.0% 59.0% 74.0% 74.0% 54.0% 58.0%BALAGTAS 79.0% 77.0% 84.0% 83.0% 87.0% 88.0% 76.0% 79.0% 85.0%BALIUAG 96.0% 96.0% 64.0% 84.0% 71.0% 83.0% 84.0% 89.0% 73.0%BOCAUE 52.0% 58.0% 58.0% 78.0% 79.0% 57.0% 53.0% 74.0% 63.0%BULACAN 87.0% 100.0% 39.0% 81.0% 113.0% 82.0% 77.0% 73.0% 86.0%BUSTOS 81.0% 74.0% 95.0% 55.0% 52.0% 48.0% 47.0% 94.0% 84.0%

Table 6. Bulacan TB Case Detection Rate and Cure Rate, 2004–2008

Municipality/CityTB Case Detection Rate [CDR] TB Cure Rate

2004 2005 2006 2007 2008 2004 2005 2006 2007CALUMPIT 52.0% 104.0% 66.0% 65.0% 53.0% 79.0% 84.0% 49.0% 82.0%Doña Remedios Trinidad 30.0% 104.0% 100.0% 47.0% 85.0% 100.0% 84.0% 83.0% 83.0%GUIGUINTO 44.0% 102.0% 33.0% 43.0% 44.0% 75.0% 54.0% 61.0% 41.0%HAGONOY 77.0% 71.0% 76.0% 69.0% 50.0% 90.0% 100.0% 90.0% 77.0%MALOLOS CITY 69.0% 67.0% 62.0% 73.0% 69.0% 71.0% 92.0% 69.0% 70.0%MARILAO 69.0% 44.0% 36.0% 37.0% 42.0% 85.0% 88.0% 85.0% 75.0%MEYCAUYAN 38.0% 61.0% 51.0% 49.0% 53.0% 60.0% 83.0% 83.0% 91.0%NORZAGARAY 35.0% 86.0% 77.0% 79.0% 106.0% 50.0% 93.0% 80.0% 64.0%OBANDO 81.0% 58.0% 51.0% 71.0% 77.0% 96.0% 72.0% 89.0% 50.0%PANDI 78.0% 49.0% 54.0% 66.0% 49.0% 50.0% 75.0% 93.0% 73.0%PAOMBONG 68.0% 42.0% 93.0% 37.0% 69.0% 80.0% 54.0% 53.0% 61.0%PLARIDEL 76.0% 53.0% 55.0% 56.0% 73.0% 84.0% 79.0% 84.0% 74.0%PULILAN 71.0% 76.0% 52.0% 47.0% 66.0% 94.0% 91.0% 87.0% 85.0%SAN ILDEFONSO 42.0% 29.0% 48.0% 52.0% 50.0% 85.0% 78.0% 82.0% 78.0%San Jose del Monte City 84.0% 95.0% 82.0% 89.0% 75.0% 95.0% 88.0% 92.0% 90.0%SAN MIGUEL 67.0% 67.0% 57.0% 89.0% 89.0% 68.0% 66.0% 92.0% 79.0%SAN RAFAEL 60.0% 41.0% 51.0% 54.0% 27.0% 86.0% 86.0% 80.0% 67.0%Santa MARIA 37.0% 34.0% 22.0% 37.0% 21.0% 50.0% 94.0% 87.0% 94.0%Provincial Average 66.0% 68.0% 63.0% 64.0% 63.0% 76.0% 82.0% 81.0% 80.0%

Aware of the increasing cases of TB in the various municipalities and cities in the province, 21 LGUs have put in place policies for the purchase of anti-TB Category III drugs; 20 LGUs have policies on the procurement of drugs for primary complex affecting children; while 18 LGUs have detailed policy [free and user’s fee] on the distribution of anti-TB drugs.

Record from the Provincial Health Office reported that for 2008, there were 2,088 sputum+ cases, an increase of 25% from the previous year.

TB continues to afflict the poor and non-poor alike in Bulacan. Some of the causes were preference of TB symptomatic patients to seek medical help from private doctors instead of the more accessible public health system; patients did not immediately seek medical attention due to the social stigma associated with the disease; and the overall poor health-seeking behavior of affected households and communities.

In the recent TB validation, monitoring and evaluation of the TB Control program, there were still quite a number of municipalities belonging to the low quadrant meaning low CDR and low cure rate, and these has been given priority by the province in terms of prevention and control.

The municipality of Paombong has been subjected to a provincial initiative called TB Patrol. The implementation of the project has garnered 100% local support both from the municipal and barangay officials and the community as well. The impact of the project resulted to active case finding and treatment of positive cases.

While the TB Patrol program has been successful in the identification, organization, training of community members for the anti-TB program, its reach has been limited to only a

number of barangays. The project was seen as a “best practice” and is now being targeted for replication to the other LGUs in the province on a staggered basis. There is a need to expand its coverage to 555 barangays of the province.

Health care providers from the public and private health sectors still need to be trained on the WHO/DOH standards for TB detection, treatment and management; more so for newly-hired public health nurses. In Bulacan, some public hospitals still preferred to use chest x-ray in the diagnosis of TB rather than the standard and accurate sputum examination. Also, there was no standard protocol for the treatment and management of children with TB.

Though a number of capacity building activities had been conducted in TB control, much more has to be done to completely reduce the TB morbidity and mortality in the province [Table 7. Trainings in TB Control]. With the fast turnover of health workers, particularly doctors and nurses, there is an immediate need to orient and re-orient health workers in the efficient and effective implementation of the program.

Table 7. Trainings in TB Control

Category # HR LGU Basic NTP DSSM Treatment Partner FDC TB DOTS

MHO 22 22 21 13 21 24RHP 43 22 36 26 38 42PHN 68 23 61 32 64 53MT 34 39 17 20 30RHM 455 21 300 2 242 347 418BHW 434 4 54 2,594 751 1,017

A total of 40 microscopy centers are located in the main RHUs throughout the province and a quality control laboratory at the PHO. Validation of sputum slides is done by the program coordinator, in tandem with a medical technologist at the QC Laboratory in the province.

Based on the recent monitoring and validation of the TB program, it was found out that 15% of microscopy services did not comply with established standards of laboratory procedures. This puts into question sputum examination done by these laboratories. On-board medical technologists from Guiguinto, Paombong, Angat, Bocaue and Norzagaray have to undergo refresher training course on laboratory procedures and TB sputum examination. Also, sputum collection area at the RHU facilities needs to be upgraded to conform to NTP standards. This is one factor why only twelve [12] out of the 57 rural health units are TB-DOTS-accredited by the PHIC.

The constant exposure to residues by laborers within the pyrotechnics industry in the province contributed also to TB morbidity and mortality. Around 100,000 individuals are dependent on this industry. These are located in Bocaue, Santa Maria, Baliuag and neighboring municipalities; while the marble industry is located in San Ildefonso, Doña Remedios Trinidad, San Rafael, San Miguel and Norzagaray. Due to the nature of these industries, workers and communities alike are vulnerable to lung-related diseases. Government must encourage companies to provide healthy work environments for its workers.The role and practice of private physicians in the province as to TB treatment protocol need to be addressed. The incomplete [indigents/poor] and unsupervised treatment practice of TB

patients by private physicians have added up to the increase in multi-drug resistance (MDR) among TB patients in the province. Thus, one strategy to resolve this problem is a collaborative effort among private practitioners is through the Public-Private Mixed DOTS (PPMD). The municipalities of San Miguel and Hagonoy had established a PPMD referral system. The TB Diagnostics Committee [TBDC] will have to review referrals and recommend appropriate treatment management for the projected increase in the number of sputum+ patients.

2.B HIV/AIDS/STD/STI Control Services

With the highly urbanizing character of Bulacan and its proximity to a former military American base [Clark Air Field in Angeles City, Pampanga] and the National Capital Region, there is a strong trend for the commercial sex industry to proliferate in the province, particularly in Bocaue, Marilao, Pulilan, Malolos City, Baliuag, Bustos, Meycauayan City and San Jose del Monte City.

These areas are host to a large number of karaoke bars, watering holes, and assorted commercial establishments suspected of employing commercial sex workers [CSWs]. Aware of this situation and as an interim measure, the National STD Program is being vigorously implemented by the different RHUs. The STD program includes regular smearing and treatment of registered and unregistered CSWs. For 2008, total smear examined was 5,485 and 375 cases were treated for gonorrhea and other STDs/STIs.

The chart above shows the sudden increase of women with vaginal discharge from 2005 baseline. The dip in cases seen in 2007 can be due to the non-compliance of women with active sex practice to submit themselves for regular check up. The more than 600% increase in 2008 from 2005 levels was due to the increased awareness of women of their reproductive health, the increasing number of women with active sex lives, and the active campaign of health workers with women to practice good health-seeking behaviors.

However, a more comprehensive strategy and appropriate approaches need to be developed to respond to the threats posed by HIV/AIDS/STD/STI.

Target municipalities need to conduct rapid risk assessment to map out high-risk groups in their localities. There is a need to establish social hygiene clinics in strategic areas to cater

to high-risk groups such as CSWs, men having sex with men [MSM], and the growing number of drug dependents using needles, among others. Regulation in the operation of establishments catering such kind of businesses needs to reach the attention of local officials.

Also, health care providers need to be trained on HIV/AIDS/STD/STI detection, treatment and management protocols. At the provincial level, there is a need to establish a reporting and monitoring mechanism to immediately identify potential HIV/AIDS/STD/STI breakout areas.

A technical assistance package on HIV/AIDS/STD/STI prevention program is currently being supported by the national government and implemented in the province of Bulacan. One mechanism being discussed is the formation of the Bulacan HIV/AIDS Council to serve as an advisory board to the province to respond to the growing threat of HIV/AIDS/STD/STI.

2.C Dengue Control Services

Dengue fever and its more severe form, dengue hemorrhagic fever, are transmitted to humans by the day-biting female Aedes mosquito. The mosquito vectors breed in small collections of water such as open tires, cans and drums, and backyard litter. The disease afflicts all ages but most cases were among children 0-15 years old.

Table 8. Dengue Morbidity and Mortality, 2004–2008

Municipality/CityMortality Morbidity

2008 2007 2006 2005 2004 2008 2007 2006 2005 2004ANGAT 1         43 3 6 2 6BALAGTAS         27 1 37 19 6BALIUAG         62 38 62 98 15BOCAUE     1   65 18 54 58 5BULACAN     1 2 43 7 19 53 5BUSTOS         31 4 17 11 3CALUMPIT 1 1       122 30 85 42 0Doña Remedios Trinidad 1         8 2 3 6 0GUIGUINTO 2 1     32 10 103 36 3HAGONOY 1         43 51 43 25 1MALOLOS   3 1   197 45 174 89 4MARILAO 2   1     80 21 58 24 14MEYCAUAYAN   1 1   58 9 57 33 3NORZAGARAY         45 18 4 4 1OBANDO     1   4 6 5 9 2PANDI   1     36 7 44 37 2PAOMBONG         24 14 13 13 0PLARIDEL   1     108 14 59 15 0PULILAN 3   1     94 12 18 12 0SAN ILDEFONSO     2   29 18 23 165 3San Jose del Monte 1 3 1 1 206 39 69 45 46SAN MIGUEL 1   1 1   54 99 22 91 3SAN RAFAEL     1   49 26 39 158 7Santa Maria 1 1 1   88 89 51 39 7TOTAL 10 5 14 11 3 1,548 581 1065 1131 537

For the past years, dengue fever has cast its toll on the population of Bulacan, bringing death and sickness particularly to the vulnerable sectors, children of school age and poor

communities. For the past 5 years, the province had set a trend of every other year outbreak of dengue but the present conducive environment for the vector and change in the virulence of the virus has changed to a yearly problem on dengue disease. Dengue cases peak in the months of July to November and lowest during the months of February to April. For 2008, dengue cases reached 1,548 with 10 deaths. [Table 8. Dengue Morbidity and Mortality, 2004-2008.]

Dengue morbidity, with more than 100 cases in 2008, were noted in the municipalities of Calumpit and Plaridel and the cities of Malolos and San Jose del Monte. Death was usually due to late detection of signs and symptoms and late referral to hospital care making its treatment difficult at best.

Morbidity was distributed in the 24 municipalities/cities. Factors contributing to dengue prevalence in Bulacan are the following: improper waste disposal that waste materials have become breeding sites of the vector, lack of discipline of the community residents in maintaining the cleanliness of their immediate environment; weak implementation of local ordinance in support of waste management and community cleaning practices such as proper waste disposal, de-clogging of waterways and cleaning of backyards of open containers to eliminate mosquito breeding sites; and inadequate information of the community on the early symptoms of dengue.

The province had taken steps to reduce dengue morbidity and mortality. To address this problem, the province held the Dengue Summit last year, in collaboration with the different stakeholders. Highlighted in the summit was the creation of Dengue Skul Watch teams that served as extension units of the surveillance arm of RHUs. Its tasks were to locate suspected cases of dengue in schools, monitoring of absentees due to simple signs of fever and reporting to health officials for immediate mitigation measures. Parallel activities conducted were health promotion and intensified advocacy campaign in the province and LGUs.

In a collaborative effort with the Department of Education, health care providers continuously conduct information drive to elementary and secondary schools targeting children, parents and teachers. Around 50 central schools sustain the project “Sa Iskul Ligtas Ako Sa Dengue” started last June 2007. The program was launched at the Balagtas Central School, Balagtas, Bulacan. The province is on its expansion effort of increasing the organized Dengue Skul Watch teams. There is a need to increase information materials to be provided to these teams as roving health advocates.

Efforts by LGUs to fumigate known and suspected breeding sites of carrier mosquitoes can be complemented by an aggressive information campaign to increase knowledge of communities in combating dengue. The “search and destroy operations” by frontline health personnel, the barangay health workers, proved to be an effective vector control measure.

The cooperation of the different barangay LGUs is needed in the formulation and enforcement of sanitation ordinances as another vector control measure. There is a need also

to continue monitoring and conduct surveillance activities to eliminate the breeding sites and the dengue vector as well through the activation of City/Municipal Epidemiology and Surveillance Unit [MESU].

2.D Emerging and Reemerging Infection Prevention and Control Services

The province was not spared when the first A[H1N1] case was detected in a secondary school in Bulakan, Bulacan. After the disease panned out, 44 cases of A[H1N1] were recorded in the province. No death was recorded and all cases have recovered from mild influenza. Initial reactions to disease resulted to the temporary cancellation of school until the required 7 days lapsed putting a cut on the transmission of the virus.

It was also in Bulacan that the first Ebola Reston case was detected. Two [2] human cases, farm workers at the Win Piggery Farm were subjected to laboratory examinations and treatment and closely monitored by the DOH. As a confirmed source of the virus, a piggery farm terminated 6,000 heads of pigs to prevent the further spread of the disease among animals and possible transmission to human. No mortality among suspected/affected human farm workers was noted. Health personnel conducted a series of debriefing sessions among affected farm workers and their families.

Health workers in the field are constantly monitoring suspected cases. Prompt reporting and referral to higher level care facilities contributed in case and mortality control. Existing disease surveillance system established at the provincial and district hospitals as sentinel sites and 12 municipalities trained in surveillance and basic epidemiology have proven to work in instances where it is needed. The need to expand the training on basic epidemiology to the remaining 12 LGUs and newly hired health workers is an immediate concern to respond to emerging and re-emerging diseases.

The province has been pro-active in responding to health emergencies through the enactment of ordinances and/or issuances of memoranda mobilizing all levels of responses for health and health-related emergencies. The draft Provincial Plan for A[H1N1]/Bird Flu needs to be finalized in coordination with the PAO for publication, reproduction and implementation. Efforts are currently being undertaken to finalize the Bulacan referral system as guidelines for public health workers at the RHUs and hospitals in the province.

Further orientation and capacity building activities on the prevention, detection, treatment and management of these diseases need to be conducted at the level of frontline health workers. Though the Influenza A[H1N1] epidemic has panned out in the province, efforts must be exerted to train RHU personnel on sample collection and updates be regularly conducted.

A comprehensive communications plan needs to be developed for the province. The plan will include the development of promotional materials informing the public on the preventive measures people must take in cases of disease outbreaks.

2.E. Avian Influenza

While the rest of our Southeast Asian neighbors are reeling from the effects of bird flu or avian influenza, the Philippines is still avian influenza-free [bird-flu]. However the conditions that make the Philippines high risk for avian flu is present due to the following reasons. Bulacan is near the Candaba Swamp of Pampanga, considered a haven of trans-migratory birds frequenting the country. Bulacan hosts a large number of poultry farms where there are no bio-security measures in place. There is lack of public awareness about avian influenza. Emergency response and preparedness systems are weak or absent at the local levels. Another contributory factor is the limited participation of the private health sector in the management and treatment of bird flu.

The eight [8] municipalities of Calumpit, Pulilan, Paombong, Baliuag, Hagonoy, Bulacan, Plaridel, San Ildefonso and Malolos City are the most-at-risk due to its proximity to the Candaba Swamp in Pampanga. Commercial poultry farms are meanwhile concentrated in Pandi, Santa Maria, Pulilan, Baliuag and San Jose del Monte City. Due to the recurring threat of avian flu, the national government formed the National Avian Influenza Task Force to take the lead in the prevention, treatment and management of avian influenza outbreaks. The Task Force identified the province of Bulacan, one among twenty [20] critical provinces, where the Department of Agriculture’s Bureau of Animal Industry [DA–BAI] conducts bi-annual surveillance of poultry farms. In 2006, the province and the 9 at-risk areas, with assistance from the DOH, DA–BAI and USAID, formulated their AI Preparedness and Response Plan. IEC materials in support of the avian influenza awareness campaign were distributed. The P/LGU organized the Bulacan Provincial AI Task. Local plans are currently under review.

3. Child Health

Reducing infant and under-5 mortality from 5.76/1,000 LB to 2/1,000 LB by 2013 is one of the goals of the DOH under its National Objectives for Health.

Infant mortality refers to death among children less than one year old. 2008 data showed that there were 305 registered infant deaths in Bulacan or 2.80% of the overall deaths. The ten [10] leading causes of deaths under one year old are shown in Table 9 [Ten Leading Causes of Infant Mortality in Bulacan, 2007-2008]. For the past several years, pneumonia topped the leading cause of death with 90 deaths or 29.51% of total infant deaths. Prematurity ranked second with 35 deaths or 11.48%; and congenital anomalies ranked third with 26 deaths or 8.52% of total infant deaths.

Table 9. Ten Leading Causes of Infant Mortality in Bulacan, 2007–20082007 SMR* 2008 SMR*

Pneumonia 67 1.01 Pneumonia 90 1.39

Table 9. Ten Leading Causes of Infant Mortality in Bulacan, 2007–20082007 SMR* 2008 SMR*

Prematurity 44 0.66 Prematurity 35 0.54Septicemia/Sepsis 26 0.99 Congenital Anomalies 26 0.40Congenital Anomalies 16 0.24 Septicemia/Sepsis 19 0.29Congenital Heart diseases 15 0.23 ARDS 11 0.17Asphysia Neotorum 13 0.20 Congenital Health Disease 8 0.12Birth Injury 9 0.14 Asphysia Neotorum 8 0.12ARDS 6 0.09 Diarrheal Diseases 4 0.06Diarrheal Diseases 5 0.08 Birth Injury 3 0.04Birth Injury 4 0.06 Utero Placental Insuff 3 0.04*SMR: Specific Mortality Rate per 1,000 live births.Source: FHSIS

IMR measures the risk of dying during the first year of life. It is a good index of the general health condition of a community since it reflects the changes in the environmental and medical conditions of a community. A measure of a good health status is a low infant death rate. For 2008, the IMR was only 4.72/1,000 LB, which is very low compared to the national average. Norzagaray reported the highest IMR at 14.71 per thousand live births, followed closely by Angat at 14.51% and Hagonoy at 14.42%. [Refer to Table 10. Infant Mortality Rate in Bulacan, 2003-2008.]

Table 10. Infant Mortality Rate in Bulacan, 2003–2008Municipality/City 2003 2004 2005 2006 2007 2008ANGAT 9.08 8.59 16.22 10.97 11.95 14.51BALAGTAS 14.18 16.82 5.46 5.34 7.40 3.81BALIUAG 8.19 8.54 4.59 2.93 2.05 2.98BOCAUE 4.93 8.24 7.58 6.46 10.19 6.75BULACAN 10.01 10.33 11.33 10.79 7.78 11.82BUSTOS 0 0.87 2.87 2.35 1.43 1.43CALUMPIT 15.14 5.68 20.26 6.18 1.41 0.74DRT 5.25 2.14 5.04 2.48 2.31 0GUIGUINTO 4.10 1.84 3.95 1.54 9.18 6.29HAGONOY 11.84 5.21 6.32 6.45 9.17 14.42MALOLOS 4.33 5.26 7.37 9.31 3.81 4.63MARILAO 2.36 4.44 5.24 2.76 4.89 4.00MEYCAUAYAN 8.24 3.59 5.07 5.47 6.63 4.15NORZAGARAY 0 7.86 24.94 0 19.47 14.71OBANDO 9.22 11.75 5.64 5.67 25.42 6.70PANDI 7.38 7.47 6.72 3.44 1.39 2.41PAOMBONG 4.16 5.96 6.54 2.10 1.03 1.03PLARIDEL 3.25 2.66 3.13 5.30 3.21 7.28PULILAN 4.24 2.36 2.56 2.77 1.64 2.56SN ILDEFONSO 16.46 12.65 9.41 12.77 8.11 4.19SAN JOSE DM 3.21 2.58 1.29 1.69 1.85 2.38SAN MIGUEL 7.11 7.44 4.74 3.26 3.63 2.03SAN RAFAEL 7.20 8.17 3.32 8.06 0 4.40STA. MARIA 18.33 13.48 13.33 9.96 11.25 9.03Provincial Average 7.49 6.07 5.93 4.74 5.01 4.72Note: IMR = Total Deaths below 1 year / Total Births x 1000

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irths

IMR

As shown in the table and graphs above, there is steady downward trend except in year 2007 where it spiked at 5.01% and went down at 4.72% in 2008.

3.A Expanded Program on Immunization [EPI]

As signatory to the Millennium Development Goals [MDGs], the Philippines has committed the country to reduce child mortality. Through advances in science and health care, immunization has become one of the most important components in the prevention and control of communicable diseases in children. In the last three decades since the EPI started in Bulacan, immunization has saved thousands of children.

The EPI of the DOH seeks to achieve universal immunization of children against the seven [7] diseases of TB, poliomyelitis, diphtheria, pertussis, tetanus, measles and hepatitis B. A fully immunized child [FIC] is one who, before reaching his first birthday, was given one dose of BCG [against TB], three doses of DPT [against diphtheria, whooping cough and tetanus], three doses of OPV [against polio] and one dose of measles vaccine.

While immunization average has slowly improved in some areas, recently, there is wide disparity between barangays, municipalities and cities. There have been difficulties observed in the delivery of health care services to the marginalized and unreachable populace, particularly in the upland villages of Bulacan.

For this program the province of Bulacan has immunized a total of 75,325 infants. This number covers 86% of the total children needing immunization, with an unmet need of 9%. Table 11. Fully Immunized Children, 2003-2008 shows the implementation of immunization in the province covering the period 2003–2008.

Table 11. Fully Immunized Children, 2003–2008

Municipality/City 2003 2004 2005 2006 2007 2008

Angat 1,273 1,361 1,488 1,207 1,197 1,313

Balagtas 1,867 1,735 1,738 1,760 1,867 1,631

Baliuag 3,404 3,355 3,994 4,245 4,394 4,383

Bocaue 1,838 2,009 2,170 1,930 2,160 1,960

Bulacan 1,747 1,967 1,824 1,727 1,935 2,038

Bustos 1,332 1,201 1,280 1,372 1,290 1,461

Calumpit 2,059 2,118 2,248 2,246 1,942 2,326

Doña Remedios Trinidad 297 326 341 462 393 387

Guiguinto 2,022 1,988 2,332 2,082 2,135 2,488

Hagonoy 2,807 2,845 2,654 2,888 3,133 3,073

Malolos 4,928 4,976 4,971 5,038 5,041 5,128

Marilao 2,848 3,554 3,565 4,391 4,071 4,466

Meycauayan 5,434 5,910 5,565 5,588 6,424 6,005

Norzagaray 1,701 1,807 1,795 2,629 2,086 2,077

Obando 1,536 1,667 1,634 1,577 1,487 1,513

Pandi 1,406 1,485 1,208 1,728 1,690 1,500

Paombong 894 856 918 1,060 1,017 961

Plaridel 2,346 2,359 2,415 2,551 2,910 3,065

Pulilan 1,925 2,138 2,193 2,426 2,524 2,528

San Ildefonso 2,203 2,301 2,112 2,064 2,102 2,090

San Jose del Monte 9,659 11,803 13,723 16,101 15,052 13,412

San Miguel 3,490 4,316 3,752 4,133 4,415 4,659

San Rafael 1,965 1,703 1,410 1,810 1,448 1,595

Santa Maria 4,105 4,835 5,083 5,011 4,570 5,243

Provincial Average 63,086 68,615 70,569 76,026 75,283 75,486

The high coverage of the immunization program in the province was primarily due to the availability of vaccines provided by the DOH during its Garantisadong Pambata [GP] activity. However, there is a need to systematize recording and reporting of children to address universal coverage, at least 95% of all children. [Refer to figure below.]

Fully Immunized Children, 2004 - 2008 Province of Bulacan

76.0

78.0

80.0

82.0

84.0

86.0

88.0

90.0

2004 2005 2006 2007 2008

Year

Perc

enta

ge

Another positive factor is the strong technical relationship between the DOH and the LGUs that has been evident during the conduct of the specific health program mobilization. Trained and capable health program coordinators and local counterpart staff are readily available to provide the support and services whenever immediate or long-term health

actions are needed. The continuing national and local technical sharing and arrangements facilitate the establishment of a functional coordinating mechanism and delivery structure for public health programs such as immunization.

Public health care providers may conduct community assemblies, mother’s classes and house visitations to inform mothers and caregivers not only on the importance of vaccinating their children but also to encourage them on the proper child growth and rearing practices.

3.B Breastfeeding Program

The province of Bulacan has registered an accomplishment rate of 83% versus the national standard of 85% of exclusive breastfeeding up to six months after birth. This has been largely due to the ongoing information campaign on the benefits of breastfeeding. IEC materials, i.e., posters and flyers are prominently displayed at the rural health facilities.

To further attain additional coverage, video documentaries on the breastfeeding and other components of EPI can be shown during mother’s classes, community assemblies and at the RHUs/BHSs while waiting for their turn. In compliance with the Philippine Milk Code, the project “Search for the Most Baby-&-Mother Friendly Barangay” can be initiated in the province. This project aims to drumbeat the benefits of breastfeeding versus the use of baby formula.

Other activities include the organization and training of Baby-Friendly Peer Counselors. Nursing mothers-cum-facilitators/peers are identified and trained on counseling to provide the necessary support system for first-time breastfeeding mothers.

3.C Integrated Management of Childhood Illnesses [IMCI]

Pneumonia remains to be leading cause of death in children aged 0–5 for the two consecutive years of 2007 [with 67 deaths] and 2008 [with 90 deaths]. Second is prematurity with 88 deaths [44 and 35 deaths in 2007 and 2008 respectively]. High IMR is noted among infants of mothers with no/limited education, no/inadequate antenatal and delivery care.

It also point out the weaknesses in the delivery of health care services to the mother-and-child. These deaths were from the far-flung barangays of the upland municipalities of the province. The factors contributing to this situation can be a mix of the following factors: poor health-seeking behavior of the mother before, during and after pregnancy, the child and the health care provider.

For the mother: upon conception, she may have failed to have three [3] pre-natal visits to the health facility; she may have failed to take medicines and tetanus toxoid; upon delivery, she may have failed to visit the health facility for neo-natal consultation, where the newborn is given the obligatory vaccines. These factors contributed to the weakening of the mother and the child as well. Poverty and geographical constraints prevent the mother and child to

seek immediate and critical medical attention. For the health service providers: due to limited resources, far-flung barangays are not visited. Even the BHWs may have failed to visit the hard-to-reach areas of the barangays.

Diarrhea is still listed as one of the top ten [10] leading causes of morbidity among children [with 5 deaths in 2007 and 4 deaths in 2008]. The reasons identified were: poor access of families to potable water; absence of sanitary toilets at the household level; and unhygienic practices among households especially among children.

Essential activities should continue and critical logistics [i.e., cotrimoxazole tablets, reformulated oresol sachets, zinc for sick children, among others] be ensured to further decrease the incidence of infant mortality in the province. To address this problem and strengthen the capabilities of the public health workers, the 11-day “Basic Course for Frontline Health Workers” will be conducted, followed by an on site follow-up training course. This training course aims to improve referral of severely sick children from the barangay health station [BHS] to the RHU. It also aims to improve the skills of health workers in providing preventive health care services to children. More so, due to the fast turnover of health personnel there is the need to train facilitators to ensure program continuity.

3.D Nutrition Services

One critical intervention in addressing the health and nutritional needs of infants and children and improving their growth and survival is micronutrient supplementation. Through the DOH’s bi-annual Vitamin A capsules supplementation under its GP program. However, the availability of vitamin and iron supplements depends on the capability of LGUs to procure the drugs.

The province of Bulacan has taken great strides in improving the nutritional status of its pre-school children. From 1998–2006 the prevalence rates for the more serious types of malnutrition have consistently gone done. In 2008, a total of 394,388 children aged 0 to 83 months were weighed. Of them, 1,432 or 0.36% were found to be severely malnourished. Most of them are in San Jose Del Monte, Malolos, Meycauayan, San Miguel and Bocaue. [Refer to Table 12. Nutrition Status in Bulacan, 2008.]

Table 12. Nutrition Status in Bulacan, 2008

Classification by Weight Status using IRS 0-11 mos. 12-23

mos.24-35 mos.

36-47 mos.

48-59 mos.

60-71 mos.

Total Number Percent

Below Normal

Very Low 100 279 301 291 268 193 1,432 0.36%

Below Normal 660 1,965 2,394 2,157 2,286 1,982 11,444 2.90%

Low

Normal 57,985 58,152 61,231 62,710 64,871 73,343 377,292 95.67%

Above Normal

Obese 1,305 597 616 635 582 485 4,220 1.07%

Grand Total 60,050 59,993 64,542 65,793 68,007 76,003 394,388 100.00%

Note: Rates are based on actual weighed. Source: OPT 2007

In Bulacan, coverage of Vitamin A supplementation for children 6–11 months was at 84% in 2008 as against the national target of 95%; 12–59 months was at 98% which was beyond the national target of 95%; 60–77 months at 77%, way below the national target of 95%. However, coverage of Vitamin A supplementation for sick children across the three [3] age brackets was maintained at 100%. For anemic infants, coverage for 6–23 months and 24–59 months were both at 98%, two percent below the national target of 100%. [Refer to Table 13. Nutritional Status of 0-38 months children, by Municipality, Bulacan, 2008.]

To reach national targets and sustain gains in the area of micronutrient supplementation to children 6–77 months, essential commodities must be procured, stored and distributed timely to its intended municipal beneficiaries. Parallel activities like training and mobilization of barangay health workers for micronutrient supplementation activities can be conducted. Actively promoting positive health-seeking behaviors from the communities, particularly of mothers and children is likewise crucial.

Table 13. Nutritional Status of 0-83 months children, by Municipality, Bulacan, 2008

Municipality Total Weighed

Below Normal [Very Low]

%Below Normal [Low]

% Normal %Above Normal [Obese]

%

Angat 7,238 26 0.32 281 3.44 6,837 83.61 94 1.15

Balagtas 10,015 5 0.04 156 1.27 9,822 80.26 32 0.26

Baliuag 22,816 11 0.05 712 3.43 21,766 104.75 327 1.57

Bocaue 11,828 98 0.67 793 5.39 10,784 73.34 153 1.04

Bulacan 11,549 2 0.02 78 0.70 11,408 102.40 61 0.55

Bustos 8,979 4 0.04 492 5.49 8,304 92.70 179 2.00

Calumpit 10,986 6 0.04 99 0.71 10,843 77.85 38 0.27

DRT 3,053 12 0.37 231 7.18 2,808 87.22 2 0.06

Guiguinto 14,323 0 0.00 193 1.38 14,088 100.83 42 0.30

Hagonoy 17,041 35 0.19 545 2.95 16,209 87.65 252 1.36

Malolos City 21,957 239 0.77 1,275 4.13 19,528 63.27 915 2.96

Marilao 19,036 82 0.45 406 2.24 18,397 101.29 151 0.83

Meycauayan City 33,412 180 0.54 737 2.19 32,167 95.64 328 0.98

Norzagaray 15,542 25 0.17 368 2.45 15,103 100.49 46 0.31

Obando 7,526 32 0.31 362 3.47 3,986 66.98 146 1.40

Pandi 9,678 2 0.02 418 4.33 9,070 93.89 188 1.95

Paombong 6,345 4 0.07 62 1.04 6,251 104.44 28 0.47

Plaridel 15,886 23 0.16 133 0.94 15,672 110.47 58 0.41

Pulilan 14,048 0 0.00 111 0.95 13,897 118.90 40 0.34

San Ildefonso 12,643 45 0.31 319 2.23 12,149 84.83 130 0.91

San Jose del Monte 64,067 348 0.49 1,375 1.96 62,053 88.24 291 0.41

San Miguel 17,198 199 0.98 1,319 6.47 15,434 75.68 246 1.21

San Rafael 12,616 10 0.08 300 2.41 12,188 98.02 118 0.95

Santa Maria 26,606 44 0.17 679 2.69 25,528 101.04 355 1.41

Total / Average 394,388 1,432 0.36 11,444 2.90 377,292 95.66 4,220 1.01

Note: Prevalence Rate = Number of Cases / Total Pre-school Children Weighed x 100.Source: OPT 2007

Another health issue being campaigned by the province of Bulacan is the use of iodized salt by households. Early use of iodized salt by children ensures their proper growth and development. In a survey done by the Bulacan Provincial Health Office, 88.60% of salt sold in the 1,219 market outlets in Bulacan tested positive for iodine content. At the household level, only 89.63% of the 84,242 households surveyed were using iodized salt.

Promotional and creative activities can be implemented in various strategic areas in the province to inform the public on the benefits of using iodized salt. Public and private elementary and secondary schools can become partners in health-related events, i.e., contests, fora, etc. to increase awareness of children.

At the level of local health management system, efforts can be exerted to review records and validate reports on the micronutrient supplementation program in the province, determine its weaknesses and cull lessons from it as input to planning at the local and provincial level.

In summary, the public health sector in Bulacan can implement the Reach Every Barangay [REB] strategy as a way of reaching universal coverage of micronutrient supplementation and immunization. There is also the need of intensifying health education and the promotion of positive health seeking behaviors to increase the proportion of mothers properly caring for their children such breastfeeding, immunization, oral rehydration for sick children, knowledge of danger signs of common and childhood illnesses.

3.E. Newborn Screening

Newborn screening is available in all government hospitals but not yet in local birthing homes. All new born is referred to hospitals for NBS. Though new, the province is seriously advocating New Born Screening to the local chief executives as well as to expectant mothers. Efforts, though limited, is being undertaken by health personnel to educate women and promote the benefits of newborn screening.

4. Maternal Health

Maternal mortality or death of women during pregnancy, at childbirth or in the period after childbirth is another important indicator of the province’s health. In Bulacan in 2008, the two [2] leading causes of maternal mortality were hypertension [16 cases] and hemorrhage [12 cases]. Forty four [44] maternal mortality cases recorded in 2008 occurred in government hospitals. [Refer to Table 14. Leading Causes of Maternal Mortality in Bulacan, 2008 compared to 2007.] General guidelines dictate that maternal deaths should record “place of occurrence” and residence of the deceased. Majority of maternal deaths brought hospitals were already in serious/severe stage where emergency life saving procedures may be too late to matter to save the mother’s life. These deaths could have been prevented had the mother herself subjected herself for routine check-up [pre-natal], availed of complete tetanus toxoid immunization, or immediate referral of pregnant woman by attending rural health midwife once complications have been detected. [See figure on the next page.]

Table 14. Leading Causes of Maternal Mortality in Bulacan, 2008 compared to 2007

2007 SMR* 2008 SMR*

Eclampsia 13 0.20 Hypertension 16 0.24

Ante/Post Hemorrhage Indirect 11 0.17 Hemorrhage 12 0.18

Ectopic Pregnancy 3 0.05 Cardiovascular Diseases 8 0.12

Seizure Disorder 3 0.05 Non-Obstetric 4 0.06

Cardiovascular Diseases 1 0.02 Pulmonary Embolism 3 0.04

CHF, Severe Pneumonia 1 0.02 Sepsis 2 0.03

Postpartum Cardiomyopathy 1 0.02 Infection 1 0.01

DH Fever 1 0.02 Blood Dyscrasia 1 0.01

Undetermined 1 0.01*SMR: Specific Mortality Rate per 1,000 live births.Source: FHSIS

For the past year, the PHO took time in organizing the Maternal Death Review Committee [MDRC] in all district hospitals with the exception of the Bulacan Medical Center. The MDRC is composed of experts such as the hospital Ob-Gyne for the hospital, MHOs/RHPs and PHNs from the catchment RHU. Unfortunately after one review the MDRCs became inactive at the district level. One reason was the absence of a permanent committee chairman [usually from hospital] due to rapid turnover of hospital doctors.

0.00

1.00

2.003.00

4.00

5.00

6.00

7.008.00

Rat

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r 10,

000

live

birt

hs

Maternal Mortality Ratio, 2007-2008 Province of Bulacan

MaternalDeaths

2007 2008

Reducing maternal deaths in the province of Bulacan remains a challenge to the public health sector. Pregnancies become risky once pregnant women are delayed in seeking medical care, health practitioners delay in referring risky pregnancies to higher medical facilities and the overall delay in providing the appropriate medical care. For the uneducated and young mothers-to-be, closely spaced births and frequent pregnancies result to maternal death. This is further compounded by the poor access of clients to health facilities due to geographical limitations and cost of transportation. Another is the inadequate skill of health care providers in detecting and managing high-risk pregnancies. Another is the lack of competence of health care providers in handling obstetrical emergencies.

In Bulacan, pregnant and non-pregnant women 14–44 year old have been given tetanus toxoid shots. As shown in the table below, coverage of tetanus toxoid was registered at 77.8%. In 2004, accomplishment decreased by 11.9% covering only 65.9% of the total

target. From 2004 to 2007, there was a steady increase in coverage. Coverage decreased again in 2008 with only 71% accomplishment. [See graph below.]

Fully Immunized Mothers, 2004 - 2008 Province of Bulacan

62.0

64.0

66.0

68.0

70.0

72.0

74.0

2004 2005 2006 2007 2008

Year

Perc

enta

ge

Another aspect of maternal care is tetanus toxoid immunization. The total percent of the fully immunized mothers in 2008 was 71.0% of the eligible population. Bulacan performed the highest coverage at 99.7%, followed by Baliuag at 96.6% and Meycauayan at 93.2%. The lowest performances were registered in Paombong [34.2%], San Rafael [35.9] and in Pandi [37.3%]. [Refer to Table 15. Prenatal with TT2+, Consolidated, 2003–2008 and Table 16. Percentage of Mothers given TT2+, by Municipality, 2003–2008.]

Table 15. Prenatal with TT2+, Consolidated, 2003–2008Year Population Target Accomplishment %age2003 2,156,463 75,476 58,692 77.8%2004 2,697,441 94,410 62,182 65.9%2005 2,889,216 101,123 69,231 68.5%2006 3,048,336 106,692 71,794 67.3%2007 2,826,926 98,942 72,296 73.1%2008 2,921,974 102,335 72,670 71.0%

Note: Percent = Number of Cases / Population x 3.5% x 100

Table 16. Percentage of Mothers given TT2+, by Municipality, 2003–2008Municipality/City 2003 2004 2005 2006 2007 2008ANGAT 70.3% 63.2% 70.5% 51.3% 54.5% 62.6%BALAGTAS 55.0% 61.1% 67.3% 62.8% 71.1% 66.1%BALIUAG 68.6% 68.6% 90.4% 106.8% 95.6% 96.6%BOCAUE 58.0% 42.4% 52.2% 44.3% 53.9% 46.6%BULACAN 89.3% 89.7% 77.7% 73.4% 79.6% 99.7%BUSTOS 55.5% 56.6% 62.2% 58.4% 56.4% 68.8%CALUMPIT 65.0% 54.3% 60.4% 55.3% 51.9% 57.3%DRT 50.9% 49.5% 53.9% 56.4% 55.2% 47.4%GUIGUINTO 81.1% 70.8% 80.7% 70.3% 80.4% 89.5%HAGONOY 73.8% 73.5% 61.9% 66.2% 72.1% 69.3%MALOLOS 58.4% 51.4% 49.6% 46.5% 45.8% 44.2%MARILAO 81.1% 65.1% 57.4% 59.5% 78.4% 74.4%MEYCAUAYAN 91.5% 79.1% 85.1% 81.7% 85.7% 93.2%NORZAGARAY 75.4% 44.0% 47.3% 54.3% 52.8% 51.8%OBANDO 79.4% 76.8% 82.6% 71.6% 74.9% 76.2%PANDI 79.6% 65.4% 43.4% 35.8% 35.3% 37.3%PAOMBONG 50.5% 34.9% 34.8% 40.6% 46.8% 34.2%PLARIDEL 83.7% 55.2% 63.2% 60.4% 65.9% 72.9%PULILAN 63.5% 57.7% 75.1% 78.0% 77.4% 73.0%SAN JOSE DM 102.6 84.8% 86.8% 87.7% 105.1% 87.6%

Table 16. Percentage of Mothers given TT2+, by Municipality, 2003–2008Municipality/City 2003 2004 2005 2006 2007 2008SAN MIGUEL 74.5% 73.9% 74.4% 76.2% 90.3% 86.2%SAN RAFAEL 71.3% 61.8% 40.9% 51.1% 40.8% 35.9%SN ILDEFONSO 81.0% 62.8% 54.9% 55.2% 58.9% 62.1%STA. MARIA 84.8% 53.8% 60.8% 53.1% 67.9% 62.9%Provincial Average 77.8% 65.9% 68.5% 67.3% 73.1% 71.0%Note: Percent = Number of Cases / Population x 3.5% x 100Source: FHSIS

Of the total births reported in 2008, 61.89% were delivered at home, while 34.26% were delivered at health facilities. Compared to 2007, there was a slight increase among pregnant women preferring to deliver their babies at health facilities. Table 17. Trends, Births by Place of Delivery, 2002-2008 shows that from 2001 to 2008, there is a steady increase in the number of women going to health facilities for delivery. At the same time, there is a noticeable downward trend of pregnant women delivering their babies in their homes, or not being attended to by trained health professionals.

Some of the factors contributing to the positive trend of increasing deliveries at the health facilities are the following: government-run health facilities provide the essential pre-pregnancy, pre-natal and post-natal services to pregnant women and mothers. This batch of services can spell the difference between life and death of the mother and/or the child. Another is the accessibility of these services to the clientele through the main RHUs and its satellite BHSs.

Table 17. Trends, Births by Place of Delivery, 2002-2008.

Year Births Home Hospital Others

2008 64,551 61.89% 34.26% 3.25%

2007 66,123 65.25% 30.46% 4.29%

2006 64,508 64.67% 32.91% 2.42%

2005 61,072 69.55% 28.33% 2.29%

2004 57,374 70.38% 26.78% 2.84%

2003 53,677 67.35% 28.17% 4.48%

2002 51,794 68.95% 29.00% 2.05%

2001 47,167 76.16% 21.81% 2.03%

Source: FHSIS

In terms of birth attendants, trained health personnel assisted to about 93.21% of the reported births in 2008. Table 18. Trends, Births by Attendant at Delivery, 2002-2008 below shows that doctors, midwives and trained hilots assisted more deliveries compared to year 2007.

Table 18. Trends, Births by Attendant at Delivery, 2002–2008

Year Births MD Nurse Midwife Trained Untrained Others

Hilot Hilot

2002 51,794 28.62% 0.34% 61.09% 7.98% 1.65% 0.32%

2003 53,677 29.18% 0.47% 60.50% 8.03% 1.48% 0.34%

2004 57,374 28.94% 0.40% 61.80% 7.00% 1.60% 0.30%

2005 61,072 28.40% 0.20% 63.10% 7.00% 1.20% 0.10%

2006 64,508 28.90% 0.40% 61.80% 7.00% 1.60% 0.30%

2007 66,123 29.32% 0.14% 63.60% 5.84% 0.77% 0.34%

2008 64,551 31.41% 0.17% 61.63% 5.61% 0.97% 0.21%

Source: FHSIS

One positive development in the province is the accreditation of privately-managed birthing homes. These birthing homes are owned and managed by licensed midwives. Eleven [11] birthing homes have passed stringent DOH standards and all are PHIC-accredited. They cater to a segment of the market [pregnant women]. They are strategically located in the municipalities of Obando, Balagtas, Bustos, Guiguinto, Bulakan, Plaridel, Angat, Baliuag and Santa Maria.. Also, these birthing clinics, which only perform normal deliveries, reduce the traffic of deliveries at government-run hospitals. Hospitals can then concentrate on high-risk deliveries and other medical cases needing secondary and tertiary health care.

However, with the increased number of maternal deaths in the province for the year 2008, there is a need to activate and strengthen the Maternal Death Review Committee [MDRC] to determine what aspect of maternal health care can be improved.

High-risk pregnancies can be minimized if pregnant women regularly go for pre-natal consultations. Currently, public health facilities request their clientele to have at least three [3] visits prior to delivery. Pre-natal visits should be increased to four [4] to provide enough time for thorough evaluation and management of diseases and conditions that may jeopardize the pregnancy. Equally important is the provision of post-partum care not only to women after children but should also include women who had miscarriage or an unsafe abortion.

Table 19. Pregnant Women with Three Pre-Natal Visits, Consolidated, 2003-2008 shows that there is a steady increase, from 2005 up to the present, of pregnant women in Bulacan who had their four [4] pre-natal visits at the health facilities. However, this is still far from the national target of 85%. [See graph on next page.]

Prenatal with 3 Visits, 2004 - 2008 Province of Bulacan

70.072.0

74.076.0

78.080.0

82.084.0

86.0

2004 2005 2006 2007 2008

Year

Perc

enta

ge

Table 19. Pregnant Women with Three Visits, Consolidated, 2003–2008Year Population Target Accomplishment %age

2003 2,156,463 75,476 73,237 97.0%2004 2,697,441 94,410 76,531 81.1%2005 2,889,216 101,123 80,530 79.6%2006 3,048,336 106,692 80,277 75.2%2007 2,826,926 98,942 82,839 83.7%2008 2,921,974 102,335 86,409 84.4%

Note: Target = population x 3.5%Source: FHSIS

Municipalities that performed well in 2008 for pregnant women with at least three pre-natal visits were in San Miguel with 108.8%, followed closely by Baliuag with 107.6% and Guiguinto with 100.6%. Lowest were registered in the municipality of Paombong with 33.7%, Bocaue with 43.3% and Doña Remedios Trinidad with 44.4%. [Refer to Table 20. Percentage of Pregnant Women with Three Pre-Natal Visits, 2003-2008.]

Table 20. Percentage of Pregnant Women with Three Pre-Natal Visits, 2003-2008

Municipality/City 2003 2004 2005 2006 2007 2008

ANGAT 115.3% 102.4% 95.1% 63.2% 68.3% 73.4%

BALAGTAS 85.4% 82.1% 70.9% 75.2% 87.3% 85.8%

BALIUAG 144.5% 84.8% 89.1% 94.9% 105.8% 107.6%

BOCAUE 58.8% 40.3% 42.6% 45.8% 61.0% 43.3%

BULACAN 87.4% 91.7% 85.5% 79.4% 88.7% 93.9%

BUSTOS 77.7% 69.4% 78.4% 74.2% 75.0% 78.5%

CALUMPIT 113.8% 116.1% 75.9% 38.5% 73.3% 72.4%

DRT 63.0% 49.5% 57.5% 59.3% 53.6% 44.4%

GUIGUINTO 86.5% 83.5% 78.5% 92.0% 98.7% 100.6%

HAGONOY 76.9% 76.4% 51.5% 56.7% 68.4% 74.7%

MALOLOS 89.8% 73.8% 75.5% 71.7% 64.1% 66.2%

MARILAO 102.2% 76.3% 68.9% 75.7% 83.8% 82.5%

MEYCAUAYAN 97.1% 92.7% 91.4% 84.5% 96.1% 94.0%

NORZAGARAY 79.9% 49.3% 49.2% 51.6% 57.8% 49.9%

OBANDO 86.9% 96.1% 88.7% 89.1% 78.9% 79.0%

PANDI 88.6% 88.3% 83.3% 83.0% 81.8% 86.3%

PAOMBONG 70.9% 51.6% 42.0% 49.3% 12.5% 33.7%

PLARIDEL 103.6% 80.6% 90.2% 88.8% 96.8% 93.3%

PULILAN 93.0% 92.5% 89.0% 95.0% 91.2% 91.7%

SAN ILDEFONSO 72.5% 58.8% 53.1% 53.2% 52.5% 53.5%

SAN JOSE DM 112.1% 91.4% 93.8% 89.6% 97.0% 94.1%

SAN MIGUEL 122.0% 104.1% 93.1% 97.4% 114.0% 108.8%

SAN RAFAEL 84.5% 79.6% 68.2% 60.4% 56.1% 54.6%

STA. MARIA 93.9% 66.1% 74.0% 61.1% 105.7% 73.6%

Provincial Average 97.0% 81.1% 79.6% 75.2% 83.7% 84.4%

Note: Percent = Number of Cases / Population x 3.5% x 100Source: FHSIS

Post Partum Women with At Least 1 Visit, 2004 - 2008 Province of Bulacan

72.0

74.0

76.0

78.0

80.0

82.084.0

86.0

88.0

90.0

92.0

2004 2005 2006 2007 2008

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In 2008, there were 74,210 post-partum mothers who were visited by RHU RHMs, at least once within six weeks after delivery. [See graph above.] The mothers and their newborn babies were thoroughly examined by the midwives. After the examinations, mothers underwent health education. Quality post-partum care in the province has been improving through the years, except for the year 2007. Top performers for 2008 were San Miguel [106.2%], Baliuag [102.2%] and San Jose del Monte [101.1%] while the lowest were registered at Doña Remedios Trinidad [49.7%], Bocaue [56%] and Paombong [57.6%].

4.A BEmONC/CEmONC Facility Mapping and Upgrading

Another strategy to reduce maternal deaths is through the establishment of Basic Emergency Obstetrics and Newborn Care [BEmONC] facilities. The BEmONC strategy involves the establishment of a facility, located in a strategic area/catchment basin, staffed with highly trained health professionals, and providing emergency obstetric care. Also included is the care for newborn babies.

In consultation with the different inter-local health zones and the LGUs, the province of Bulacan has identified all municipalities/cities as sites for BEmONC facilities. Preparatory activities such as facility and capability assessments are currently on going at these sites. Next steps will facility construction/renovation/installation and the procurement of medical equipment and supplies. Parallel training activities for the BEmONC facilities will also be conducted. These aim to improve the quality of prenatal and postnatal care.

4.B Women’s Health Team

The formation of Women’s Health Team in every municipality/city in Bulacan is deemed an important step to contribute to the reduction of maternal mortality. The Women’s Health Team is composed of the Municipal/City Health Officer [M/CHO], rural health midwives [RHMs], BHWs and traditional birth attendants [TBA, “hilots”]. The inclusion of TBA is a necessary step to introduce the TBA to DOH standards of delivery. The TBA is equipped in early detection and management of high-risk pregnancies, leading to reduction of maternal mortality. The responsibility of the team is to locate from within their area of responsibility pregnant women who, due to financial and geographical limitations, are constrained to seek

pre-pregnancy counseling, pre-natal and post-natal care at the health facility. The team is also responsible in conducting health promotion activities in hard-to-reach areas. Capacity building activities for the team are counseling, family planning, among others.

4.C Contraceptive Self-Reliance [CSR]

Donations of modern FP commodities [i.e., pills, condoms, etc.] from foreign sources have already stopped. In this regard, the DOH issued an Administrative Order detailing strategies and approaches how the Philippines can attain contraceptive self-reliance or CSR. So as not to disrupt the flow of FP services and commodities, a step-down reduction in commodity donation was initiated at the national level. LGUs were expected to fill in the shortages caused by the withdrawal.

The implementation of the foreign-funded LEAD for Health Project in Bulacan assisted the LGUs in coming up with strategies and approaches to continuously provide FP commodities to clients. To determine actual unmet needs, a Community-Based Management Information System [CBMIS] was established purposely to determine FP needs of each municipality/city.

In 2006, former Bulacan Governor Josefina dela Cruz enacted an executive order allocating Php 2,000,000 every year for five [5] years as augmentation budget for the procurement of FP commodities. Said fund is used to subsidize 100% unmet needs of government-run hospitals and ten percent [10%] of unmet needs of the LGUs. This means that the LGUs have to mobilize resources for the remaining unfunded 90%.

Currently, all LGUs have their updated CSR+ Plans. However, in 2008 only seventeen [17] out of the 24 LGUs have been able to procure their FP commodities. With growth rate of 3.36% [based on 2007 Census], it is imperative that FP commodities be provided, particularly for the poor and marginalized.

The FP program in Bulacan registered 326,175 current users in 2008, which is nearly double than 2007 figures. [Refer to Table 21. Total Number of FP Current Users, 2002-2008 and Table 22. Percentage of Current Users, Consolidated, 2003-2008.] Current User is the key indicator for the FP program; it refers to FP clients who have been carried over from the previous month after deducting the dropouts of the present month and adding the new acceptors of the previous month. New Acceptors refers to clients who are using a contraceptive method for the first time or new to the program. FP methods available are condom, injectables, intra-uterine device [IUD], LAM, natural FP [which includes BBT, CM and symptothermal], pills, male sterilization [vasectomy] and female sterilization [tubal ligation]. However, available data can only measure those using pills, IUD, condom, injectables, LAM and NFP.

Table 21. Total Number of FP Current Users, 2002–2008

Municipality/City 2003 2004 2005 2006 2007 2008

Angat 3,233 3,086 3,003 3,189 3,432 5,278Balagtas 3,111 3,216 3,654 4,426 4,549 4,400Baliuag 4,747 8,778 6,346 5,503 10,685 5,882Bocaue 1,840 2,005 1,878 3,418 4,222 3,786Bulacan 4,159 4,653 5,097 5,243 5,454 7,905Bustos 2,298 2,843 2,309 2,428 3,445 783Calumpit 2,715 3,082 1,467 1,918 4,559 3,189Doña Remedios Trinidad 427 2618 655 592 665 8,707Guiguinto 3,132 2,980 7,385 2,581 3,003 6,910Hagonoy 7,531 7,501 5,004 5,617 10,981 9,153Malolos City 28,576 13,372 9,523 8,569 11,693 8,519Marilao City 3,019 4,171 3,917 11,989 9,281 6,565Meycauayan 10,194 7,008 6,218 4,976 7,158 2,380Norzagaray 2,527 2,670 2,982 5,004 5,547 815Obando 1,969 2,058 2,342 2,220 2,289 2,883Pandi 756 826 876 845 862 6,881Paombong 1,754 1,966 2,357 2,574 2,752 4,130Plaridel 3,142 3,352 2,888 6,217 6,753 5,640Pulilan 2,894 3,113 2,591 3,998 4,517 30,784San Ildefonso 2,680 2,450 3,360 4,994 5,290 7,817San Jose del Monte 19,578 20,465 25,565 28,154 34,675 5,898San Miguel 7,847 8,142 5,851 5,976 12,368 11,808San Rafael 2,041 1,479 1,301 3,517 5,606 0Santa Maria 6,841 6,048 7,248 11,246 10,979 157,800Province 127,011 117,882 126,706 135,194 170,765 326,175

Table 22. Percentage of Current Users, Consolidated, 2003–2008

Year Population Target Accomplishment %age

2003 2,156,463 144,912 127,011 87.65%

2004 2,697,441 181,268 117,882 65.03%

2005 2,889,216 139,722 126,706 90.68%

2006 3,048,336 147,418 135,194 91.71%

2007 2,826,926 136,710 170,765 124.91%

2008 2,923,847 242,080 326,175 134.74%Note: Percent = Number of Cases / Population x 12% x 40.3% x 100Source: FHSIS

Issues still persist in the implementation of the FP program. A major reason cited by women for not practicing any FP method was health concerns, which refer to their worries about the possibility of consequences of the method that affect their health. This was followed by reasons of actual experience of side effects, and couples wanting to riase children. Other reasons were infrequent sex, dislike of husband to use any method, inconvenience, close to menopausal period, and not sexually active. The lack of knowledge on FP is another reason.

Though coverage has become relatively consistent since 2000, promotional activities still need to be conducted. Another area of improvement is FP counseling. Trained FP counselors can answer most of the factors stated above. There is also the need to reactivate the CBMIS by the LGUs since it stopped in 2007 due to lack of local funds. The CBMIS determines the actual FP unmet needs. New RHU health personnel and BHWs have to be trained on the system.

5. Healthy Lifestyle and Management of Health Risks

Healthy lifestyle-related morbidity and mortality has been on the rise in Bulacan for the past years. Data on the leading causes of death for the years 2007 and 2008 indicate an alarming pattern. 5,506 deaths were reported in 2007 due to heart diseases [2,981], cancer [987], CVA [901], diabetes mellitus [427] and renal failure [210]. In 2008, deaths due to heart diseases were 1,879, CVA was 1,365, cancer was 1,167, diabetes mellitus was 357, and renal failure was 174. [See graphs on the next page.]

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Heart Diseases

CVA

Cancer, all forms

Pneumonia

Tuberculosis

Diabetes Mellitus

Accidents, all forms

COPD

Kidney Diseases (Renal Failure)

Septicemia / Sepsis

Known as non-communicable diseases [NCDs], these degenerative diseases are caused usually through a combination of socio-economic and environmental factors, the existing health care system and the individual’s personal and medical history. Every person is bound to experience any of these NCDs after reaching a certain age. Once a person acquires a non-communicable disease, this becomes lifetime chronic disease that can be managed through a mix of behavioral, medical or surgical interventions.

The most rational and most efficient public health approach to these diseases is prevention. Every individual must be equipped with the critical information and right tools to promote health and prevent the early onset and arrest the advancement of these diseases. Major risk factors leading to these diseases are lifestyle-related, that is, the food we eat, liquid we drink, the air we breathe in. These are food containing high salt and high fat, liquors and intoxicating drinks, primary and secondary smoke, and a stressful and sedentary lifestyle.

The highly urbanizing character of Bulacan has increased the accessibility of people to various food and drink items, recreation and lifestyles, both healthy and unhealthy. Consumerism and untruthful advertising lead people to imbibe unhealthy lifestyles. Individual susceptibility to developing degenerative diseases increases depending on the person’s genetic and physical makeup and exposure to disease-causing agents and environmental hazards. Health intervention therefore should aim to equip every person with vital information and the right tools to lead a healthy lifestyle. The healthy lifestyle approach includes the promotion of proper diet and nutrition, increased physical activity, smoking prevention and cessation, among others.

In this aspect, it is imperative to develop a comprehensive NCD Control and Prevention Program for Bulacan. This entails the training and deployment of NCD point person in every LGU. Orientation and training activities on NCD prevention, detection, treatment and management for the different RHU personnel can effectively disseminate critical orientation on the disease.

As part of its regulatory function, government, through its medical and sanitary offices, can ensure that food establishments follow the minimum protocols for sanitation. As of end 2008, there were registered 11,806 food outlets/establishments with 31,953 food handlers in the province. Government inspectors have only certified 89.20% or 10,527 establishments complied with existing health and business regulations. Lobbying food owners and entrepreneurs to include in their menu healthy foods can also be done. They can be persuaded that offering healthy food to customers is a practical business step as people slowly understand the importance of good diet and nutrition.

Efforts must also be exerted to include ambulant food vendors. These vendors ply their wares near educational institutions and public areas. If food preparation does not meet minimum sanitary requirements, the public particularly school children are susceptible to various illnesses.

Existing promotional materials from the province and the DOH shall be inventoried. Appropriate materials can be reproduced for distribution to the different hospitals, RHUs and BHSs; new materials can also be developed, pre-tested and reproduced to suit Bulacan needs. Partnership with private hospitals, clinics and physicians/specialists shall also be established and strengthened to widen the reach of NCD prevention and treatment.

5.A Advocacy Campaigns for Risk Behaviors

Some of the existing health programs in promoting healthy lifestyles are the HATAW and the No Smoking campaign. These programs however have reached only a limited number of people in the province.

HATAW aims to inculcate the value of increased physical activity to reduce stress and mitigate the effects of heart-related diseases. Studies have shown that the unmitigated advertising of tobacco companies have drastically increased tobacco sales in the country, notwithstanding the passage of Philippine Congress of Republic Act 9211 in 2003 to

regulate the tobacco industry and Republic Act 9335 increasing taxes for tobacco and alcohol products. LGUs must exert efforts for the strict enforcement of relevant laws and policies on smoking in public areas [public areas, malls, public transportation, among others]. Also, the Clean Air Act provides the banning of smoke-belching industries and vehicles.

A province-wide and across sectors advocacy campaign on risky behaviors should be immediately implemented. Orientation on healthy lifestyles should be provided to business owners, operators of public transportation, and law enforcement agencies. Promotional materials on healthy lifestyles can be prominently displayed on business establishments and health facilities in the province. Promotional activities, e.g., healthy lifestyles caravan, can be regularly conducted to reach the widest number of the population.

5.B Water and Sanitation Programs

91.15% [601,831] of households in Bulacan [with total households of 660,237] have access to safe, potable water. [Refer to Table 23. Access to Safe Water, by Municipality, 2008.] Majority of these households get their water from deep wells, or Level I point source. More are served by existing local waterworks systems through the Local Water Utilities Associations [LWUAs] and the Barangay Water System Associations [BWSAs], providing the water needs of households through a system of pipes right to their homes or Level III water system. The municipality of Pandi registered 34.1% of households with access of households to potable water, the lowest in the province. Areas that registered below 80% were San Ildefonso, Doña Remedios Trinidad, and Plaridel, while the remaining areas were 80% and above.

Table 23. Access to Safe Water, by Municipality, 2008

Municipality/City HHs Level I Level III %age

ANGAT 12,044 4,861 5,138 83.0%

BALAGTAS 14,001 2,758 10,863 97.3%

BALIUAG 34,430 14,309 17,623 92.7%

BOCAUE 21,756 5,510 15,136 94.9%

BULACAN 18,069 5,136 12,281 96.4%

BUSTOS 11,762 4,003 7,270 95.8%

CALUMPIT 20,454 593 19,380 97.6%

DRT 4,119 171 2,432 63.2%

GUIGUINTO 23,322 14,256 8,469 97.4%

HAGONOY 27,155 2,843 23,410 96.7%

MALOLOS 49,388 21,520 18,832 81.7%

MARILAO 42,623 18,754 23,445 99.0%

MEYCAUAYAN 49,561 12,845 33,086 92.7%

NORZAGARAY 19,380 5,798 12,743 95.7%

OBANDO 12,017 447 10,742 93.1%

PANDI 13,928 70 4,676 34.1%

PAOMBONG 10,651 942 7,785 81.9%

PLARIDEL 24,774 4,733 11,361 65.0%

PULILAN 17,132 15,956 610 96.7%

SAN JOSE DM 123,994 3,650 119,084 99.0%

SAN MIGUEL 28,907 15,456 13,451 100.0%

SAN RAFAEL 21,898 14,515 5,038 89.3%

Table 23. Access to Safe Water, by Municipality, 2008

Municipality/City HHs Level I Level III %age

SN ILDEFONSO 17,866 7,539 3,356 61.0%

STA. MARIA 41,006 15,582 23,373 95.0%

PROVINCE 660,237 192,247 409,584 91.2%

Another measure of the sanitary condition of a locality is the proportion of sanitary facilities used by households. A sanitary toilet is one that is water-sealed. In the last survey done in 2007, about 93.27% [or 615,807] of households have sanitary toilet. Sewage disposal is through the use of septic tanks. There is no sewerage system operating in the province. Households with satisfactory garbage disposal were pegged at 66.5% [or 439,240] while only 63.9% [or 421,882] households have complete sanitation facilities. [Refer to Table 24. Households with Sanitary Toilet, 2007.]

Most indigent households have to existing sanitary toilets. Through the “Oplan Bantay Palikuran” of the Agapay sa Barangay program, indigent households will be identified and provided with sanitary toilets. Sources of funds will come from the Clean and Green budget of the province, municipality/city and barangay. Beneficiaries will provide their labor as counterpart.

Table 24. Households with Sanitary Toilet, 2007

Municipality/City Number of Households

HH with Sanitary Toilet %age

ANGAT 12,044 10,716 89.0%

BALAGTAS 14,001 13,635 97.4%

BALIUAG 34,430 31,788 92.3%

BOCAUE 21,756 20,425 93.9%

BULACAN 18,069 16,726 92.6%

BUSTOS 11,762 11,301 96.1%

CALUMPIT 20,454 18,490 90.4%

DRT 4,119 2,156 52.3%

GUIGUINTO 23,322 21,615 92.7%

HAGONOY 27,155 24,056 88.6%

MALOLOS 49,388 44,661 90.4%

MARILAO 42,623 40,490 95.0%

MEYCAUAYAN 49,561 44,604 90.0%

NORZAGARAY 19,380 17,942 92.6%

OBANDO 12,017 9,926 82.6%

PANDI 13,928 11,848 85.1%

PAOMBONG 10,651 10,165 95.4%

PLARIDEL 24,774 23,877 96.4%

PULILAN 17,132 15,685 91.6%

SAN ILDEFONSO 17,866 15,760 88.2%

SAN JOSE DM 123,994 123,326 99.5%

SAN MIGUEL 28,907 25,727 89.0%

SAN RAFAEL 21,898 20,155 92.0%

STA. MARIA 41,006 40,733 99.3%

PROVINCE 660,237 615,807 93.27%Source: Environmental Health Statistics

The data shows that the province of Bulacan has scored relatively high in the area of making accessible safe and potable water to the community. This is also true in the number of households with sanitary toilet facilities. However, much has to be done at the local levels to attain 100% access of households to both safe, potable water and sanitary toilet facilities.

Water as a resource is already scarce as it is. With the rapid population growth in Bulacan, water becomes all the more scarce, not to mention costly in the long run. Collaborative efforts must be undertaken by the municipality/city LGUs, the RHUs, the barangay LGUs and the affected communities and households to secure and sustain sources of safe and potable water. Water conservation through education promotional activities must be immediately undertaken at the local levels. According to climatologists, climate change will impact most on water, the earth’s most vulnerable commodity. Coastal communities are already threatened by the slow rising of sea water which threatens to intrude into water tables and aquifers. Upland communities are already experiencing the effects of water scarcity due to forest cover denudation and the drying up of natural springs.

Accessibility to safe and potable water impacts on the health and well-being of the people. Dirty water is the cause of many water-borne diseases. Water is needed to ensure personal hygienic practices like hand washing and bathing in children and women. Water samplings shall continuously be implemented in all areas in partnership with the LWUAs and BWSAs. New sources of water and existing unsafe water sources shall be disinfected using chlorine granules. At the household level, safety measures through the provision of disinfectant tablets shall be implemented. All of these measures will be undertaken to reduce morbidity and mortality due to diarrhea, and maintain zero morbidity and mortality due to cholera, typhoid and paratyphoid fevers. The rural sanitation inspectors [RSIs] are at the forefront of these intervention activities.

Bulacan is host to a number of industrial complexes, providing needed employment and ancillary livelihood to thousands of workers and allied services. These industries, though, excrete wastes up in the air and in waterways. In a recent study made by the Department of Environment and Natural Resources [DENR] Bulacan hosts some of the deadliest rivers in the country due to its toxicity and heavy metal contamination.

The waterways in the three [3] municipalities of Marilao, Meycauayan and Obando have been confirmed with heavy metal contamination. Seven [7] additional municipalities have also been included in the list of high-risk areas. The provincial government, through the Provincial Environment and Natural Resources Office [PENRO], can conduct regular inspection of manufacturing companies if such companies strictly adhere to standard waste management and disposal procedures.

On-board personnel from the provincial and municipal/city LGUs can be tapped to carry on environmental inspection, if there are no environmental specialists. Capacity building on pollution monitoring, measuring toxicity and heavy metals contamination will be conducted.

5.C Risk-Factor Screening

Risk-factor screening is another strategy towards NCD prevention. For the period 2007-2008, deaths due to cancer [all forms] were 2,154. While this could not have been cured due to different stages of the disease, cancer prevention and control can be done through early detection. Individual self-assessment can detect early signs of cancer. Early detection of cancer can greatly affect the outcome of clinical management.

Screening for breast cancer, which is the most common form of malignancy among Filipino women, is being promoted through self-breast examination campaign called “Sariling Salat sa Suso,” and through clinical breast examination done by a physician. According to DOH standards, mammography is recommended every five years among women more than 50 years old to detect non-palpable breast masses. High tech equipment for risk factor screening such as mammography units are available on send-out basis, most of which are privately owned. Only a few are government-owned. There is the need to equip strategically located RHUs or ILHZs with mammography units to reach the most number of vulnerable groups.

Another is blood pressure taking as a way measure to high-risk groups in danger of heart attacks and other heart-related diseases. While every RHU/BHS is equipped with at least one [1] blood pressure [BP] apparatus, there is a need to at least provide roving BHWs with their own BP apparatus as the BHWs can reach the farthest areas.

Cervical cancer has been on the rise in the country. Cervical cancer, like breast cancer, can also be detected early by women themselves. According to a study done by Sherries [1993], pap smear, when conducted every three [3] years, can reduce the incidence of cervical cancer up to 90.8%, and when done yearly can reduce it further up to 93.5%. A study conducted by the UP-DOH Cervical Cancer Screening Research Group found out that the visual examination of the cervix aided by acetic acid wash is the most cost-effective screening method for cervical cancer. The DOH now recommends this method for early detection of cervical cancer. In this regard, RHUs must be equipped with the minimum materials for women to be able to conduct cervical examination.

Majority of the population in Bulacan have misconceptions on the causes of lifestyle-related diseases. Cancer, diabetes, heart diseases among others are considered diseases afflicting the rich and well-to-do families. But NCD knows no bounds; it afflicts the most vulnerable and high-risk groups, rich and poor alike. Increasing the awareness of the population and persuading them to seek good health seeking behavior, like screening procedures for different illnesses, can come a long way in the early detection and treatment of NCD.

4.E. Voluntary Blood Program

Providing safe and quality blood at all times is the vision of the Bulacan Provincial Blood Center, the first government-managed blood center in the province. The Center was built in 2004 to respond to the needs for a one-stop shop for all blood needs of the province and beyond. Due to the increasing demand for blood for various medical reasons, the Bulacan

Blood Council was organized in 1999 through an Executive Order. The Bulacan Blood Council was the highest policy-making body with the task of ensuring the supply of blood. It also leads the province’s Voluntary Blood Program.

For more than 5 years, the Bulacan Provincial Blood Center caters not only to the needs of the public hospitals but also the needs of the private health sector, like the PNRC-Bulacan and the nearby provinces of Pampanga, Nueva Ecija and even the National Capital Region. The Bulacan P/LGU allocates yearly budget for its capital outlay, procurement of equipment and maintenance and other operating expenses.

To keep up with the demand and ensuring the continuous supply of safe blood, local Blood Councils were established in the three [3] municipalities of Hagonoy, Plaridel and San Jose del Monte City. Also, local Blood Teams were organized in 21 municipalities/cities to ensure take the lead in voluntary blood donations by civic-minded individuals. In partnership with other government agencies, non-government organizations and the private sector, these teams conduct awareness sessions in the communities, emphasizing the need to stay healthy so that the blood they donate will save lives.

6. Surveillance and Epidemic Management System

The province’s goal on this aspect is to prevent, control and manage the occurrence of outbreaks on reportable, immunizable diseases and other emerging and re-emerging diseases. Bulacan has experience, time and again, epidemic outbreaks like dengue, malaria, avian flu, and the new swine flu virus or Influenza A[H1N1]. The immediate response of the provincial government and affected LGUs, through its health offices, minimized the number of cases.

Containment procedures have been instituted at the onset of the first signs of epidemic symptoms. Relevant health information and advisory were timely released to the general population to institute protection measures against the spread of these diseases. Affected individuals and communities were provided with the necessary commodities [e.g., medicines, vaccines, masks, among others]. These are the elements for a functional surveillance and epidemic management system.

At the local level, seven [7] sentinel sites have been identified, corresponding to the location of the major public hospitals in the province. Emergency procedures are immediately instituted upon the appearance of notifiable diseases, i.e., AEFI, anthrax, HAI, measles, meninggocemia, SARS, rabies, PSP, and neonatal tetanus. Category II diseases [acute bloody diarrhea, acute encephalitis syndrome, acute hemorrhagic fever, acute viral hepatitis, bacterial meningitis, cholera, dengue, diphtheria, ILI, leptospirosis, malaria, non-neonatal tetanus, pertusis, pyphoid and paratyphoid fever] are considered weekly notifiable.

In Bulacan, only twelve [12] out of the 24 LGUs have formed their epidemic surveillance units [MESUs]. The Municipal/City Epidemic Surveillance Unit [M/CESU] is the unit tasked in identifying and locating at its early stages, and in controlling and managing epidemic outbreaks, in their localities. However, existing surveillance units have varying

stages of development and functionality. There is a need to standardize unit operations and staff competencies.

Training and orientation on basic epidemiology, logistics management, management information systems, referral systems with secondary and tertiary health facilities, planning and monitoring systems, among others needs to conducted and established for all LGUs in the province. Policies supportive to these initiatives must be mustered from the local executives and legislative bodies. All of these activities and systems require funding.

7. Disaster Preparedness and Response System

On a global scale, disasters, both natural and human-induced, are increasing in frequency and impact, threatening the lives and livelihoods of millions of men, women and children. The Philippines lies in an area highly vulnerable to many natural hazards and has shown signs of climate change impacts [i.e., increased intensity of typhoons, heavy rainfall, sea level rise and temperature rise, among others]. The archipelagic nature of the Philippine coastal areas increases susceptibility to storm surges, tsunamis and sea-level changes. Floods are common due to rains brought by typhoons and the monsoon. These natural phenomena impact greatly on the health of the people.

In 2006 alone, the Philippines ranked third in the world in terms of death per 100,000 inhabitants, and ranked second in terms of population affected by natural disasters. On the average, we get twenty [20] typhoons annually, of which seven [7] are considered destructive enough. In Bulacan, disasters from 2003–2008 claimed hundreds of lives, destroyed properties and livelihoods. Bulacan, like the rest of the country, is vulnerable to these disasters. The most vulnerable groups are the children, women and the elderly.

The municipalities of Obando, Bulacan, Calumpit and Hagonoy and Malolos City are prone to floods; the low-lying areas of Bocaue, Paombong, Marilao, San Miguel and Meycauayan City are prone to mudslides; while Meycauayan City, Baliuag, Bocaue and Santa Maria are vulnerable to industrial and commercial accidents. These data should be regularly updated and validated.

LGUs are empowered by law to release funds during a state of calamity; however critical commodities [antiviral drugs, paracetamol, antibiotics] and supplies [alcohol, tongue depressor, etc.] are lacking during emergency situations. Drinking water, blankets, first-aid kits, and essential medicines should be readily available so that emergency responses can be affected immediately. Health officials should persuade local executives on the need to formulate various plans for different kinds of disaster.

People cannot prevent the occurrence of disasters, but it can reduce its impact. Health care professionals from the public and private sectors can make disaster risk reduction a priority. This means understanding and knowing the risks involved in disasters and taking action and share relevant information to the public to synchronize emergency responses during actual disasters.

8. Health Promotion and Advocacy

The goal of health promotion and advocacy for the covered plan period is improved health and increased health awareness among clients and the entire community. Using effective behavior change communications strategies, people are hoped to exhibit good health-seeking behaviors. The National Policy on Health Promotion, stated in DOH Administrative Order 58, S–2001, covers all health facilities and agencies in the health sector throughout the Philippines. It also listed down three [3] major strategies to attain a healthy Philippines. First is changing living conditions. Second is changing lifestyles. Third is re-orienting health services, under which health promotion falls.

As defined by the DOH, health promotion is a process of enabling people to take action to improve their health through healthy behaviors. There are five [5] areas to effect good health-seeking behaviors: a public policy supportive to health concerns, a supportive external environment for people to live healthy lives, a strengthened and empowered community to take action for health, and a re-oriented health care delivery system.

Health promotion, to affect behavioral change, therefore, in this context and times, goes beyond the distribution of IEC materials. Traditional methods of increasing awareness and knowledge of a particular health problem is usually not enough for people to take action. Neither is a new or improved health service or technology. Health promotion must focus on promoting, facilitating and sustaining behaviors that motivate people to act on healthy behaviors, address barriers or resistances to health-seeking behaviors, and provide correct practical knowledge on how to do the good health-seeking behavior.

A behavior is considered “feasible” if the health program, community or family actions can sufficiently use positive motivations and actions to eliminate or reduce the major barriers standing between current and “improved” health promoting behaviors. These barriers [sometimes called “resistances”] may be internal – such as a lack of awareness, motivation, positive beliefs and perceptions, and feelings of control – and/or external – such as a lack of money, time, access to key products or technologies, support from the family or community, or key program services.

Without a focus on behaviors from the very beginning, health programs may end up with interventions that are under-used and that have only a modest impact. This is shown by the fact that many program evaluations that find dramatic increases in knowledge and attitudes, but little or no change in behavior. Instead, focusing on behaviors [or the “P” element in KAP – knowledge, attitudes, practices] from the beginning should help prevent this from happening.

In this regard, training courses on behavior change communications need to be provided to all key health personnel at the RHUs/BHSs. The training will enable health personnel to determine what factors enable and prevent people from acting in a particular way. After a series of processes, the participants determine and formulate appropriate messages to affect positive behavior change.

The RHU must designate their respective Health Education and Promotions Officer [HEPO] to take the in lead in implementing the health promotion program of the municipality/city. If funding is allowed, additional health personnel can be hired. HEPOs will undergo various capacity building activities to equip them with the necessary skills and competencies to be able to perform their health education tasks.

Health promotion in Bulacan can designate the year 2010 as Cancer Awareness Year, 2011 as Healthy Lifestyle Year, 2012 as Maternal Health Year, 2013 as Child Health Year. Each month of the year will then focus on particular health initiative/concern, for example January as Cancer Awareness Month, February as Heart Awareness Month, and so on. Health messages can be channeled through partnership with the media establishments in Bulacan.

Various events can be conducted to popularize health messages to the public. Search for the healthiest/most healthy restaurant, resort, hotel, workplace, school, barangay among others can be initiated to generate support and increase awareness for healthy sites.

9. Health Facilities Development Program

Developing health facilities aims to contribute to the national health objective of increasing accessibility and providing effective and efficient quality health services to the community in general and to clients in particular. Performance indicators include Sentrong Sigla [SS] Phase I and Phase II certification of RHUs and other health facilities. Another is PHIC accreditation to deliver OPB, MCP and TB-DOTS packages.

The hospital system, as an integral part of healthcare delivery in the Philippines, is composed of the public and private hospital sectors, classified into primary, secondary and tertiary levels according to their service capabilities. In a nutshell, government hospitals are over-taxed in terms of resources, clients and service personnel. RHUs and BHSs are the first point of contact in the communities for the delivery of basic and quality health care. However public perception of RHU and BHS delivering quality health care is low. For example, existing laboratory and diagnostic equipment in the hospitals are worn-out through constant use and outright out of order. Working equipment are already outmoded.

Patients and clients bypass the RHUs and BHSs due to non-satisfaction of service. Patients repeatedly visit the health facilities due to poor diagnosis of illnesses. Commodities are considered inferior, and if superior in quality, unavailable. RHU/BHS personnel are rarely at their stations. As the first point of contact at the community level, patients stand long, services are not only 24/7 open, and facilities are not at par with their counterpart at the private sector.

Improving public private facilities will facilitate easy access of clients to crucial primary health care services. This will minimize the traffic at the secondary and tertiary facilities. Hospitals can then provide what they are supposed to deliver, specialized services that cannot be provided at the primary health care facilities. Also, referral mechanisms among different RHUs/BHSs and across LGUs/ILHZs need to be strengthened.

The curative health care delivery system in Bulacan is provided largely by the private sector. The public health sector has only ten [10] government hospitals, which can be further classified to one [1] Level 1, eight [8] Level 2 and one [1] Level 4 hospitals.

The hospital bed to population ratio is 1:1,541, well below the DOH standard of 1:500. The Bulacan Provincial Hospital has a very high bed occupancy rate of 124.6% while the district/city hospital occupancy rate ranges from 80%–163%. [Refer to Table 25. Hospitals in Bulacan, 2008.]

Table 25. Hospitals in Bulacan, 2008

Municipality/city Name Public Hospital Bed Capacity Name of Private Hospital Bed

CapacityNumber of Hospitals

BALAGTAS     Community Medical Clinic 5Doctor's HospitalGrace General HospitalGubatan ClinicHoly Family Hospital

BALIUAG Baliuag District Hospital

75 De Jesus General Hospital 5Marcelo HospitalRugay General HospitalSagrada Familia

BULAKAN Gregorio del Pilar District Hospital

25 ES Garcia Hospital 2

 BOCAUE   BMMG Hospital 5Dr. Yanga HospitalMt. Carmel ClinicSan Lorenzo Ruiz HospitalSt. Paul Hospital

BUSTOS Bustos Community Hospital

10 San Vicente EENT 3Santo Niño Clinic

CALUMPIT Bulacan Maternity & Children's Hospital

25 

Rhamine Doctor's   

3 Sta. Cruz Hospital

GUIGUINTO  

Guiguinto Municipal Hospital 

   

Bulacan Polymedic    

4Jesus NazarethMagpoc Maternity

HAGONOY 

Emilio Perez Memorial District Hospital

50 

Divine World Hospital   

3San Agustin Hospital

Malolos City Bulacan Medical Center

300  Balagtas Doctor's Hospital 15EENTMalolos Nephrology CenterMary Immaculate HospitalOfelia General HospitalRommel HospitalSacred Heart HospitalSan Ildefonso CountySan Roque HospitalSan Vicente HospitalSantisima General HospitalSantos ClinicSantos General HospitalSt. Michael Clinic

MARILAO 

  

  Ma. Santisima dela Paz   

2 St. Michael Family

Meycauayan City     

      

      

B.A. Hospital       

8     

Evangelista HospitalLozada's General HospitalMeycauayan DoctorsNazareno's HospitalPadriguilan Medical Clinic

Table 25. Hospitals in Bulacan, 2008

Municipality/city Name Public Hospital Bed Capacity Name of Private Hospital Bed

CapacityNumber of Hospitals

  

  

    

  

St. Clara de Montefalco Medical centerSt. Francis of Assissi General Hospital

NORZAGARAY 

  

  Nodalo's General Hospital   

2 Norzagaray Emergency Hospital

PANDI   Poscablo Hospital   1PAOMBONG   San Pascual Baylon   1PLARIDEL     Country Hospital   5

Marcelo - Padilla & Medical ClinicMary the Queen General Foundation, Inc.Plaridel EmergencySan Diego General Hospital

PULILAN 

  

  FM Cruz General Hospital   

2 Jesus the Good Shepherd

SAN ILDEFONSO   Flores Hospital   1SAN MIGUEL San Miguel District

Hospital50 Emmanuel Vera Hospital   2

SAN RAFAEL   Caypihan Polymedic   1Santa MARIA   

Rogaciano M. Mercado Memorial Hospital   

100   

Garden Village Country      

6   

Mateo's DiagnosticMendoza General HospitalSantiago PediatricSt. Mary's Hospital

San Jose del Monte City

Ospital ng Lungsod ng San Jose del Monte

50 Roquero Hospital   2

Baseline from 2008 data shows that all government hospitals met the minimum DOH licensing and PHIC accreditation requirements. Only the Bustos Community Hospital is not accredited by the PHIC. 53 RHUs are SS-certified. Only one [1] RHU is accredited by PHIC to deliver MCP; 21 RHUs to deliver OPB package; and 12 RHUs are TB-DOTS accredited.

The goal for the planning period is to make all [100%] public health facilities SS-certified and PHIC-accredited. SS certification entails that facilities strictly adhere to the standards set down by the DOH. Concretely, RHU facilities need to be renovated and improved, equipment upgraded, and core health competencies developed from among health personnel.

9.A. Rationalization of Local Health Facilities to include BEmONC/CEmONC

With the width and breadth of the public health sector in Bulacan, there is a need to rationalize the operations of its health facilities. Rationalization is critical in the light of LGU funding limitations and the growing health needs of the population. Rationalization will determine which limited resources will go to what health facility, creating the biggest social impact in terms of making accessible health care services. A comprehensive assessment, including health facility mapping, of the province’s health facilities should be undertaken.

As stated earlier, there is no existing Basic Emergency Obstetrics and Newborn Care [BEmONC] or Comprehensive Emergency Obstetrics and Newborn Care [CEmONC] facility in the province. However, the plan calls for the improvement and repair of RHU

facilities in eighteen [18] municipalities to become BEmONC facilities while seventeen [17] municipalities will establish their own for a total of 35 BEmONC facilities.

Support from the local executives and legislators will be gathered for the establishment of BEmONC facility in the area, including staff complement and training, establishment of operations manual, procurement of ambulance, equipment and supplies among others.

Existing RHUs and BHSs in Bulacan still lacks the complete equipment, logistics and supplies to be able to effectively provide quality health care services to the people. Fourteen [14] RHUs need to immediately purchase basic equipment. Health officials need to request for additional funding, yearly, to cope up with the rising health needs of the people. These needs, if met, will facilitate SS certification and PHIC accreditation of health facilities.

The RHUs of Meycauayan, Marilao and Santa Maria still need to undergo the process of re-organization to be able to attain full status as RHU. Efforts must be made to solicit support from their respective legislative bodies to attain full recognition, thus funding support for health programs and projects.

Quality assurance needs to be maintained in existing SS-certified and PHIC-accredited health facilities. This involves regular facility monitoring and assessment. This is particularly true to attain continuing accreditation by the PHIC to deliver OPB, MCH and TB-DOTS packages.

Referral system is another area for improvement in the province and in the ILHZs. This comprises referrals not only between public health facilities but also between the private and public health sectors. RHUs are not yet equipped with the minimum communications gadgets making emergency referrals difficult at best.

9.B Health Human Resource Provision/Capability Building

Health care manpower and facilities in Bulacan are classified into the Field Health Services [FHS] and Hospital Operations. The FHS which includes health programs have been devolved to the municipal/city LGUs. The latter have assumed full responsibility in the delivery of primary health care services to their respective communities.

The FHS is a network of 59 RHUs covering the province’s 24 municipalities/cities and 569 barangays. There are also satellite stations in the barangays numbering 535 BHSs. Around 863 professional health workers manage the RHUs and BHSs. They are the first points of contact to the health care system by the community. They deliver the basic health services, which are promotive, preventive, curative and rehabilitative. The health facilities in the municipalities/cities constitute of the RHUs and the BHSs. Each BHS may serve one or more barangays, depending on population, location and availability of health personnel.

[Refer to Table 26. FHS Facilities, by Municipality, 2008 and Number of BHWs and Table 27. Field Health Service Workers, by Category, 2008.]

Table 26. FHS Facilities, by Municipality, 2008 and Number of BHWsMUNICIPALITY/CITY RHU BRGY BHS BHW

ANGAT 1 16 13 43BALAGTAS 2 9 9 64BALIUAG 4 27 26 59BOCAUE 2 19 19 37BULACAN 2 14 14 94BUSTOS 1 14 14 221CALUMPIT 2 29 29 302DRT 1 8 8 78GUIGUINTO 2 14 14 67HAGONOY 4 26 26 161MALOLOS 4 51 49 278MARILAO 1 16 16 57MEYCAUAYAN 4 26 26 45NORZAGARAY 2 13 13 68OBANDO 1 11 11 54PANDI 1 22 22 72PAOMBONG 2 14 13 94PLARIDEL 2 19 19 43PULILAN 2 19 14 85SAN ILDEFONSO 3 36 32 213SAN JOSE DM 5 59 59 579SAN MIGUEL 4 49 40 169SAN RAFAEL 2 34 25 112STA. MARIA 3 24 24 34PROVINCE 57 569 535 3029

Table 27. Field Health Service Workers, by Category, 2008.Position Quantity %age

MHO/Rural Health Physician [RHP] 67 7.33%Public Health Dentist 43 4.70%Public Health Nurse [PHN] 95 10.39%Rural Health Midwife [RHM] 485 53.06%Engineer/Sanitary Inspector 55 6.02%Medical Technologist [Med. Tech.] 38 4.16%Dental Aide 39 4.27%Nutritionist 15 1.64%Non-Technical Staff 77 8.42%Source: FHSIS [Demographic Report]

Providing technical assistance to the FHS units are twelve [12] members of the Provincial Public Health Office [PPHO] and six [6] members of Bulacan Provincial Blood Center. The PPHO has its office at the Bulacan Medical Center, Malolos City, Bulacan.

Directly assisting the FHS are 3,029 active BHWs. They are volunteer health workers residing in the different barangays throughout the province. They provide health information and education to the community. They also serve as motivators for health. They have been trained to recognize simple cases of ailments, urging the patient to seek consultation at the BHSs or RHUs.

In determining the need for health workers, the suggested ratio to population is often used. Bulacan has a total population of 2,923,847. In the above FHS manpower of health workers,

the rural health physician to population ratio is 1:43,640, below the DOH standard of 1:20,000; public health nurse is 1:30,777 below the DOH standard of 1:20,000; rural health midwife is 1:6,029, below the DOH standard of 1:5,000; and sanitary inspector is 1:52,212, below the DOH standard of 1:20,000.

The RHU to population ratio is 1:49,557, within the DOH standard of 1:50,000. The municipalities of Angat, Santa Maria, Bocaue, Marilao, Norzagaray, Pandi, Obando, and the cities of Malolos and San Jose del Monte exceed the 1 RHU:50,000 population ratio. The municipalities of Baliuag, Santa Maria, Bocaue, Marilao, Meycauayan, Norzagaray, Bulacan, Balagtas, Obando, Guiguinto, Plaridel, Pulilan and San Jose del Monte City exceed the BHS:population ratio.

The spirit of volunteerism is very well alive in the communities. The number of active BHWs who provides time to help their community, particularly in health aspects shows this. Many of these BHW started in the early 1980s when the concept of primary health care [PHC] was first introduced into the country. Their main role is to provide health information, assist in mobilizing the people for health activities and participate in planning and implementing health program for their communities. These BHWs were registered and/or accredited by each municipal/city LGU through the RAC or their respective Local Health Boards.

The problem of fast turnover of health workers in the different RHUs/BHSs persists. Due to the low compensation package and overloaded work, many leave the public health sector after getting enough experience to apply abroad or to the private health sector. Also, due to limited budget most LGUs cannot hire additional health personnel to lighten workload shouldered by current staff. Overworked health personnel impacts on the delivery of quality health service to the community.

At first glance, the province’s population needs 89 additional RHUs and 50 BHSs. This is to comply with the DOH standard ratio of health facilities to population. These new health facilities need to be staffed by 85 new RHPs, 100 dentists, 85 nurses, 91 sanitary inspectors, 50 midwives and 106 medical technologists. Efforts must be made at the different levels of local governments for increased funding for health. This includes funds for the hiring and training of new health personnel, construction and improvement of health facilities, regular procurement of commodities and supplies, maintenance and operational expenses among others.

9.C Integration of Wellness Services in Hospitals

The Bulacan Medical Center is in need of critical improvements and additional structures. The current layout has no pharmacy and cashier. Patients and clients have to walk far and back to transact their hospital business. Onboard administrative and health staff is limited in the laboratories, x-ray department and operating room resulting to inadequate time of service. The OPD and ancillary services are housed in a dilapidated building. The RMMMH have poor ventilation and poor layout resulting to unnecessary time delays.

Hospital occupancy rate is high at 160%, taxing the resources of the medical institution. Most patients needing primary health care do not go to the primary health care centers. Instead they go directly to the provincial hospital, draining hospital resources which could be used to treat tertiary-level or more complicated illnesses primary health centers cannot treat and manage.

While there is an existing two-way referral system at the hospital level, it is not fully implemented. Neither is monitoring done of referred patients. There is delayed referral of high-risk pregnancies at the district hospital level. This is due to the poor seeking behaviors of pregnant women who are constrained by limited funds. There is no computerized database to track down and monitor patient progress from sickness to recovery.

There is no standard management of pathologic and infectious waste disposal at the provincial and district hospitals. Only the provincial hospital has an existing liquid waste disposal system. This poses a hazardous threat to the immediate environment and surrounding human settlements.

Interventions need to be undertaken to make the Bulacan Medical Center as a center of wellness.

HEALTH FINANCING

For 2008, funding for the public health sector amounted to Php ___, ___% of the total provincial budget. For a population of 2,826,926 [2008 data], this translates to a health fund of Php ___ per household. [INSERT graph showing increase in population and decreasing health financing] This was an increase of ___% or Php ___ from 2006 levels. Budgetary allocation for health and health-related activities from the municipalities and cities are also within the ___% standard. As can be seen, current provincial public health spending is not enough to cover all priority health and health-related programs.

Public health financing aims to secure increased, better and sustained investments in health to provide equity and improve health outcomes, especially for the poor and vulnerable. Strategies include mobilizing resources from other fund sources, strengthening coordination between province and municipal/city spending for health, direct subsidies to priority health programs, adopting a performance-based and needs-based financing system, and increasing the coverage of health insurance program.

The PGB has allocated in 2009 a total of Php 478,796,425 for the operation and maintenance of its seven [7] hospitals. As shown in Table 00, the P/LGU has been steadily increasing its budgetary allocation for its hospitals from 2007 data. The 2009 budget for hospitals is more than 90% of the total budget allotted to the public health sector, leaving less than 10% for field operations. [Refer to Table 28. Provincial Budget Allocation for Hospitals, 2007-2008.]

Table 28. Provincial Budget Allocation for Hospitals, 2007–2009Year Bulacan

Maternity and Children’s

Bulacan Medical Center

Gregorio del Pilar District

Hospital

Rogaciano M. Mercado Memorial

Baliuag District Hospital

San Miguel District Hospital

Emilio G. Perez

Memorial

Hospital[BMCH] [BMC] [GPDH]

Hospital[RMMMH] [BDH] [SMDH]

Hospital[EGPMH]

2007 11,234,551 131,750,467 11,272,145 43,501,693 26,657,171 17,553,863 15,256,1972008 14,803,417 201,246,348 15,270,006 71,276,816 42,207,766 24,243,870 23,122,6812009 18,835,565 258,556,705 17,514,460 82,354,052 44,286,247 28,927,301 28,322,095

Mobilizing other fund for health entails increasing revenue generation capacities of health facilities. Applying user’s fees and other charges for personal health care and other services for the non-poor will increase available health funds. Table 29. Financial Performance of Public Hospitals in Bulacan, 2008 shows how the public hospital system fared in generating income for 2008. This will increase access by the poor. Another source of revenue aside from user’s fees and other charges is the rationalized use of real property assets of public health agencies. Increasing revenues and lessening costs with the same output of delivering quality health care is the goal in improving efficiency of the public health sector.

Table 29. Financial Performance of Public Hospitals in Bulacan, 2008

Indicators

Bulacan Maternity & Children’s Hospital[BMCH]

Bulacan Medical Center[BMC]

Gregorio del Pilar District

Hospital[GPDH]

Rogaciano M. Mercado Memorial Hospital

[RMMMH]

Baliuag District Hospital[BDH]

San Miguel District Hospital[SMDH]

Emilio G. Perez

Memorial Hospital

[EGPMH]Bed Occupancy Rate 102.74% 141.24% 97.00% 141.66% 120.40% 94.77% 88.51%Total Patients Served 19,918 13,896 8,282 4,135Daily Cost Recovery [in Php] 1,619.32 1,779.89 1,674.10 1,363.12 1,263.95 1,473.07

Total Income [in Php] 11,680,534 68,375,450 6,485,310 43,811,673 20,484,496 7,860,890 10,128,887Recovery Rate 95.11% 90.89% 91.27% 89.65% 95.13% 91.89% 92.55%

As stated earlier, the different municipalities and cities of Bulacan had formulated their respective CSR+ Plans for the year 2008. The eleven [11] LGUs of Angat, Balagtas, Baliuag, Bocaue, Bulacan, Bustos, Doña Remedios Trinidad, Meycauayan, San Ildefonso, San Miguel and San Rafael implemented cost-recovery scheme for FP commodities. The LGUs of Balagtas, Norzagaray, Santa Maria and San Jose del Monte City line budgeted the procurement of CSR commodities. The plus [+] in the CSR+ refers to anti-TB drugs and Vitamin A supplementation for children and pregnant women.

One of the issues besetting the public health system in Bulacan is low budget utilization. For example, an aggregated Php 54.14 million was budgeted for the purchase of FP, TB and Vitamin A supplementation commodities. However, only Php 24.07 million was actually spent for the purchase of commodities. Table 30 shows the budget-expenditure performance for selected commodities.

Table 30. Budget vs Actual Expenditures for Selected Commodities, 2008

Family Planning TB Program Vitamin A Program Total

Budget [in million pesos] 22.34 27.30 4.50 54.14Expenditure [in million pesos] 7.57 11.10 5.40 24.07

1. Expansion of National Health Insurance Program

Of the total indigents in the province, only 93% were enrolled in 2008. Only a few municipalities/cities have been able to attain 85% national standard of indigent enrollment. This is also true for the informal sector.

Poor municipalities, particularly the 4th, 5th and 6th classes, have difficulties in sustaining PHIC enrollment of indigents. Some LGUs have high coverage of indigents on the first year but cannot renew all on the second and third year. Maintaining the current provincial enrolment of indigent families require fund infusion. Continuing education for local executives must be undertaken for them appreciate the concept of investing in social health insurance, as well as the concrete benefits accruing from the utilization of the capitation fund.For 2008, there were 40,378 indigent enrollees. Of this number, only a number of indigents used their PHIC cards in availing of health services from the public health centers. This translates to ___% utilization. While indigent PHIC members can avail of health services and benefits from accredited health centers, they do not have the available cash resources to purchase essential drugs and medicines. Also, many indigent PHIC card holders are not fully aware of their right and responsibilities as PHIC members. They also do not know how to access their membership benefits.

For the year 2007, the P/LGU sponsored 14,796 indigents worth Php 9.34 million while the municipal/city LGUs have an aggregate total of 22,174 indigents enrolled worth Php 11.68 million. Total enrolled under the Sponsored Program was 35,970 indigents, which is 66% of the estimated 56,008 indigent households in Bulacan. A total of Php 27.79 million worth of medical claims was reimbursement by the PHIC. The P/LGU submitted claims worth Php 7.10 million while the municipal/city LGUs have claims amounting to Php 20.69 million. Total capitation fund released to the LGUs was Php 22.74 million. [See graph below.]

Public health expenditures for Bulacan totaled Php 402,650,361 for 2008. These expenditures were from the Bulacan Provincial Hospital with Php 200+ million, Php 191+ million from the district hospitals and only Php 10+ million or 3% from the public health system. [See graph in next page.]

2. PHIC Accreditation of Health Facilities

54 out of the 57 RHUs are SS-certified. However all government hospitals in the province are both DOH-certified and PHIC-accredited. [Refer to Table 31. Accreditation Status of government-Owned Hospitals in Bulacan and Table 32. Accreditation Status of Health Facilities in Bulacan, 2008.]

Table 31. Accreditation Status of Government-Owned Hospitals in BulacanHospital DOH PHIC Occupancy Rate ALOS

Bulacan Medical Center Level IV Tertiary with Training Capability

141.24% 4.92

Baliuag District Hospital Level II Secondary 120.26% 3-4Bulacan Maternity and Children’s Hospital Level II Secondary 91.85% 2.91Emilio G. Perez Memorial Hospital Level II Secondary 91.23% 3.8Gregorio del Pilar District Hospital Level II Secondary 111.00% 3Rogaciano M. Mercado Memorial Hospital Level II Secondary 142.90% 3San Miguel District Hospital Level II Secondary 94.77% 4

Table 32. Accreditation Status of Health Facilities in Bulacan, 2008

Municipality/City No. of RHU No. of SS-Certified

TB-DOTS Accredited

MCP Accredited

OPB Accredited

Angat 1 1     1Balagtas 2 2 1 1 1Baliuag 4 3     4Bocaue 2 2     1Bulacan 2 2     1Bustos 1 1   1 1Calumpit 2 2      Doña Remedios Trinidad 3 1     1Guiguinto 2 2     1Hagonoy 4 3 1   1Malolos City 1 4      Marilao 1 1      Meycauayan City 4 4      Norzagaray 4 2      Obando 2 1 1 1 1Pandi 1 1 1   1Paombong 1 2 1   1Plaridel 2 2 1   2Pulilan 2 2     2San Ildefonso 2 2     1San Jose del Monte City 5 3 2   3San Miguel 3 4 2   1

San Rafael 4 2 2   2Santa Maria 2 3     1Total 57 52 12 3 27

As can be seen from the Table 32, 27 RHU facilities are accredited by the PHIC to provide OPB packages, 3 for MCP and 12 for TB-DOTS.

PHIC accreditation of health facilities involves passing accreditation requirements. These are in the areas of facility improvement, availability of equipment and commodities. Once accredited, facilities must sustain compliance requirements, which need continuing funding from the LGUs. Capitation funds or PHIC reimbursements are not enough to sustain same level of PHIC enrollment, much more for facility improvement.

Most of the RHU health facilities are in need of improvements. Improvements can be in form of repairing broken windows, inoperable and unsanitary comfort rooms, private examination room, no 24/7 water supply, inadequate chairs for clients, poor ventilation and lighting, among others. Many RHUs have incomplete equipment.

3. Rationalization of PHIC Reimbursement

Utilization of PHIC reimbursement is solely at the discretion of the LGU. Standard division is 20% for administrative costs and the remaining 80% is for facility improvement and monthly operating and other expenses [MOOE]. However, this standard is not strictly followed by the LGUs.

Most LGUs utilize PHIC reimbursement for facility maintenance, purchase of essential medicines and supplies, among others. There is a need for the LGUs to rationalize the utilization of PHIC capitation fund. This involves data gathering and analysis of municipal/city health needs viz. allocated budget. Health officers must advocate for increased budgetary allocations from municipal/city regular funds and from other sources of funds to their local executives and municipal councilors for health.

HEALTH REGULATION

Health regulation pertains to the power of the State to make necessary laws supportive to health and health-related initiatives. It also deals with the power of the government to enforce these laws.

1. Enforcement of and Compliance to National Health Legislation and Standards

Around 80% of all municipalities/cities have had enacted local legislation adopting the implementation of national health laws and regulations. These national health-related laws are the Milk Code, Mother-Baby Friendly Hospital, Asin Law [Republic Act 8172], Expanded Child Care Development, Sanitation Code, the Clean Air Act of the Philippines.

Enforcement of nationally mandated laws at the province and municipalities/cities is moderate at best. Contributory factors are the absence of local ordinances strengthening the

implementation of these policies and the lack of capability of local policy makers and enforcers.

For instance, data shows that 83.4% of all infants born in 2008 were exclusively breastfed for the first six months. This clearly manifests the good implementation of the Milk Code at the hospital and birthing stations. Rate of compliance to the Milk Code would have been more higher is provincial and municipal/city legislations reinforced the code. The 83.4% accomplishment of mothers exclusively breastfeeding their children for the first six months was due to the active education and health promotion activities of health workers, particularly the BHWs.

Another is the Asin Law. Municipal/city legislative councils have passed local ordinances on the use of iodized salt by households and food establishments. Spot inspections by health workers in households and in commercial/market areas reveal 88.6% compliance rate in commercial/market areas and 89.63% compliance rate at the household level.

The provincial capitol grounds, including hospital compounds and public areas housing health agencies were declared Smoke-Free Zone 2008 by an Executive Order. Bulacan Governor Jonjon Mendoza has been vocal actively persuading local chief executives to do the same in their respective municipalities and cities.

All municipalities and cities in the province had enacted resolutions and policy statements on CSR+. Processes have been undertaken province-wide to determine the best possible way of mitigating the effects of decreased FP commodities due to pullout of foreign donations. This was in line with DOH Administrative Order 158 Series of 2004 outlining the strategies to reach Contraceptive Self-Reliance. However, not all LGUs have the necessary funds to implement the full CSR+ plans.

Policy makers at the local levels do not have adequate knowledge on the important health legislations passed by Congress. There is a need to educate and inform local policy makers on these important health laws and regulations so as to make the necessary legislations supporting national health laws.

Eleven [11] private-owned birthing homes, with the assistance of the PHO and a USAID-funded program, were accredited by the PHIC in 2008. This step was taken to increase participation of the private sector in delivering family planning health services. Bulacan Gov. Jonjon Mendoza signed an executive order creating the Private Health Desk .

2. Access to Low-Cost Quality Drugs and Commodities

For 2008, there were 284 existing Botika ng Barangay [BnB] located in the different areas of the province. 108 of these were assisted by the P/LGU through the infusion of Php 25,000 cash for the purchase of medicines for a total of Php 2,700,000. Total current assets of the BnBs amounted to Php 9,966,852.92. [Refer to Table 33. Botika ng Barangay Establishments in Bulacan, 2008.]

Table 33. Botika ng Barangay Establishments in Bulacan, 2008

Municipality/City No. of Brgys.

Existing BnB

P/LGU Funded

For Expansion

Angat 11 3Balagtas 11 2Baliuag 4 2Bocaue 5 3 2Bulacan 12 5Bustos 12 11Calumpit 14 8Doña Remedios Trinidad 8 4Guiguinto 12 4 3Hagonoy 12 9 1Malolos City 8 2 2Marilao 7 5 2Meycauayan City 15 13Norzagaray 9 3 2Obando 8 4Pandi 7 5 1Paombong 7 3Plaridel 15 1Pulilan 7 5San Ildefonso 13 4San Miguel 25 3San Rafael 15 2San Jose del Monte City 31 5Santa Maria 16 2 8Total 284 108

A BnB is established in a barangay following this process. The concerned barangay, through the Barangay Council, writes a resolution stating the reasons for the need to set up a BnB. Said resolution is endorsed to the Bulacan Provincial Health Office for action. The PHO sends over a team to the area and conducts an evaluation. The evaluation team then prepares a report and recommendation to the PHO. If approved, the PHO endorses the resolution to the Office of the Provincial Governor for funding. In many instances, funding for BnBs did not come from the Office of the Provincial Governor but from other sources, e.g., municipal or congressional funds.

The establishment of a BnB aims to increase access of clients to low-cost quality drugs and commodities. As is, drug prices are increasingly becoming more expensive and the purchasing power of the population, particularly the poor, has been decreasing for the past decades.

The BnBs sell over-the-counter drugs and eight [8] prescription drugs namely: metformin [500mg tablet], glibenclamide [5 mg tablet], metoprolol [50 mg tablet], captopril [25 mg tablet], salbutamol [2 mg tablet] and salbutamol [60 ml syrup]. These establishments also sell other goods and supplies.

Making these BnBs profitable, that is, recovering cost with profit margins, remains to be a challenge. As village-based enterprises funded by the public sector, it should at the least, show profit to be able to expand its operations and stocks.

HEALTH GOVERNANCE

The Local Government Code gave greater autonomy to local government units. Correspondingly, devolution brought the responsibility of maintaining the people’s health at the hands of the LGUs. The challenge therefore, continuing to the present time, is providing quality primary health care to the people with finite resources. At the helm of health governance is the local chief executive, through the municipal/city health officer. Advising the local executive is the local health board. The local health board’s formation is mandated by the LGC.

The formation of inter-local health zones [ILHZs] in the provinces is a strategy to respond to this need of limited resources. In Bulacan, the ILHZ is the Unified Local Health System [ULHS]. It is composed of the district hospital and its designated catchment areas where non-primary health care needs are referred to by the RHUs/BHSs. Referral system is also established and strengthened to facilitate the flow of clients from one health facility to another. District-wide health issues are discussed and health promotion strategies are formulated at the ULHS. Relevant health information is collected, collated and analyzed at the district-level.

The operation, management and sustainability of the ULHS rest on the expertise of the members of health boards at the district level and the cooperation of the municipality/city local health boards. As is, there is no local political entity with executive powers reigning over the district. The challenge therefore is maintaining cooperation or striking a balance between the concerned LGUs, their local executives, the needs of their areas and their financial health.

The Provincial Health Board is functional, with members from civil society organizations actively participating in all its deliberations. It held two [2] meetings in 2008 with the Bulacan Governor in attendance. All municipalities and cities in the province have formed their local health boards. Except for the municipalities of Guiguinto and Pandi, the health boards are functional. A functional health board means that the board is convened and meets regularly on a monthly, quarterly, bi-annual or as often as necessary. A non-functional health board means the body was not yet convened or does not meet regularly.

Civil society participation is seen in all health boards except in the municipalities of Angat, Bulacan, Doña Remedios Trinidad, Guiguinto and San Ildefonso.

1. LGU Health Management

1.A. Local Health Systems Development

The delivery of secondary and tertiary health care services in the province is catered to by the provincial hospital and the 7 hospitals strategically located in each congressional district. These hospitals are owned and maintained by the provincial government and two [2] community hospitals owned by the municipal governments. 59 private hospitals offering various health services complement the pubic hospital system.

Of the 57 RHUs/CHOs, 53 are Sentrong Sigla Level I-certified. All RHUs/CHOs are TB-DOTS centers; however only 12 are accredited by the PHIC. 27 RHUs/CHOs are accredited by the PHIC to provide OPB package and only one [1] is MCH-accredited in the municipality of Bustos.

The creation of a Public Health Desk at the ULHS is another strategy formulated to increase accessibility of clients to quality health care. Preparatory activities like orientation to RHU/BHS personnel and community and signing of Memorandum of Agreement with LCEs and chiefs of hospitals were undertaken. The Baliuag, San Miguel Hagonoy and Bulacan ULHS even constructed facilities, purchased basic equipment and supplies for initial its operations. However, the public health desk became non-functional across time due to a number of factors. One of which was the absence of full-time staff to man the desk, changing priorities thus changing budget allocations of the concerned LGUs.

1.B. Local Human Resource Strengthening

The Provincial Health Office is divided into two [2] service areas, public health and hospital services. Each service area is headed by a PHO II. The PHO II for Public Health plans, implements, monitors and evaluates public health programs. Counterpart at the municipality/city is the municipal/city health officer [MHO/CHO].

Human resource management and development is a critical concern among health service providers. Current ratio of health staff to population in Bulacan is below the standards set by the DOH to adequately provide for the health needs of the people.

Public hospitals need medical specialists that can perform highly specialized procedures. RHUs/BHS need highly competitive health workers to effectively implement public health programs. Continuing medical and non-medical education through capacity-building programs is needed to update and upgrade skills and core competencies of health personnel and volunteers at the barangay level.

The limited financial resource of the P/LGU and the LGUs prevent the LCEs from offering competitive compensation packages to skilled health professionals. Existing structures and workplace environment of health facilities do not facilitate productivity and excellence from among health workers. Due to limited internal revenue allocation from the national government and low taxation collection, LCEs prefer to utilize job orders rather than the more permanent plantilla position to cut down cost. The Magna Carta for Health Personnel has not been fully implemented as well. Job satisfaction is an issue among health workers.

Improving quality of care and increasing client satisfaction are among the key indicators of quality health service delivery system. There is no data on client satisfaction in Bulacan as a way of measuring the delivery and quality of care. There is a need therefore to improve quality of health services at the hospital and public health levels. Many clients still perceive private facilities as better providers of quality care; thus the low preference for government health facilities. Even PHIC members prefer to go to private health facilities. Aside from the

need to really provide quality services, there is a need to attract more PHIC enrollees to PHIC-accredited public health facilities as a means of increasing revenues.

Improving quality of services not only requires upgrading of facilities, it also needs the provision of quality equipment and technically capable staff and technicians. Interpersonal and communications skills of public health providers can also be improved.

1.C. Sectoral Development Approach for Health Implementation

The Local Government Code of 1991 [LGC] encourages local government units to group themselves, coordinate their efforts, services and resources for purposes commonly beneficial to them. One such purpose where inter-local/district cooperation can prosper is the delivery of health services. Considering the limited capabilities and resources of public health providers at the municipal/city level, cooperation is a strategic option to address inherent gaps and challenges in the delivery of health care services.

There are six [6] ULHS in Bulacan, each revolving around existing hospitals. They are the Malolos ULHS, Baliuag ULHS, San Miguel ULHS, Hagonoy ULHS, Bulacan ULHS and Santa Maria ULHS. The Baliuag ULHS was established first in 1999, followed by the Santa Maria ULHS in 2000. The remaining four [4] ULHS were formed in 2002. [Refer to Table 34. Unified Local Health Systems in Bulacan, 2008.]

Table 34. Unified Local Health Systems in Bulacan, 2008Name of ULHS Base Hospital Coverage

Baliuag ULHS Baliuag District Hospital AngatBaliuagBustosDoña Remedios TrinidadSan Rafael

Santa Maria ULHS Rogaciano M. Mercado Memorial Hospital BocaueMarilaoMeycauayan CityNorzagarayPandiSanta Maria

Malolos ULHS Bulacan Medical Center CalumpitGuiguintoMalolos CityPlaridelPulilan

Hagonoy ULHS Emilio G. Perez Memorial Hospital HagonoyPaombong

Bulacan ULHS Gregorio del Pilar District Hospital BalagtasBulacanObando

San Miguel ULHS San Miguel District Hospital San IldefonsoSan Miguel

Initially, existing ULHS in the province increased the number of referrals from one health facility to another, i.e., BHS RHU hospital. Smooth referrals and successful treatment cases in the past have contributed to the increased enthusiasm and high morale shown by health workers. Grants from the P/LGU DOH were used to upgrade health facilities and

procure necessary equipment and supplies. LCEs recognized the importance of shared responsibility, equity of access to health care and efficient use of resources.

At present, existing ULHS regularly meet but do not share resources on a regular basis. There was no Memorandum of Understanding [MOU] signed when the ULHS was formed between and among concerned LGUs, thus multilateral cooperation was not formalized and binding. In 2007, an assessment of the ULHS in Bulacan was conducted. DOH Undersecretary Antonio Lopez facilitated the assessment. No action however was taken on its findings and recommendations.

Private-Public partnership is evident by the presence of three [3] Public-Private Mix DOTS.

Generally, there is poor awareness on the importance of inter-local cooperation among LGUs and health service providers in Bulacan. For instance, the guidelines on the two-way referral system between hospitals and RHUs have not been fully implemented which would have defined protocols for the proper handling of cases and effectively facilitated complementation of health expertise and health resources at all levels.

One positive development in the public health sector is the involvement of CSOs/NGOs. These voluntary organizations are doing residual/relief, preventive, rehabilitative, curative and even developmental health services in the province. However there is no comprehensive information on these groups. An organizational profiling of these groups will determine exactly on how these private initiatives complement with the public health service. The Fourmula One for Health strategy promotes the involvement of CSOs/NGOs and the private sector in the health sector reform. The involvement of these groups could be enhanced to maximize their participation in achieving health sector reform.

1.D. Local Health Information System Development and Utilization

The official reporting system of the public health sector is the Field Health Service Information System [FHSIS]. The FHSIS provides basic service data needed to monitor activities in each of the health programs on a weekly, monthly, quarterly and annual basis. Data are generated from the grassroots levels; the RHU consolidates the data and submits it to the PHO every quarter. Provincial data is submitted by the PHO to CHD 3.

Program coordinators monitor and evaluate the different health programs. This is done through monitoring visits, review of reports and program implementation reviews. Program coordinators do monitoring visits where they interact with the frontline workers as well as the community beneficiaries/clients. They also review records and reports. Program coordinators also mentor and coach frontline workers during monitoring visits. Field visits are however limited due to lack of manpower. Technical staff needs to attend to their own programs and projects. Program implementation review [PIRs] is conducted every six [6] months. This is done with the RHU health staff. In 2007, the Service Delivery Implementation Review [SDIR], an enhanced PIR, was conducted with the assistance of HealthGov and the CHD. The SDIR

includes a review of all the programs, including the geographic performance along various indicators. The PHO plans to adopt this system as part of the monitoring and evaluation system.

C hap te r 4 :Gaps and De f i c i enc i e s

HEALTH SERVICE DELIVERY

1. Disease-Free Zone Initiatives

Rabies Elimination Services

Bulacan registered a total of 8,584 animal bite cases with six [6] cases of human rabies. Of these, 1,238 were given post-exposure treatment. However, 6 deaths were reported due to bites. Animal Bite Centers are established in the Bulacan Medical Center in Malolos City and in the other district hospitals.

The proliferation of animal bites in the province is due to the inability of pet owners to immunize their pet dogs with anti-rabies vaccines. While there is strong awareness of the population on the dangers of animal bites, victims and their families do not immediately seek medical attention once bitten by dogs. Due to the perception that animal bite treatment is expensive, victims resort to home-based remedies, e.g., tawak, instead, making treatment and management difficult once symptoms become critical and referred at the health facilities. Even though bite victims seek professional help, they rarely complete the treatment protocol due to the expensive cost of post-bite shots.

At the level of service providers, front line workers are not adequately trained and equipped on the treatment and management of animal bites. Much more for newly-hired health personnel. Animal bite centers are located at the provincial and district hospitals, making it inaccessible for victims and potential victims from 21 LGUs. There is also the weak referral system between the RHUs/BHSs and with the animal bite centers. RHUs/BHSs have limited supply of anti-rabies vaccine and post-exposure medicines due to its high cost.

Exacerbating this situation is the inadequate funds of LGUs for the procurement of anti-rabies vaccines. Anti-rabies vaccines are still expensive. While many LGUs have existing ordinance on responsible pet ownership, local enforcement agencies have limited resources to apply the full force of the ordinance. More than 20 LGUs have existing legislation on responsible dog ownership but lacks the provision on pet registration and corresponding fines if violated. Not all, if any, LGUs have existing veterinarians. Regulation is either lodged with the Municipal/City Agriculture Office or directly under Environmental Sanitation Department. LGUs do not have facilities for the impounding and management of stray dogs.

Immunization pet dogs and cats is possible is the cost of anti-rabies vaccine is lowered. While this cannot be done in the immediate future, efforts can be undertaken by making representation with pharmaceutical companies at the national level to provide anti-rabies vaccine at a lower cost or at subsidized prices.

Leprosy Elimination Services

Leprosy prevalence rate registered in the province is 0.04/10,000 population which is translated to 13 active cases. Prevalence rate is nearing the WHO/DOH goal of zero incidences. Leprosy cases are present in the eight [8] municipalities of Angat, Balagtas, Baliuag, Bocaue, Guiguinto, Marilao, San Miguel and Santa Maria.

Leprosy patients are currently undergoing multi-drug therapy on the way to their rehabilitation to wellness. However, the social stigma associated with the disease is still strong. While the leprosy registry has only detected 13 cases, there is a need to inform the public, particularly barangays and municipalities considered leprosy areas. This is to prevent the spread of the disease, leprosy being a communicable disease. Target communities needs to be informed on signs and symptoms of the disease and modes of transmission. People with symptoms can immediately go to health facilities for confirmation of diagnosis and 6-months multi-drug therapy.

Health service providers in affected communities do not conduct active case finding. Another round of house-to-house survey can be conducted in all municipalities and cities. Active case finding will identify leprosy symptomatic patients, and treatment can be undertaken. Active prevention and transmission measures can be initiated. Parallel training on leprosy detection, treatment and management needs to be provided to barangay health workers and RHU health personnel.

LGUs do not have adequate resources for the procurement of commodities and materials needed for leprosy detection, diagnosis and supplies. With low prevalence rate, LCEs may not prioritize leprosy elimination. LGU officials must put efforts and resources in totally eliminating leprosy as a disease in their respective areas. Multi-drug therapy supplies must be ensured to cater to new leprosy cases.

Malaria Control Services

The province of Bulacan is not a malaria-endemic province. However, there were 30 malaria positive cases registered in 2008 in San Jose del Monte City, Doña Remedios Trinidad, San Miguel, Norzagaray, and San Ildefonso, afflicting the poor upland dwellers and settlers. There are currently 12 malarious B-category barangays and 3 MEPA-category barangays. Malaria-infected barangays are located in the upland areas of the affected municipalities and city.

Bulacan has a parasite incidence of 30.7/100,000 population in 2008; malaria morbidity was 26.2/100,000 population. The RHUs has clinically diagnosed 766 patients. There were no deaths due to malaria reported.

Malaria cases are rising in the province, from 15 in 2005 to 30 in 2008. Communities living in malaria-vulnerable areas have inadequate information on malaria transmission, prevention and treatment. People with malaria symptoms are constrained to seek immediate medical attention due to geographic limitations. There are rarely health stations in far-flung barangays. Upland households do not use mosquito nets as active malaria prevention measures. Due to poverty, households become even more vulnerable due to the absence of insecticide-treated bed nets. Even when insecticide-treated bed nets are available, households do not use it due to the humid temperature.

Presence of stagnant water, favorite breeding site of the malaria-carrying mosquito, and poor environmental sanitation contribute to the increase of the mosquito population. While local legislations on environmental sanitation through the Clean and Green Program are in place, barangay officials lack the political will to enforce these ordinances.

Malaria microscopy is crucial in the detection and diagnosis of the disease. However, only one [1] medical technologist is trained in malaria microscopy. RJU/BHS personnel and barangay health are not trained on malaria diagnosis and treatment protocol, particularly collecting smear samples and on the use of rapid diagnostic test [RDT] kits. RHU personnel and BHWs need to conduct aggressive smear collection and examination to identify malaria positive patients. Health promotion activities on malaria prevention are rarely done.

The malaria control program is under the direct supervision and management of the DOH. It is not yet devolved to the LGU. Anti-malaria drug supply at the RHU/BHS is inadequate. Malaria-infected city and municipalities has no system for the procurement and distribution of anti-malaria drugs. LGUs lack sufficient supply of insecticides and bed nets for distribution to poor households due to financial constraints.

2. Intensified Disease Prevention and Control

Tuberculosis Control Services

TB ranks 5th as the leading cause of mortality and 8th as the leading cause of morbidity. Provincial case detection rate 63% against the national target of 70% and cure rate of 80% in 2007 compared to national target of 85%. Balagtas, Baliuag, Bocaue, Bulacan, Norzagaray, Obando, Plaridel, San Miguel, Doña Remedios Trinidad and San Jose del Monte City are the areas that achieved the national standard of CDR of 70%; while Balagtas, Bulacan, Meycauayan, Pulilan, Santa Maria and San Jose del Monte City national standard of TB Cure Rate of 85%.

TB afflicts different segments of the provincial population but afflicts more the poor. Poor seeking behavior of TB symptomatic patients make detection and treatment impossible. There is also the social stigma associated with the disease. TB treatment is long and arduous, particularly if the patients are from far-flung barangays. This situation prevents patients from giving the standard three [3] sputum specimens for accurate diagnosis. Family members of patients avoid being treatment partners, making rehabilitation difficult. Due to the perception of low quality of health service from the public health facilities, patients prefer to seek medical help from private

physicians, who in turn prescribe anti-TB drugs. When forced to seek medical attention at the public health facilities due to financial constraints, sputum examination appear negative.

The P/LGU in cooperation with the different LGUs have successfully implemented, albeit in limited number of barangays, the TB Patrol program. There is a need to expand TB Patrol coverage to all barangays. There is also the lack of TB advocates from the communities to assist health workers in promoting good health-seeking behaviors for TB symptomatic patients. Public health care providers are not adequately trained on the WHO/DOH standards for detection, treatment and management. Private physicians and doctors at the district hospitals, on the other hand, still prefer to use chest x-ray in the diagnosis of TB rather than the standard and accurate sputum examination. There is also no standard protocol for the treatment and management of children afflicted with TB.

Many manufacturing and commercial companies in Bulacan are engaged in production processes where workers become vulnerable to contacting TB. Companies have no existing safety standards to lessen the risk of workers getting TB.

While all 57 RHUs serve as TB-DOTS centers, only 12 facilities are PHIC-accredited. This means that the standard TB detection, treatment and management protocols are not being followed. Microscopy laboratories need improvements and equipment needs upgrading. Another concern is that only 85% of public microscopy laboratories in the province comply with sputum examination standards. 33 diagnostic laboratories and technicians lack training in sputum smear microscopy. Medical technologists from Guiguinto, Paombong, Angat, Bocaue and Norzagaray have not undergone refresher-training course on laboratory procedures and TB sputum examination.

Fast-turn over of health professionals at the RHU level continue to beset the TB program. This constraints the delivery of quality health care to TB patients in the province. Laboratories are under-staffed and medical technologists are over-worked due to the volume of microscopy examinations. PHNs, RHMs and BHWs involved in the TB program do not regularly conduct follow up visits to TB patients to determine if treatment protocol is being followed. Health workers are not adequately trained to do counseling for TB symptomatics.

Through previous technical assistance projects from the past, LGUs have been equipped to estimate budget requirements for regular health programs. For the TB program, LGUs have allocated budget for the procurement of anti-TB drugs. However, budget allocated were not all used for the TB control program. Unspent funds mostly revert back to general funds. There were also quarters where there were no anti-drugs available at the RHU/BHS.

As a national health program, RHUs are late in submitting timely reports. Some data on the program are also not validated, making planning difficult. Not all LGUs have policies for the purchase of anti-TB Category III drugs, procurement of drugs for primary complex affecting children, and have detailed policy [free and user’s fee] on the distribution of anti-TB drugs.

Except for the municipalities of San Miguel and Hagonoy, all municipalities and cities nave no Public-Private Mix DOTS referral system. Health system management for TB, particularly referrals for x-ray positive, sputum negative, needs to be enforced. Not all municipalities have existing TB Diagnostics Committees; if convened, the TBDC seldom meet to discuss cases.

HIV/AIDS Control Services

For 2008, RHUs examined 5,485 smears. 375 cases were positively identified and treated for gonorrhea. The changing sexual norms and hetero-homo behaviors of the population, particularly teens and young adults, contribute to the vulnerability of the communities to HIV/AIDS/STD/STI. Commercial sex workers and persons with multiple sexual partners are already at risk. The highly industrializing and urbanizing areas of Bocaue, Marilao, Pulilan, Malolos City, Baliuag, Bustos, Meycauayan and San Jose del Monte City are susceptible for the spread of HIV/AIDS/STD/STI.

Vulnerable communities and a segment of the population are not aware of the risks involved in contacting HIV/AIDS/STD/STI. Current health promotion activities and materials are inadequate in saturating affected business establishments and communities.

At the provincial level, there is no comprehensive program for STD/STI/HIV/AIDS. Current activities are limited to STD/STI/HIV/AIDS smear tests and other reactive activities. There is also no reporting and monitoring mechanism to immediately identify potential STD/HIV/AIDS breakout areas. At the RHU level, health care providers are not trained on HIV/AIDS/STD/STI detection, treatment and management protocols.

LGUs, through the local RHUs, have no supervision over female and male workers of the night entertainment industry in their localities. There are ordinances or mechanisms for registered and unregistered CSWs to strictly comply with mandatory standard HIV/AIDS/STD/STI testing. This is not to discriminate against the workers but as a preventive measure and surveillance sentinel for possible outbreaks. There is no risk assessment undertaken to map out and determine location of high-risk groups. There are no existing social hygiene clinics in strategic areas to cater to high-risk groups such as CSWs, men having sex with men [MSM], and the growing number of drug dependents using needles, among others.

There is no regular monitoring of HIV/AIDS/STD/STI at all levels of health program implementation. There is also no HIV/AIDS/STD/STI Council formed at the different levels of local governments to take the lead in the prevention and treatment of HIV/AIDS/STD/STI.

Dengue Control Services

For 2008, there were 1,548 dengue incidences reported with 10/17 mortalities or a case fatality rate of 1.08%. The municipalities of Calumpit and Plaridel and the cities of Malolos and San Jose del Monte registered with more than 100 dengue cases. Dengue morbidity was distributed in the remaining areas of the province. The 10 moralities due to dengue were due to late detection, making its treatment difficult at best.

Breeding sites of the day-biting Aedes mosquito, the dengue carrier, continue to exist in the province. Community residents and households lack the discipline in maintaining the cleanliness of their immediate surroundings. While there are existing ordinances on cleanliness, i.e., clearing and de-clogging of waterways and backyards of open containers, barangay officials do not strictly enforce these laws. Compounding this is the lack of community awareness and information on dengue symptoms and the need to seek medical treatment once symptoms appear. Households mistake the symptoms of dengue to fever, thus resort to routine remedies, without the benefit of advice from health professionals. Deaths due to dengue happened due to late detection and referral to hospital care. Dengue cases for 2008 mostly took its toll on children of school age.

Dengue prevention is not the sole task of the public health sector. Dengue case reduction needs the cooperation of all members of the households, the barangay council and school administrators. Children of school age whose immune systems are still developing need to be safe from mosquito bites. School administrators in cooperation with the barangay council and the Parents-Teachers-Community Association should ensure the cleanliness and adequate ventilation of classrooms to prevent mosquitoes from breeding in dark and dank places.

RHU personnel, on a limited basis, conduct health promotion activities on dengue prevention and treatment. There is no comprehensive communications plan for dengue and other health programs. But these activities are being done during the months of July to December where dengue cases peak. There is no vector survey conducted by the RHUs/BHSs on a regular basis to determine suspect areas of dengue cases.

“Sa Iskul Ligtas Ako sa Dengue” started last June 2007, was not sustained due to lack of health personnel and IEC materials. The program covered not all public primary and secondary schools. Referral system is weak between first level health facilities and hospitals.

LGU-sponsored fumigation activities are not enough to eradicate the Ardes mosquito. Fumigation drives away the mosquito only to return later. Fumigation, to be effective, must be complemented by an aggressive information campaign to increase knowledge of communities in vector control to combat dengue.

Health personnel are not adequately trained on dengue prevention and first-level treatment. Municipal/City Epidemiology and Surveillance Unit [M/CESU], though existing in the different areas, are not functional and adequately equipped in monitoring and surveillance activities.

3. Emerging and Reemerging Infection Prevention and Control Services

Avian Influenza

Existing commercial poultry farms in the province have no bio-security measures in place.

The participation of the private health sector in times of disasters is weak or non-existent during the last avian influenza attack. The public health sector, on the hand, has inadequate training and treatment facilities and medicines to respond to another avian influenza epidemic. There is no

comprehensive health communications plan for avian influenza at the province and affected LGUs. Health promotion activities were limited in the distribution of IEC materials. Orientations on avian influenza were provided to limited number of communities.

Disaster coordinating councils at the province and municipal/city levels are immediately convened when disasters strike. However, efforts to mitigate the effects of man-made and natural disasters are weak. LCEs do not see the need to reduce the risk of disaster. LGUs of the nine vulnerable areas of Calumpit, Pulilan, Paombong, Baliuag, Hagonoy, Bulacan, Plaridel, San Ildefonso and Malolos have no common plan to respond to avian influenza. The National Avian Influenza Task Force and its local counterpart at the province and municipality/city levels are still in the process of reviewing its plans. Surveillance systems, as planned, are not yet implemented at the municipal/city level.

Health personnel from the RHUs/BHSs and hospitals lack regular updates on emerging and re-emerging diseases. Emergency response teams formed in the province are not yet trained on basic emergency procedures.

3. Child Health

There were 305 registered infant deaths in Bulacan in 2008 or 2.80% of the overall deaths, which was higher than the 198 infant deaths in 2007. For the past several years, pneumonia topped the leading cause of death with 90 deaths or 29.51% of total infant deaths. Prematurity ranked second with 35 deaths or 11.48%; and congenital anomalies ranked third with 26 deaths or 8.52% of total infant deaths. For 2008, the IMR was only 4.72/1,000 LB, which is very low compared to the national average. Norzagaray reported the highest IMR at 14.71 per thousand live births, followed closely by Angat at 14.51% and Hagonoy at 14.42%.

The rising incidence of infant mortality in the province was contributed by the following factors. Due to poverty and inadequate knowledge, mothers do not seek immediate medical attention from health professionals when symptoms appear on their children. Only when symptoms become critical or the child has been sick for days will the mother bring the child to the health facility. Poor nutrition and poor environmental sanitation are factors that weaken the child’s immune system, making the child vulnerable to illnesses. Households are prone to apply household remedies to childhood illnesses. Pregnant women do not follow medical advice on taking care of themselves and their babies.

There is no master list of children 0-5 years of age in the municipalities, making monitoring by health workers difficult. LGUs have no sufficient funds to conduct regular home visits to post-partum women.

Expanded Program on Immunization [EPI]

The province of Bulacan has immunized a total of 75,325 infants for the year 2008. This number covers 86% of the total children needing immunization, with an unmet need of 9% to achieve 95% coverage. 2008 data shows that two [2] out of the [3] cities and four [4] out of the 21 municipalities have achieved 95% and above coverage of fully-immunized children.

Immunization data shows disparity between barangays, municipalities and cities. RHUs/BHSs have no master list or systematic recording and reporting of children 0-5 years of age, making monitoring by health workers difficult. CMBIS is not conducted annually to determine actual number of children needing immunization. Children belonging to poor households located in marginalized and hard-to-reach areas, become vulnerable to childhood illnesses due to non-immunization. Though immunization schedules are announced, mothers oftentimes forget, thus excluding their children from illness-preventing, life-saving vaccines.

Health workers, both old and new, need training on basic EPI. The Reach to Every Barangay [REB] strategy is not fully implemented by the RHU/BHS health personnel due to LGU limited financial resources. Health promotion activities on immunization, through the conduct of mothers’ classes, bench conferences, among others need to be aggressively pursued. Immunization materials [syringes, cotton, among others] and vaccine refrigerators are inadequate at the local health facilities. Private practitioners are also not mobilized or are not participating during immunization drives.

The province/region is late in the delivery of immunization commodities to the LGUs. There are also irregular distribution patterns of commodities, which is, requested volumes are not satisfactorily met.

Breastfeeding Program

The province of Bulacan has registered an accomplishment rate of 83% versus the national standard of 85% of exclusive breastfeeding up to six months after birth.

There are still mothers and caregivers in Bulacan who have low awareness on the importance and benefits of breastfeeding up to six months.

Available health promotion materials on breastfeeding are inadequate. Existing IEC materials provided to expectant mothers and post-partum women are inadequate to effect behavioral change. Health service providers at the RHUs/BHSs are not trained on Infant and Young Child Feeding [IYCF]. The IYCF equip mothers-cum-facilitators/peers on counseling to provide the necessary support system for first-time breastfeeding mothers.

Integrated Management of Childhood Illnesses [IMCI]

Performance indicators on this aspect are: children under 5 years of age with diarrhea seen and given ORS [oresol] and children under 5 years of age with pneumonia seen and treated. Pneumonia remains to be leading cause of death in children aged 0–5 for the two consecutive years of 2007 [with 67 deaths] and 2008 [with 90 deaths]. Second is prematurity with 88 deaths [44 and 35 deaths in 2007 and 2008 respectively]. Diarrhea is still listed as one of the top ten [10] leading causes of morbidity among children [with 5 deaths in 2007 and 4 deaths in 2008].

The high infant mortality rate was noted among infants with mothers of no/limited education, no/inadequate antenatal and delivery care. These factors contributed to the poor health-seeking behavior of the mother. Mothers with limited financial resources and living in remote areas did

not immediately seek medical attention from health professionals. Mothers also failed to have at least four [3] pre-natal visits to the health facility. Critical immunization, i.e., tetanus toxoid was not provided. There might have been complications during delivery, risking the life of both the mother and child. The newborn did not get the obligatory vaccines to strengthen the child’s immune system.

Geographical, financial and educational limitations prevented the mother and child from seeking immediate medical attention.

Infant mortality and morbidity due to diarrhea continued in the province. At the community level, poor households have no sanitary toilets. Most of the poor households have no access to clean and potable water. This is compounded by unhygienic practices among households especially among children.

Due to limited LGU resources, health personnel did not conduct home visitations to pregnant women residing far-flung barangays. Even BHWs, living in the communities failed to visit the hard-to-reach areas of the barangays. There was no updated master list of all pregnant women and post-partum women in the areas. CBMIS data was not updated, thus requested supply may not be enough during immunization activities. There was also the issue of under-reporting of cases from the private health sector. Hospital cases were also not integrated into the province’s public health data information system.

Due to inadequate LGU financial resources, RHUs have no inadequate supply of reformulated oresol, zinc for sick children and cotrimoxazole tablets. Health workers are neither trained on IMCI nor the Basic Course for Frontline Health Workers. The Basic Course for Frontline Health Workers aims to improve referral of severely sick children from the barangay health station [BHS] to the RHU. It also aims to improve the skills of health workers in providing preventive health care services to children.

Nutrition Services

In Bulacan, 2008 program performance for Vitamin A supplementation for children 6–11 months was at 84%/95% national target; 12–59 months was at 98%/95% national target; 60–77 months at 77%/95% national target. However, coverage of Vitamin A supplementation for sick children across the three [3] age brackets was maintained at 100%. For anemic infants, coverage for 6–23 months and 24–59 months were both at 98%, two percent below the national target of 100%. In 2008, a total of 394,388 children aged 0 to 83 months were weighed. Of them, 1,432 or 0.36% were found to be severely malnourished. Most were from the cities of San Jose Del Monte and Malolos and the municipalities of Meycauayan, San Miguel and Bocaue.

Contributory to the malnutrition incidence in the province was the neglect of mothers to complete Vitamin A and iron supplement dosages of their children. Also, due to poverty and lack of education, mothers cannot provide necessary nutrition required by their children. Not all households use iodized salt in the preparation of their food, making their children susceptible to malnutrition. Only 88.60% of salt sold in the 1,219 market outlets in Bulacan tested positive for

iodine content. At the household level, only 89.63% of the 84,242 households surveyed use iodized salt.

LGUs do not have adequate funds for the procurement of Vitamin A and iron supplements. There was poor implementation of the GP program, increasing the number of children not provided with Vitamin A and iron supplements. Health workers due to their passive attitudes did not follow up on missed children. Information system on children at the RHUs/BHSs is weak. Data is manually inputted, making validation difficult and time-consuming. Health workers have problems ensuring that the same children were given the required two [2] doses of Vitamin A supplements during the April and October GP events. There is inadequate health education conducted from among mothers and caregivers on the importance of micronutrient supplementation and the use of iodized salt.

Dental Health Services

Even with the assistance of television and radio advertisements on the importance of dental hygiene, many household members have dental problems. Pre-school children and their parents/guardinas have low awareness on the oral care.

There is no existing dental health program at the level of the Bulacan PHO. The Bulacan PHO did not include the plantilla position of a dentist in its structure, thus no budget was allocated for the creation of a Provincial Dentist and its corresponding dental health program. Due to the absence of the general thrusts and supervision from the province, existing municipal/City dentists make and implement their own plans. Existing number of dentists is not adequate to service the oral health needs of the population. Municipal/City dentists are located at the main RHUs and the LGUs have limited transportation budget to conduct dental clinics in schools and in the communities.

Newborn Screening

Newborn screening is available in all government hospitals but not yet in local birthing homes. There is low awareness of pregnant and post-partum women on this new available service. The costly procedure of Php 650-750 per screening/test is out of the reach of most mothers, particularly the poor. There is low awareness among pregnant women and mothers that newborn screening service is reimbursable by the PHIC.

Newborn screening facilities are only located at the provincial and district hospitals. There is no data on the newborn screening services in private clinics and hospitals in the province.

Mother-Baby Friendly Hospital [MBFH] Initiatives/Breastfeeding

There is still low percentage of women initiating early breastfeeding for their children. This is due to the low awareness of mothers on the importance of exclusive breastfeeding up to six months. Though IEC materials were distributed on the health facilities on the benefits of breastfeeding, there was low turnout of mothers initiating breastfeeding.

There is poor implementation of the Milk Code in the seven [7] public MBFH-certified hospitals. This is also true in the private hospitals. Some medical practitioners do not adhere the provisions of the Milk Code and the Mother-Baby Friendly Hospital Initiative because of the incentives they derive from commercial milk manufacturers and distributors. There is weak monitoring and enforcement of the code.

4. Maternal Health

2008 Bulacan data shows that the two [2] leading causes of maternal mortality were hypertension [16 cases] and hemorrhage [12 cases]. Maternal mortality in 2008 occurred in hospitals/clinics with 44 deaths, all of which occurred in government hospitals, mostly recorded at the Bulacan Medical Center. Most of these were late referrals of complicated pregnancy on time of delivery.

One area of maternal care is tetanus toxoid immunization. Fully immunized mothers or mothers provided with tetanus toxoid in 2008 was 71.0% of the eligible population. The municipality of Bulacan performed the highest coverage at 99.7%, followed by Baliuag with 96.6% and Meycauayan with 93.2%. The lowest performances were registered in Paombong [34.2%], San Rafael [35.9] and Pandi [37.3%].

The maternal deaths in the province of Bulacan were due to the following. Pregnant women delay seeking medical attention for regular check [at least four pre-natal visits] upon conception. One reason is due to their poor economic standing and low awareness on how to properly carry on their pregnancies. Most poor women, usually residing in remote villages, have low access to medical facilities that are located in the municipal and urban centers. For the uneducated and young mothers-to-be, closely spaced births and frequent pregnancies result to complicated pregnancies and ma even lead to maternal death. They also perceive that the vaccine may affect the unborn child.

Health service providers are late in referring complicated pregnancies of higher medical facilities. There is also the inadequate skill of health care providers in detecting and managing high-risk pregnancies. Another is the lack of competence of health care providers in handling obstetrical emergencies, lack of knowledge and practical experience on safe motherhood. Current health facilities at the LGUs are not equipped to handle obstetrical cases and emergencies. LGUs have limited emergency transportation vehicles [ambulances] to transfer patients from RHU/BHS to hospitals for maternal care or delivery.

There are six [6] out of the seven [7] ULHS with organized but non-functional Maternal Death Review Committees [MDRCs]. There is also no provincial-level MDRC. Existing MDRCs are at the municipal/city levels only. The inactivity or non-functioning of the MDRCs were due to the fast turnover of committee members without proper endorsement of cases and no orientation were given to new members. There was also the poor monitoring and reporting of maternal deaths at the health facilities.

Immunization and Supplementation

Pregnant women given complete dosage of iron supplementation or at least for 6 months for 2008 was 68% versus the national performance standard of 90%. Performance achievement for post-partum women given complete iron dosage 90 tablets was 72% versus the national performance standard of 90%.

Some LGUs do not have adequate budget for the procurement of iron and Vitamin A supply for pregnant and for post-partum mothers. Reporting system or the filling up of accomplishment reports by health workers was not evidence-based. Some health workers relied on feedback from pregnant women.

Facility-Based Deliveries

Of the total births reported in 2008, 61.89% were delivered at home, while 34.26% were delivered at health facilities, far from the national performance standard of 85%. In terms of birth attendants, trained health personnel assisted to about 93.21% of the reported births in 2008.

Some mothers, particularly from poor households, still prefer to deliver at home, rather than in health facilities, and with the help of traditional birth attendants rather than trained midwives. Since some pregnant women do not go for at least four pre-natal visits, they are not oriented on the benefits of facility-based delivery. Sometimes, even if they underwent at least four pre-natal visits, they still prefer home-based delivery due to their perception of convenience, comfort, nearness of relatives, and less costly. Those who can afford facility-based deliveries prefer private clinics or birthing homes rather than government clinics due to perception of low quality of health care service.

Most of the normal, spontaneous deliveries [NSD] were done in hospitals, rather than at the RHU clinics. Hospitals therefore spent man-hours, resources and bed occupancy for NSD rather than on complicated pregnancies, high-risk deliveries and other medical cases needing secondary and tertiary health care. Health workers, particularly RHMs at the RHUs do not have adequate experience in delivering babies. Doctors, nurses and midwives have no adequate training on community-managed maternal and newborn care.

Pre-Natal Visits and Post-Partum Women

For 2008, the municipalities that achieved the national standard for at least three pre-natal visits were San Miguel with 108.8%, followed closely by Baliuag with 107.6% and Guiguinto with 100.6%. Lowest performances were registered in the municipality of Paombong with 33.7%, Bocaue with 43.3% and Doña Remedios Trinidad with 44.4%.

The poor health-seeking behaviors of pregnant women compounded by poverty and in most cases by inaccessibility to health facilities prevent them from undergoing pre-natal check ups. They also perceive that being pregnant is normal and there is no need to consult health workers. When they feel aches and hemorrhage occur, they rely on household remedies. There is no

master list of pregnant women at the RHU to assist health personnel in monitoring pregnancies. Existing data [FHSIS] is not undated.

BEmONC/CEmONC Facility Mapping and Upgrading

Identified BEmONC sites/facilities are still being prepared, that is, facilities are being improved and human resource training needs analysis is being conducted. Identified sites, with existing facilities, have no complete equipment and supplies for a full and operational BEmONC clinic. Onboard RHMs need intensive training on Life Saving Skills [LSS].

Women’s Health Team

There is low understanding of health workers at the LGUs on the role of the Women’s Health Team in reducing maternal mortality. Not all LGUs have had formed and convened their respective Women’s Health Team.

Contraceptive Self-Reliance [CSR]

Provincial CPR is 42% for 2008. The CBMIS which was discontinued in 2007 by the LGUs due to insufficient financial resources has to be activated to determine actual CPR of all municipalities and cities. There was also no client segmentation to determine the poor from those who can afford FP commodities. Not all LGUs have adequate funding for the purchase of FP commodities to be provided free to all users, both poor and non-poor alike. Basing from projected population growth, LGUs have been able to determine estimated FP needs in their areas. 19 LGUs have specific FP budgets but only seventeen [17] LGUs have been able to procure their FP commodities for 2008. However, procured FP commodities do not meet 100% of FP needs of clients.

Women clients cited fear of side effects for not practicing FP modern methods. This was followed by reasons of actual experience of side effects. FP dropouts occur when couples want children. Other reasons for non-use of FP methods were infrequent sex, dislike of sex partner/husband to use any method, inconvenience, women are close to menopausal period, and either partner is not sexually active. Most current users or couples prefer to use natural FP methods, i.e., withdrawal, rhythm, calendar among others. The lack of knowledge on FP is another reason. If the CBMIS is to be continued, there is a need to train new and refresh the old health personnel and BHWs on the system.

Health personnel do not include discussions on FP methods during mother’s classes, bench conferences, pre-marriage and individual counseling sessions. FP service providers lack adequate training on FP Counseling and on FP methods. Onboard health personnel also need refresher courses on the different natural and modern FP methods. Doctors, nurses, midwives and volunteer health workers have no training on CBTFP Levels 1 and 2. They also lack interpersonal communications skills in persuading new FP users.

5. Healthy Lifestyle and Management of Health Risks

5,506 deaths were reported in 2007 due to heart diseases [2,981], cancer [987], CVA [901], diabetes mellitus [427] and renal failure [210]. In 2008, deaths due to heart diseases were 1,879, CVA was 1,365, cancer was 1,167, diabetes mellitus was 357, and renal failure was 174. These deaths occurred in the different municipalities and cities of Bulacan. It has been noted that there was increased accessibility of people to various food and beverages contributing to healthy-lifestyle diseases. These are food containing high salt and high fat, liquors and intoxicating drinks affecting the liver and heart, primary and secondary smoke affecting the lungs, and a stressful and sedentary lifestyle.

People lack awareness on how slow lifestyle-relate diseases accumulate and spread in the human body. Only when symptoms appear that people their eating and drinking habits. By that time, the body has been contaminated and is prone to be ill again. Poor health-seeking behaviors of the majority of the population lead to the increase of these diseases. There is also the perception that lifestyle-related diseases only afflict the non-poor.

Health promotion activities by the public health sector are limited in the health facilities. Information is being provided through the distribution of IEC materials, with inadequate time devoted to elaborating the causes and effects of lifestyle-related diseases. There is no existing inventory of NCD IEC materials at all levels of the province.

At the provincial level, there is no comprehensive Non-Communicable Disease Control and Prevention Program. There is no NCD focal person in every LGU. Doctors, nurses, midwives and BHWs are not sufficiently trained on NCD prevention, detection, treatment and management. They are also not trained on the healthy lifestyle approach which includes proper diet and nutrition, increased physical activity, smoking prevention and cessation, among others.

There is also no private-public partnership for the prevention and treatment of lifestyle-related illnesses. Cooperation of the public health sector with private hospitals, clinics and physicians on NCD is weak and limited in coverage. Not all LGUs have existing registry of incidences of lifestyle-related diseases their areas. There is weak reporting and monitoring of cases by health care providers at the facilities.

LGUs, as regulatory bodies, fail to ensure 100% compliance to the Asin Law and sanitation ordinances. As of end 2008, there were 11,806 food outlets/establishments registered with 31,953 food handlers in the province, with only 89.20% certified or 10,527 establishments complied with existing health and business regulations. This does not include the ambulant vendors plying their wares near educational institutions and public areas. LGUs lack the manpower and resources to enforce nationally-mandated health laws and regulations.

Advocacy Campaigns for Risk Behaviors

Due to adventurism, peer and family pressures, people are forced to engage in risky behaviors, like partaking of fatty foods and sweets, drinking beverages, smoking and staying awake late at night. Small children and teenagers have no adult role model for healthy-lifestyle to follow in

their households. This is exacerbated by TV and radio advertisements promoting instant gratification and instant lifestyle.

Advocacy campaigns for risky behaviors implemented in the past have reached only a limited number of people in the province. This was due to the absence of a comprehensive health communications plan and limited budget for its implementation. LGUs, through its sanitary/health and law enforcement offices do not strictly enforce laws and policies on smoking in public areas [public areas, malls, public transportation, among others]. This is also true to the provisions of the Clean Air Act regulating and imposing fines for smoke-belching vehicles and dirty industries.

There is no partnership with the business sector with regards to increasing public awareness on lifestyle-related diseases. There is lack of orientation and training on healthy lifestyle from among entrepreneurs and owners of medium enterprises, particularly those engaged in the food business.

Not all LGUs regularly conducted HATAW exercises. These exercises, however, were only limited to the municipal/city employees with some community residents.

Voluntary Blood Program

There is low awareness of potential blood donors on taking care of their blood for donation purposes. This is the reason for the low rate [50%] of blood collection in the province. Also, some commercial blood banks are buying blood thus subtly removing the voluntary aspect of the program.

Blood collection is centralized at the RHU facility. There are no blood collection points outside of the RHU premises [mobile units] due to lack of skilled personnel, insufficient funds for the materials, transportation and other expenses. Transfusion units at the hospitals able to receive blood donations are inactive. There are only four [4] public hospitals with blood refrigerator, limiting accessibility of other areas needing blood units.

There are only three [3] existing local blood councils out of the 24 municipalities/cities in the province. There is no updated registry of blood donors at the local and provincial levels. There is also weak reporting and monitoring of blood utilization at the hospitals.

Risk Factor Screening

Information on self-examination for breast and cervical cancers as examples is limited. Many women shy away from public health facilities for fear of knowing the emerging diseases within their bodies. Screening procedures are costly and out of reach of poor households; thus, they do not seek medical attention.

Existing laboratory, examination and diagnostic machines and facilities at the RHUs and hospitals are already worn out and dilapidated. There are only a few mammography units in the provincial and district hospitals used for breast cancer screening. Ratio of health apparatus [e.g.,

BP apparatus] to personnel is low, thus many areas are not reached. Health personnel lack adequate and continuing training on many non-communicable, lifestyle-related diseases. Many BHWs lack training on accurate BP taking and information on the different symptoms of NCDs. There is also no master list of HPN patients in the areas.

Breast and cervical examination are not commonly offered services at the RHU facilities. This is also true for prostrate cancer for men. LGUs do not have adequate funds for the procurement of supplies and materials for enable RHU to perform self-examination procedures.

Water and Sanitation Programs

Data shows that 87% [481,288] of households in Bulacan [with total households of 513,014] have access to safe, potable water with the remaining 71,381 households has no access to potable water. Diarrhea cases are 740 per 100,000 population in the province. About 83.96% of households have existing sanitary toilets while the remaining 71,381 households do not have sanitary toilets.

Most indigent households have no existing sanitary toilets, making household members susceptible to illnesses. Households also have no access to safe, potable water, making them vulnerable to diarrhea. Households do not treat water from unsafe sources with chlorine granules to rid it of impurities and germs. Personal hygiene is not conscientiously being taught by parents in their homes. There is weak enforcement of sanitation regulation at the barangay level.

LWUAs and BSWAs do not continuously test the potability and safeness of existing water sources in their areas. LGUs have limited budget for the procurement of chlorine granules and water sampling kits to ensure safety of water. Not all LGUs have onboard rural sanitation engineers to take the lead in ensuring sanitation laws are being followed, both by households and commercial establishments. There is no master list of existing water sources at the RHU/LGU level, making regular monitoring difficult. Health personnel are passive in perceiving sanitation as a health issue.

There are no reading or IEC materials on heavy metal contamination in the province. There There are no trainings conducted for health personnel and other specialists on toxicology in the ten [10] high-risk areas of Bulacan. There is also no assessment of waterways and communities with high of contamination. There is also no existing referral system for heavy metal contamination in the province. Existing hospital facilities cannot deal with industrial disasters. LGUs do not have the capacity to enforce strict environmental laws over companies and manufacturers operating in the province.

6. Surveillance and Epidemic Management System

At the local level, seven [7] sentinel sites have been identified, corresponding to the location of the major public hospitals in the province. In Bulacan, only twelve [12] out of the 24 LGUs have formed their epidemic surveillance units [MESUs]. However, existing surveillance units have varying stages of development and functionality. There is a need to standardize unit operations and staff competencies.

There is no epidemic management committee formed at the provincial level. There is no legislative ordinance supportive for the creation of such an office the provincial board. It has been noted that there is poor reporting and investigation of diseases under surveillance. This is due to the non-standardization of forms for some diseases. There is also delayed investigation and surveillance of diseases. Data input and communication exchange protocols at the LGU level are outmoded. Hospitals do not report disease outbreaks [for notifiable diseases] to concerned LGUs.

Health workers are not updated on standard protocols on clinical management of diseases [outbreak risks] and lacks training/updates on basic epidemiology, emerging and re-emerging diseases, PIDSR and dengue among others. Training and orientation on basic epidemiology, logistics management, management information systems, referral systems with secondary and tertiary health facilities, planning and monitoring systems, among others needs are yet to be undertaken. There are no policies enacted supportive to these initiatives. There is no budget allocation for the operation and maintenance of the MESU.

7. Disaster Preparedness and Response System

Children, women and the elderly are the most vulnerable groups in disaster situations. Households and communities lack the critical awareness and knowledge of reducing the risk of disasters. Due to poverty, poor households neither can purchase nor avail of emergency commodities to tide them over the disaster period.

At the LGU level, critical disaster commodities [antiviral drugs, paracetamol, antibiotics] and supplies [alcohol, tongue depressor, etc.] are lacking during emergency situations. Drinking water, blankets, first-aid kits, and essential medicines are also in limited supply during emergency responses. LGUs lack critical transportation vehicles and communication equipment mobilization during emergencies. LGUs do not have comprehensive plans for disaster mitigation and response or Health Emergency Preparedness Response and Recovery Plan. It only has plans for the distribution of relief goods.

LGUs do not regularly conduct dry run of disaster scenarios to emotionally and psychologically prepare the first line of disaster workers, health workers and law enforcers. Health workers and other emergency volunteers lack training on basic life support and first aid application. There is no private-public health sector coordination/referral system in times of disaster. Though some LGUs had conducted training on MESU, not all MESU were convened and 50% only of the MESU are functioning. Health personnel at the RHUs/BHSs and hospital level are not adequately trained to handle basic disaster response. This is also true for health facilities, commodities and supplies.

Some health officers are not included in the formulation of disaster preparedness training making them uninformed on standard protocols in the declaration of calamity. This leads to uncoordinated efforts between the health office and the local municipal/city disaster coordination council.

8. Health Promotion and Advocacy

Majority of the Bulacan population have poor health-seeking behaviors, going to health facilities when disease symptoms are already critical, instead for the more proactive disease prevention. Most prefer the services of the private health sector rather the public health sector due to the perception that private physicians offer more quality health care services. Much of relevant health information is not accessible to the public, exacerbating the public’s misconceptions on health and health-related practices. Over-all, there is lack of health promotional activities being conducted in the province.

Health workers, particularly the HEPOs are not trained on behavior change communications. Not all RHUs have hired/designated their HEPOs. There is no comprehensive health communications plan across the different health programs implemented by the RHUs. LGUs lack the financial resources to fund health promotion activities.

The private sector, i.e., business and commercial establishments, schools, the churches, civic organizations, civil society organizations, among others are not effectively tapped by the LGUs/RHUs to assist in health promotion activities.

9. Health Facilities Development Program

2008 data shows that 53 RHUs are SS-certified. Only three [3] RHUs are accredited by PHIC to deliver MCP; 21 RHUs to deliver OPB package; and 12 RHUs are TB-DOTS accredited.

The hospital bed to population ratio is 1:1,541, well below the DOH standard of 1:500. The Bulacan Provincial Hospital has a very high bed occupancy rate of 124.6% while the district/city hospital occupancy rate ranges from 80%–163%. The Bustos Community Hospital is not accredited by the PHIC.

Public hospitals are over-taxed in terms of resources, clients and service personnel. Hospital laboratory and diagnostic equipment are worn-out through constant use and outright out of order. Working equipment are already outmoded. Public perception of RHU and BHS delivering quality health care is low. RHU/BHS personnel are rarely at their stations. As the first point of contact at the community level, patients stand long, services are not only 24/7 open, and facilities are not at par with their counterpart at the private sector. Referral mechanisms among different RHUs/BHSs and across LGUs/ILHZs are weak and needs strengthening.

Patients and clients bypass the RHUs and BHSs due to non-satisfaction of service. Patients repeatedly visit the health facilities due to poor diagnosis of illnesses. Commodities are considered inferior, and if superior in quality, unavailable.

Rationalization of Local Health Facilities to include BEmONC/CEmONC

There is no comprehensive assessment done, including health facility mapping, of the province’s health facilities. There is no existing Basic Emergency Obstetrics and Newborn Care [BEmONC] or Comprehensive Emergency Obstetrics and Newborn Care [CEmONC] facility in

the province. Facility improvement, staff complement and training, operations manual, transportation vehicle, equipment and supplies are needed for a BEmONC to be operational.

Existing RHUs and BHSs in Bulacan still lacks the complete equipment, logistics and supplies to be able to effectively provide quality health care services to the people. Fourteen [14] RHUs do not have the basic equipment for SS Level 1 certification. The RHUs of Meycauayan, Marilao and Santa Maria are still not officially recognized as rural health units. Quality assurance needs to be maintained in existing SS-certified and PHIC-accredited health facilities. This involves regular facility monitoring and assessment. This is particularly true to attain continuing accreditation by the PHIC to deliver OPB, MCH and TB-DOTS packages.

Referral system is another area for improvement in the province and in the ILHZs. This comprises referrals not only between public health facilities but also between the private and public health sectors. RHUs are not yet equipped with the minimum communications gadgets making emergency referrals difficult at best.

Health Human Resource Provision/Capability Building

At the field level, The RHU to population ratio is 1:49,557, within the DOH standard of 1:50,000. The rural health physician to population ratio is 1:43,640, below the DOH standard of 1:20,000; public health nurse is 1:30,777 below the DOH standard of 1:20,000; rural health midwife is 1:6,029, below the DOH standard of 1:5,000; and sanitary inspector is 1:52,212, below the DOH standard of 1:20,000. Directly assisting them are 3,029 active BHWs.

The problem of fast turnover of health workers at the different RHUs/BHSs persists. Due to the low compensation package and overloaded work, many leave the public health sector after getting enough experience to apply abroad or to the private health sector. Also, due to limited budget most LGUs cannot hire additional health personnel to lighten workload shouldered by current staff. Overworked health personnel impacts on the delivery of quality health service to the community.

Current and project provincial population needs an additional 89 RHUs and 50 BHSs. New facilities need 85 new RHPs, 100 dentists, 85 nurses, 91 sanitary inspectors, 50 midwives and 106 medical technologists. The P/LGU and LGUs have inadequate budget for hiring and training of new health personnel, construction and improvement of health facilities, regular procurement of commodities and supplies, maintenance and operational expenses among others.

Integration of Wellness Services in Hospitals

The Bulacan Medical Center is in need of critical improvements and additional structures. The current layout has no pharmacy and cashier. Patients and clients have to walk far and back to transact their hospital business. Onboard administrative and health staff is limited in the laboratories, x-ray department and operating room resulting to inadequate time of service. The OPD and ancillary services are housed in a dilapidated building. Hospital occupancy rate is high

at 160%, taxing the resources of the medical institution. Most patients needing primary health care do not go to the primary health care centers.

While there is an existing two-way referral system at the hospital level, it is not fully implemented. Neither is monitoring done of referred patients. There is delayed referral of high-risk pregnancies at the district hospital level. Hospital workers are not sufficiently trained on post-natal care. They also lack inter-personal communication skills. This is due to the poor seeking behaviors of pregnant women who are constrained by limited funds. There is no computerized database to track down and monitor patient progress from sickness to recovery. It is also noted the increasing number of malnourished children brought to the hospitals without malnutrition wards.

The RMMMH have poor ventilation and poor layout resulting to unnecessary time delays. There are no installed computerized data base network and reporting system [BHIS] at the district hospitals.

There is no standard management of pathologic and infectious waste disposal at the provincial and district hospitals, which poses a threat to the immediate environment and surrounding human settlements.

HEALTH FINANCING

Current provincial public health spending is not enough to cover all priority health and health-related programs. Provincial budget allocation for the public health sector is heavily in favor of the hospital services with more than 90%, while the remaining goes to the public health services.

Not all LGUs, even the financially strapped LGUs, are applying the user’s fees and other charges for the non-poor clients.

1. Expansion of National Health Insurance Program

There is low PHIC enrollment in the informal sector in the different municipalities and cities of Bulacan. LGUs have no master list of the informal sector in their areas due to the migratory character of the sector. Poor municipalities, particularly the 4th, 5th and 6th classes that heavily depend on their internal revenue allotment, have difficulties in sustaining PHIC enrollment of indigents. Some LGUs have high coverage of indigents on the first year but cannot renew all on the second and third year.

Not all LCEs and legislators appreciate the concept of investing in social health insurance, as well as the concrete benefits accruing from the utilization of the capitation fund.

2. PHIC Accreditation of Health Facilities

54 out of the 57 RHUs are SS-certified. However all government hospitals in the province are both DOH-certified and PHIC-accredited. 27 RHU facilities are accredited by the PHIC to provide OPB packages, 3 for MCP and 12 for TB-DOTS.

PHIC-accredited facilities find it difficult to continuously improve and upgrade facilities and services to comply with renewal requirements. Poor municipalities who rely heavily on their internal revenue allocations, cannot afford to fund facility improvement, availability of equipment and commodities. Capitation funds or PHIC reimbursements are not enough to sustain same level of PHIC enrollment, much more for facility improvement.

Most of the RHU health facilities are in need of improvements. Improvements can be in form of repairing broken windows, inoperable and unsanitary comfort rooms, private examination room, no 24/7 water supply, inadequate chairs for clients, poor ventilation and lighting, among others. Many RHUs have incomplete equipment.

3. Rationalization of PHIC Reimbursement

Utilization of PHIC reimbursement is solely at the discretion of the LGU. Standard division is 20% for administrative costs and the remaining 80% is for facility improvement and MOOE. However, this standard is not strictly followed by the LGUs.

There is a need for the LGUs to rationalize the utilization of PHIC capitation fund. This involves data gathering and analysis of municipal/city health needs viz. allocated budget. Health officers must advocate for increased budgetary allocations from municipal/city regular funds and from other sources of funds to their local executives and municipal councilors for health.

HEALTH REGULATION

1. Enforcement of and Compliance to National Health Legislation and Standards

Around 80% of all municipalities/cities have had enacted local legislation adopting the implementation of national health laws and regulations. However, LGUs have difficulties in enforcing and imposing fines for repeat violators. LCEs and legislators have inadequate knowledge and interest on health and health-related laws and regulations. Health officers lack the advocacy skills in conveying health issues to local legislators.

Enforcement of nationally mandated laws at the province and municipalities/cities is moderate at best. Contributory factors are the absence of local ordinances strengthening the implementation of these policies and the lack of capability of local policy makers and enforcers.

Only 80% of RHUs are PHIC-accredited. 27 RHU facilities are accredited by the PHIC to provide OPB packages, 3 for MCP and 12 for TB-DOTS. LGUs and RHUs find it difficult to complete the requirements for certification and accreditation and continuing accreditation/ renewal. PHIC enrollees are decreasing with respect to the number of population.

2. Access to Low-Cost Quality Drugs and Commodities

For 2008, there were 284 existing Botika ng Barangay [BnB] located in the different areas of the province.

Not all barangays have BnBs. Some BnBs are still waiting for the release of Php 25,000 from the CHD 3. There is weak monitoring and supervision of BnB establishments from the PHO.

HEALTH GOVERNANCE

Local Health Systems Development

There are 57 RHUs/CHOs of which 53 are Sentrong Sigla Level I-certified. All RHUs/CHOs are TB-DOTS centers; however only 12 are accredited by the PHIC. 27 RHUs/CHOs are accredited by the PHIC to provide OPB package and only three [3] is MCH-accredited.

The Public Health Desk as a ULHS strategy was discontinued in the different zones due to a number of factors. One was the absence of full-time staff, another was the changing priorities of the zonal LGUs.

Local Human Resource Strengthening

Current ratio of health staff to population in Bulacan is below the standards set by the DOH to adequately provide for the health needs of the people. Public hospitals need specialists who can perform highly specialized procedures. RHUs/BHS need highly competitive health workers to effectively implement public health programs. Continuing medical and non-medical education through capacity-building programs is needed to update and upgrade skills and core competencies of health personnel and volunteers at the barangay level.

The limited financial resource of the P/LGU and the LGUs prevent the LCEs from offering competitive compensation packages to skilled health professionals. Existing structures and workplace environment of health facilities do not facilitate productivity and excellence from among health workers. Due to limited internal revenue allocation from the national government and low taxation collection, LCEs prefer to utilize job orders rather than the more permanent plantilla position to cut down cost. The Magna Carta for Health Personnel has not been fully implemented as well. Job satisfaction is an issue among health workers.

There is no data on client satisfaction in Bulacan as a way of measuring the delivery and quality of care. Many clients still perceive private facilities as better providers of quality care; thus the low preference for government health facilities. Even PHIC members prefer to go to private health facilities.

Sectoral Development Approach for Health Implementation

There are six [6] organized ULHS in Bulacan, out of the seven [7] ULHS in the province. There is poor coordination of integration/reform-oriented activities and programs at the zonal level. Local health boards respond passively towards the development of the ULHS. Existing ULHS regularly meet but do not share resources on a regular basis. No actions were taken on the findings and recommendations of the ULHS assessment in 2007. There is poor awareness on the importance of inter-local cooperation among LGUs and health service providers in the ULHS. The guidelines on the two-way referral system between hospitals and RHUs have not been fully

implemented which defines protocol for the handling of cases and effective facilitation of health expertise and resources at all levels. There is also weak collaboration between the public and private health sectors.

While there are already 17 small-medium enterprises with their in-house family health program, 11 private midwives with birthing homes, and 23 private sector partners for health, there is still no enabling policy to integrate private sector health initiatives into the public health care system. Integration does not only mean service delivery, but also education and training and information sharing.

There is no comprehensive information on private voluntary organizations doing residual/relief, preventive, rehabilitative, curative and even developmental health services in the province.

Local Health Information System Development and Utilization

CBMIS was discontinued in 2007 in the municipalities, thus there is no updated data on community health.

There are data gaps and inconsistencies in the reports being done at the different levels. Health workers in all levels need to be oriented anew on the FHSIS and other revised health monitoring forms needs.

C hap te r 5 :Ove r a l l H ea l t h S t r a t eg i e s and In t e r ven t ions

The Province of Bulacan envisions “… a province that is progressive, peaceful and self-reliant where its people are living models of its historical heritage and cultural excellence with a strong middle class as the core of the citizenry with equal access to opportunities and services.” As Bulacan province continues to struggle with increasing poverty and rapid population growth, efforts are being undertaken to carry out a balance between economic and social development, with particular bias to the poor. Increasing the human development index for Bulacan means focusing on the three aspects of education, housing and health.

With this directive, the PGB and the municipal and city government units, in partnership with the Department of Health shall pursue to promote the general wellness and health of the people of Bulacan, particularly the poor by ensuring the efficient delivery of affordable, accessible, available and quality health services.

For the plan period covering 2010-2013, the Provincial Government of Bulacan shall pursue the strategies of increasing public and private investments for health programs and projects, strengthening local health systems to deliver quality health care services, improving the quality and quantity of its health service providers, intensification of health promotion activities leading to good health-seeking behavior, and increased collaboration and partnership with the private health sector.

Health Service Delivery Programs

1. Disease-Free Zone Initiatives

A. Rabies Elimination Services

Goal: Rabies is eliminated as a public health issue and Bulacan is declared a rabies-free by 2013.

Objectives: To reduce human rabies death from 6 cases in 2008 to 0 in 2013; and 50% yearly reduction

of dig bites To increase to at least 90% of households practicing responsible dog ownership To strictly enforce ordinances on responsible pet ownership which includes compulsory dog

immunization, impounding and disposal of stray dogs among others To increase to at least 90% of households that practice immediate washing of bite area with

soap and water when bitten and immediately seek medical attention from animal bite centers To increase to 100% the proportion of high-risk animal bite victims given post-exposure

treatment

Interventions:The province shall pursue the twin strategy in rabies control of responsible pet ownership [prevention aspect] and dog bite victim immunization [curative] in all LGUs. The preventive approach is characterized by intensified health promotion activities and advocacy campaigns on dog immunization at all households, management and control of stray dogs and capacity building of health workers [on the management and treatment of animal bites] and law enforcement agencies [on proper dog handling and disposal].

LGUs shall increase budget for the purchase of pre- and post-exposure human vaccines at the RHUs to eliminate mortality due to rabies. Referral systems shall be strengthened between the RHUs and existing animal bite centers in the province.

B. Leprosy Control Program

Goal: To eliminate leprosy as a public health problem

Objectives: To maintain leprosy prevalence rate at <1 case per 10,000 population To increase by 5% the leprosy case detection rate by 2013 To maintain leprosy cure rate at 100%

Interventions:Coverage of contact tracing shall be expanded in affected communities and municipalities with leprosy cases. Health workers shall be trained on the quality diagnosis and case management protocols to ensure treatment. Affected LGUs shall designate a focal person at the RHU for leprosy control. Budget shall be secured for the procurement of anti-leprosy drugs [multi-drug therapy] for identified leprosy cases, which will supplement commodities from the DOH.

Health promotion shall be intensified at the community level to increase awareness and remove the social stigma associated with the disease. Treatment partners shall be trained to ensure observance of treatment protocols, that is, MDT is continued until cleared by the RHU.

C. Malaria Control Services

Goal: Malaria morbidity is significantly reduced in the 5 endemic municipalities and 15 barangays and the risk of malaria transmission is lessened in the province.

Objectives: To provide universal access to quality diagnosis and treatment services by expanding and

improving microscopy facilities in the affected areas To intensify vector control to reach 100% of the population in malaria endemic

barangays To develop and strengthen capacities of households and communities in malaria

prevention and control, surveillance and information system

Interventions:Health promotion to effect behavioral change shall be intensified in malaria endemic communities. In partnership with the barangay council, the RHU shall mobilize community residents in sustaining sanitation drives to deprive mosquitoes of their breeding sites. Households shall be encouraged to use insecticide-treated bed nets. Financing schemes for the insecticide-treated bed nets shall be explored for indigent households.

Health workers shall be trained on the use of rapid diagnostic test kits to determine positive malaria smears for immediate treatment. Basic malaria microscopy and clinical management shall be provided to health workers to ensure delivery of quality health care to clients. LGUs shall allocate funds to ensure availability of anti-malarial drugs to affected communities.

Community residents shall be trained on malaria surveillance. At the first instance of outbreak, containment procedures are installed and precautionary measures are undertaken. Information is also immediately forwarded to concerned agencies. Referral mechanism for malaria cases shall also be strengthened. A province-wide policy on malaria control and prevention shall be crafted.

2. Intensified Disease Prevention and Control

A. Tuberculosis Control Services

Goal: TB mortality is reduced from 369 per 100,000 population in 2008 to 299 per 100,000 by 2013

Objectives: To increase case detection rate for TB smear positive from 63% in 2008 to 70% in 2013 To increase cure rate of TB smear positive from 80% in 2008 to 85% in 2013 Involvement of the business sector in the TB control program

Interventions:Instilling good health-seeking behaviors from among TB symptomatic patients will be pursued by the public health sector. Families of TB patients will be encouraged to take on a more active role in the treatment process and prevent treatment dropouts. Health promotions, in various forms and carrying content, will be aggressively conducted at all levels. Special emphasis will be on vulnerable groups such as the public transportation sector, urban poor, public education sector and the law enforcement agencies.

LGUs shall pursue accreditation of all RHU facilities as TB-DOTS centers. By 2013, all RHUs will have complete TB control program staff complement, including laboratories and medical technologists. This will ensure the quality and accurate sputum diagnosis. Active case finding for TB cases shall be intensified at the RHU/BHS level. Dropouts will be encouraged to continue treatment procedure. All TB patients, non-poor and poor alike, will be encouraged to be PHIC members. Capacities and competencies of health workers involved in the TB control program shall be improved to deliver quality health service.

Hospital-based TB program shall be strengthened. Private physicians shall be trained on standard TB diagnosis, treatment and management. Private-Public Mixed DOTS shall be established in all municipalities and cities to expand coverage for TB case detection and treatment. An improved TB registry in all levels will ensure tracking of TB patients and treatment status.

The PHO shall ensure the continuous supply of Category 1 & 2 anti-TB drugs from the DOH. It shall also ensure that all LGUs have adequate funds for the procurement of Category 3 anti-B drugs. User’s fee and other charges shall be applied to the non-poor while indigent patients will be provided free Category 3 drugs.

The TB Diagnostics Committee will be activated and strengthened at the municipality/city and province. It will take the lead in ensuring that the TB control program is efficiently running. This means ensuring quality assurance measures are followed. It shall monitor implementation of TB-DOTS protocols with emphasis in public and private laboratory diagnoses. Moreover, it shall develop, maintain and sustain a Quality Assurance System on TB microscopy.

Private companies and manufacturers with high-risk of TB incidences will be encouraged to put in place safety mechanisms to prevent and reduce the risk of TB transmission.

B. HIV/AIDS Control Services

Goal: HIV/AIDS/STD/STI and other reproductive tract infections are identified, contained, treated and prevent its transmission.

Objectives: To reduce +GC from identified STI cases from 123 to 62 To implement the National AIDS Prevention Law and other related ordinances To reduce the incidence of HIV/AIDS/STF/STI from 375 cases to 20 cases among high

risk or vulnerable population by 2013 To increase case finding among high risk groups and ensure HIV/AIDS/STF/STI (+)

cases traced, diagnosed, treated and counseled To establish Social Hygiene Clinics in the cities of Malolos, Meycauayan, Baliuag and

other high-risk municipalities To organize HIV/AIDS/STD/STI Councils at the provincial and municipal/city levels

Interventions:The province of Bulacan will strengthen disease prevention measures and further improve the diagnostic capabilities of health facilities in high-risk areas to stop the spread of HIV/AIDS/STD/STI. High-risk groups will be mapped out and degree of vulnerability assessed as input to the formulation of the province-wide HIV/AIDS/STD/STI Program. High-risk areas shall establish Social Hygiene Clinics manned with health professionals providing counseling and other health prevention services. Health service providers will be trained on the detection, diagnoses and management of HIV/AIDS/STD/STI. IEC materials on the causes, modes of transmission and treatment protocols will be distributed to high-risk groups and areas.

Local ordinances in support of the National AIDS Prevention Law will be enacted by the concerned LGUs. Ordinances will include provisions logistics support and laboratory supplies, and contact tracing and treatment of cases.

C. Dengue Control Services

Goal: Reduced dengue mortality from 17 cases in 2008 to 0 in 2013; and reduced morbidity cases from 1,578 cases in 2008 to 929 [60%] in 2013..

Objectives: To conduct intensified advocacy and information campaigns on dengue prevention and

control leading to households using bed nets, removal of mosquito breeding sites, general sanitation and increased practice of personal hygiene

To adopt an integrated vector control approach in the prevention and control of dengue infection

To increase capacity of health workers in the diagnosis and management, prevention and control of dengue infection

To implement an effective surveillance system for dengue control and the development of a dengue epidemic contingency plan for emergency response

Interventions:The strategic approach of the province for the prevention of dengue is through the intensification of mosquito vector control. Dengue prevention is primarily done by depriving mosquitoes of their breeding sites. Residents shall be mobilized to continuously conduct “search-and-destroy” operations against dengue carriers and improve sanitation practices. The province and LGUs shall intensify community awareness campaign in understanding the disease, its causes and effects, and measures to stop its spread. One critical activity is the avoidance of mosquito bites in the afternoon as this is the hour when the Aedes mosquito specie strikes.

LGUs shall ensure the availability of sufficient anti-dengue drugs and other commodities when dengue outbreaks occur. Health workers from the RHUs/BHSs and hospitals will be trained on dengue diagnosis and treatment management. Funds from the DOH, the provincial government and LGUs will be pooled together for capability building and improvement of existing facilities to respond to dengue cases. Referral mechanism from among and between private and public medical practitioners will be strengthened with respect to the handling of dengue cases.

3. Emerging and Re-emerging Infection Prevention and Control Services

Goal: To maintain 0 incidence from emerging and re-emerging diseases such as avian flu and influenza A [H1N1] or swine flu, and 0 mortality from Ebola Reston virus in 2013 from 2 mortalities in 2008.

Objectives: To equip the public health sector and the general population to respond properly to

threats brought by avian and swine flu To strengthen surveillance of emerging and remerging infections

Interventions:The province and LGUs shall put into place multi-sectoral mechanisms for the planning and implementation of health emergency response plans to ensure containment and treatment of emerging and remerging infections with potential for causing high morbidity and mortality. Commercial poultry and pig farms shall be encouraged to establish bio-safety measures and shall serve also as surveillance sentinel for avian and swine flu viruses.

The province with the LGUs shall conduct mapping of high-risk areas and assess its vulnerability to emerging and remerging diseases. With the active participation of the health sector, provincial and local plans shall be formulated to respond to any emerging and re-emerging diseases. Plans will include provisions for the availability of anti-viral prophylaxis, surgical masks, disinfectant and other supplies at the RHUs/BHSs ready for distribution to affected communities. Parallel activities like capability building for health workers on emergency response shall be initiated. Massive information drives shall be conducted at the community levels to increase awareness of residents on the signs of disease outbreaks, precautionary measures for containment and treatment protocols. Existing surveillance systems at the community level, e.g., dengue, shall integrate surveillance for emerging and re-emerging diseases.

4. Child Health

Goal: IMR is reduced from 5.76/1,000 LB in 2008 to 2/1,000 LB by 2013.

Overall Objective:Promotion and implementation of child survival interventions protecting children against vaccine-preventable diseases, improvement of the nutritional status of underweight children and utilizing an integrated approach in managing childhood illnesses

A. Expanded Program on Immunization

Objectives: To sustain or increase the coverage of fully immunized children (FIC) of 86% in 2008 to

95% by 2013 To maintain 0% incidence of neonatal tetanus among new born infants by 2013 To protect children against the seven immunizable diseases

B. Breastfeeding Program

Objective: To increase exclusive breastfeeding for the first six months from 83% in 2008 to 85% in

2013

C. Integrated Management of Childhood Illness

Objectives: To ensure that 100% of all common childhood illnesses are properly and timely managed

by 2013

To reduce morbidity cases of diarrhea among the under five children from an average of 11,000 per annum to 8,000 per annum by 2013; and to reduce deaths from 4 in 2008 to 0 by 2013

To reduce mortality cases due to pneumonia among the under five children from 90 cases in 2008 to 15 cases by 2013

D. Nutrition Services

Objectives: To reduce prevalence of preschoolers with weights below normal from 6.52% in 2007 to

3% by 2013 To reduce the prevalence of preschoolers with weights above normal from 3% in 2007 to

0.96% by 2013 To increase the number of preschool children with normal weights from 85% in 2007 to

90% by 2013 To increase consumption of iodized salt/fortified products by the household from

89.630% in 2007 to 100% by 2013 To increase or surpass the 95% GP coverage for vitamin A To attain a more accurate 90% OPT coverage To improve knowledge attitude and skills of health workers on the micronutrient

supplementation program and young child infant feeding

E. Dental Health Services

Objectives: To reduce prevalence of dental caries and periodontal diseases among the 2-6 year old

children To increase orally fit children by 20% in 2013

Interventions:LGUs shall pursue the delivery of critical health packages for children through continuing quality improvement, procurement of drugs and medicines, upgrading of facility and equipment, continuing education and training of its health personnel to ensure quality of health services for children especially the poor and the disadvantaged. Health information systems shall be enhanced to enable health workers to monitor all children’s health data to 100% coverage of all children.

By 2013, all RHUs shall have been accredited by the PHIC to provide Maternal and Child Package, which means all requirements for facility improvement and staff training have been complied to, ensuring the delivery of quality health service to children. The strategy of Reaching Every Barangay [REB] for immunization and micronutrient supplementation shall be implemented. Newborn screening shall be encouraged from among pregnant women. The DOH, the province and LGUs shall ensure the availability of commodities for immunization and micronutrient supplementation, feeding for malnourished children, oresol for diarrheic children, antibiotics for pneumonia [primary complex] and acute respiratory illness and dental care among

others. LGUs shall also ensure that all households comply with the use of iodized salt in food preparation.

LGUs shall support initiatives on enhancing the supervision and monitoring work of service providers through continuing education and training to improve the quality of IMCI implementation in all health facilities. LGUs shall ensure that the required number of health staff versus the clientele population is met. LGUs shall encourage and fund, if resources permit, continuing education and training of its service providers to harness their life saving skills and familiarization on cost-effective approaches and interventions. Public-private partnership shall be strengthened to ensure 100% coverage of children and data integration.

Critical Interventions for dental health are the provision of essential dental equipment and supplies, observance of essential oral health package, training of dentists, dental aides and health workers on basic epidemiology, satisfying staff complement for dentists and dental aides at the LGUs.

A comprehensive health communications plan shall be formulated integrating the different health programs for children: expanded immunization for children, breastfeeding, integrated management of childhood illnesses, nutrition and dental health. This is to effect positive changes in the health-seeking behaviors of the mother/guardian/parent who has the responsibility for ensuring the health of the child.

5. Maternal Health

Goal: Maternal Mortality Ratio is reduced from 6.82/100,000 LB in 2007 to 1.71/100,000 LB by 2013

Overall Objective:To ensure safe motherhood and healthy newborns through provision of quality services on family planning, prenatal, intra partum and postnatal care.

A. Maternal Nutrition

Objectives: To increase the percentage of pregnant women with at least four [4] pre-natal visits from

84.4% in 2008 to 95% by 2013 To increase the percentage of pregnant women given complete iron dosage from 68% in

2008 to 90% by 2013 To increase the percentage of pregnant women given tetanus toxoid vaccines from 71%

in 2008 to 80% by 2013 To increase the percentage of postpartum women given complete iron dosage from 72%

in 2008 to 90% by 2013 To increase the percentage of postpartum women given Vitamin A from 68% in 2008 to

90% by 2013

Interventions:LGUs shall pursue to continuously improve the quality of pre-natal and post-natal care to ensure women’s reproductive health. Pregnant women will be encouraged to have at least four [4] pre-natal visits to determine status of mother and the unborn child, identify possible sources of complications and take necessary actions to reduce or eliminate complications. Post-partum women shall be encouraged to have at least four [4] ante-natal visit for check up and vitamin supplementation. Towards this end, RHUs/BHSs shall strengthen its data gathering and information system to cover all pregnant and post-partum women.

LGUs shall ensure the availability of adequate Vitamin A capsules and iron supplements for pregnant and lactating women during pre-natal and post-natal visits. Health promotion activities shall be initiated to inform pregnant women on proper nutrition and personal hygiene to lessen possibilities of contracting diseases during pregnancy.

The RHUs shall organize community-level Women’s Health Team (WHT) to take the lead in ensuring the implementation of the safe motherhood program. It will be responsible for pregnancy tracking, birth planning, facility referral, maternal death reporting, and proper newborn care to include breastfeeding, nutrition and immunization, outreach activities for family planning, counseling and replenishment of FP supplies.

B. Facility-Based Deliveries

Objectives: To increase facility-based deliveries from 34.26%% in 2008 to 95% by 2013 To increase birth deliveries assisted by health workers from 93.21% in 2008 to 95% by 2013

Interventions:Pregnant women shall be encouraged to deliver their babies in the health facilities most accessible to them to ensure safe and uncomplicated deliveries. Professional-trained doctors, nurses and midwives staff these facilities and are ready for any emergency. LGUs shall be encouraged to establish birthing homes from within the RHU/BHS facility or covert the RHU into a BEmONC facility to handle emergency obstetric procedures. The district and provincial hospitals shall remain the CEmONC facilities where blood transfusion services and caesarian section operations are accessible.

Health personnel shall undergo capacity building activities to ensure safe deliveries in the health facilities. Cases of maternal deaths shall be reviewed and lessons learned from these incidences that will lead to a more equipped and trained health workers. Parallel activity on health promotions shall be intensified elaborating the benefits to the mother and child of a facility-based delivery. Referral systems shall also be enhanced to facilitate the flow of referred complicated pregnancies to higher medical facilities.

For 2008, 4 maternal deaths were due to hemorrhage. To address this problem, pregnant woman shall be made to identify her potential blood donors so that supply is assured when needed.

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The province shall also strengthen the conduct of maternal death reporting and review. Interventions on equipping the communities and health facilities both as sources and channels of communication shall be undertaken so that accurate and timely maternal mortality data are generated, major medical and non-medical causes of deaths are identified, appropriate interventions to address these causes are formulated, and reforms in the health delivery system are institutionalized.

C. Contraceptive Self Reliance

Objectives: To provide universal access to family planning information and services To increase contraceptive prevalence rate from 42% in 2007 to 60% by 2013

Interventions:The province shall ensure the availability of and access to modern birth spacing methods through the following interventions: Installation of CBMIS in all LGUs to determine unmet needs and securing financing for

free contraceptive commodities to the poor Efficient procurement and distribution of contraceptive commodities and supplies Continuing education and training of health personnel on interpersonal communications

skills, FP counseling, FP modern methods among others Promotion of responsible parenthood and parenting Strengthening system of referral Expansion of private sector sources of FP services and commodities

6. Healthy Lifestyle and Management of Health Risks

Goal: Morbidity and mortality from lifestyle-related diseases are reduced by 5-10% in 2013.

Objectives: To intensify public awareness on lifestyle-related diseases and create consciousness on

the importance of healthy lifestyle behaviors To ensure full implementation of ordinances and programs related to healthy lifestyle To ensure availability of diagnostic services and treatment procedure on lifestyle related

disease especially to the poor To improve knowledge and skills of health workers on risk factor screening and

management of lifestyle-related diseases

InterventionsThe province shall formulate a comprehensive Non-Communicable Disease Control and Prevention Program and shall designate NCD focal person in every LGU. Doctors, nurses, midwives and BHWs will be trained on NCD prevention, detection, treatment and management, including approaches to healthy lifestyle like proper diet and nutrition, increased physical activity, smoking prevention and cessation among others. Nurses, midwives and BHWs shall be trained on self-examination for breast and cervical cancer so that risk-factor screening can be initiated even outside of the health facility. Facilities and equipment for risk-factor screening

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shall be improved to cater to the growing number of the population afflicted with lifestyle-related diseases.

Health promotion activities by the public health sector will be intensified and expanded to include public areas and business establishments, particularly those engaged in the food business. IEC materials for specific targets with specific messages elaborating the causes and effects of lifestyle-related diseases will be developed.

Private-public partnership for the prevention and treatment of lifestyle-related illnesses will be formed and strengthened at the province and in the different LGUs. RHUs shall collect, collate and analyze data of incidences of lifestyle-related diseases in their areas as input for local NCD control and prevention plan.

LGUs will be encouraged to institutionalize HATAW exercises for all of its public employees, including teachers. Efforts will also be initiated for private companies to disseminate information to its employees on lifestyle-related diseases, its control and prevention.

A. Voluntary Blood Services

Goal: A safe, sustainable, sufficient and effective blood supply is maintained.

Objectives: To increase the number of voluntary blood donors from 50% in 2008 to 100% by 2013 To ensure availability of supplies and materials for mass blood donations To increase the number of municipalities with Blood Donor registry from 3 to 24

municipalities and cities

Interventions:The strategic approach is to intensify advocacy and information and education campaign through the conduct of tri-media campaign on the importance of blood donation. In strengthening the program, the 21 LGUs shall pass an ordinance for the creation of Municipal Blood Council. Health personnel shall also be capacitated on donor recruitment, retention and care, blood storage and cold chain. Medical technologist shall be trained on Phlebotomy.

6. Water and Sanitation Programs

Goal: Environmental hazards, disease and deaths are reduced due to compliance to environmental sanitation programs, policies and procedures.

Objectives: To increase the number of households with access to safe water from 87% to 95% by

2013 To increase the number of households with sanitary toilets from 83.96% to 95% by 2013 To increase the number of establishments with sanitary permits to 100% by 2013 To increase the number of non-food and food handlers with health certificates to 100%

by 2013

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To increase the number of households/commercial establishments with proper waste disposal from 66.5% to 90% by 2013

To improve knowledge and skills of sanitary inspectors to ensure implementation of environmental sanitation laws at the household and commercial establishments

Interventions:The province and concerned LGUs shall source out financing for sanitary toilet bowls to increase the number of households with sanitary toilets. Through the “Oplan Bantay Palikuran” of the Agapay sa Barangay program, indigent households will be identified and provided with sanitary toilets. Sources of funds will come from the Clean and Green budget of the province, municipality/city and barangay. Beneficiaries will provide their labor as counterpart.

Health promotion activities on the use of chlorine granules and personal hygiene will be intensified at the household level. LGUs, through the rural sanitary engineers and its counterparts at the barangay level shall be trained in enforcing sanitation laws and regulations, both by households and commercial establishments.

Water samplings shall continuously be implemented in all areas in partnership with the LWUAs and BWSAs. New sources of water and existing unsafe water sources shall be monitored and if warranted, disinfected using chlorine granules. At the household level, safety measures through the provision of disinfectant tablets shall be implemented. All of these measures will be undertaken to reduce morbidity and mortality due to diarrhea, and maintain zero morbidity and mortality due to cholera, typhoid and paratyphoid fevers.

With regards to the contaminated waterways of Bulacan, efforts will be initiated to train health personnel and other specialists on toxicology in the ten [10] high-risk areas of Bulacan. A comprehensive assessment and evaluation of waterways and communities with high of contamination will be conducted. Referral system for heavy metal contamination in the province will be formed or integrated into existing referral system. Hospital facilities will be equipped to deal industrial disasters.

6. Surveillance and Epidemic Management System

Goal: A responsive and functional integrated Surveillance and Epidemic Management System is institutionalized.

Objectives: To build the capacity of all 24 LGUs in performing disease surveillance and response To increase utilization of disease surveillance data for decision-making, policy-making,

program management, planning and evaluation at all levels

Interventions: Establishment of Municipal/city Epidemiology and Surveillance Unit [MESU] in all

LGUs Establishment of a functional two way referral system in surveillance

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Training of health workers on basic epidemiology, logistics management, management information systems, planning and monitoring systems

7. Disaster Preparedness and Response System

Goal: Impact of disaster to families and communities is mitigated and reduced.

Objectives: Formulation of a comprehensive disaster management plan at the province and LGU

levels Strengthening of disaster coordinating councils at all levels Installation of measures to mitigate the effects of disaster life and property To increase the coping capacities of families and communities after a disaster

Interventions: Orientation of LGU officials and legislators on disaster management system Establishment and strengthening disaster coordinating councils Training on disaster management Formulation of comprehensive disaster preparedness plan at all levels, with participation

from stakeholders

8. Health Promotion and Advocacy

Goal: Health status and quality of life of the Bulacan population are improved

Objectives: To improve data recording and reporting of all IEC advocacy rendered by health workers To ensure that all IEC advocacies are being conducted at the barangay level To improve KAS of health workers including BHWs on basic promotion; and strategies

communication planning To increase percentage of localized materials reproduced To strengthen IEC advocacy To strengthen coordination with private sectors, CSO and NGOs

Interventions:The province with support from the DOH and LGUs shall increase access of relevant health information to increase the public’s knowledge on health and health-related practices. The province and the LGUs shall designate and build the capacities of its HEPOs to take the lead health promotions and advocacy work. Capacity building will include behavior change communications strategies, IEC materials development among others. Health staff and BHWs who are also channels of information shall be trained on the various health issues to widen the reach of health promotion and advocacy.

RHUs shall be assisted in the formulation of a comprehensive health communications plan of all health programs being implemented by the LGU/RHU. LGU shall ensure the availability of funds for the production and distribution of mass-based and issue-specific promotional materials.

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Partnership will be built and strengthened with the private sector, i.e., business and commercial establishments, schools, the churches, civic organizations, civil society organizations, among others to assist and/or complement health promotion activities being done by the local health sector.

9. Health Service Delivery System and Facility Improvement

Goal: Efficient, effective and integrated delivery system for rural health units and hospital services for attaining better and equitable health outcomes is institutionalized.

Objectives: To upgrade facilities and services of the provincial and district hospitals and strengthened

referral system installed with lower health facilities Establishment of baseline data of clients satisfied with services rendered at public health

facilities and hospitals to determine gaps and deficiencies in the delivery of service Establishment of BHS in every barangay especially those which are located in

geographically isolated and depressed areas

Interventions:The province with funding support from the LGUs shall build additional new rural health units and barangay health stations in strategic areas to increase accessibility of clients to public health facilities. This move will ease the flow of patients clogging the secondary and tertiary hospitals. It will also initiate the rationalization and upgrading the services and facilities of provincial and district hospitals. The province with the assistance of the DOH, will conduct a comprehensive assessment and mapping of all health facilities to determine gaps and deficiencies in the areas of facility improvement, staff complement and training, operations manual, transportation vehicle, equipment and supplies.

Existing RHUs and BHSs in Bulacan shall procure basic equipment, logistics and supplies to be able to effectively provide quality health care services to the people. Fourteen [14] RHUs shall comply with the requirements for SS-certification Level 1 while the RHUs of Meycauayan, Marilao and Santa Maria shall initiate activities to complete requirements for recognition as rural health units. Quality assurance will be maintained in all SS-certified and PHIC-accredited health facilities. This involves regular facility monitoring and assessment. Efforts will be undertaken to attain 100% accreditation of health facilities to provide OPB, MCP and TB-DOTS services.

To gauge the performance of hospital services, the province shall instruct all hospital facilities under its jurisdiction to conduct client satisfaction survey that will serve as input on service delivery performance assessment. To improve the manpower complement, the provincial government shall create additional plantilla positions for the provincial and district hospitals. At the LGU level, representations will be made with the LCE and legislative councils for the hiring of additional, but critical health plantilla positions.

10. Health Financing

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Goal 1: Investments in health from internal and external resources are increased from an average of 10%-15% in 2007 to 25% in 2013.

Objectives: To increase health expenditures vis-à-vis the total provincial government budget from

<10% in 2008 to 25% in 2013; To increase health expenditures vis-à-vis total municipal government budget from 11% in

2007 to 25% in 2013; To increase public health expenditures in relation to total local government health

expenditures from 8.45% in 2007 to 25% in 2013; and To increase social health insurance expenditures in comparison with the total health

expenditures from 14% in 2007 to 25% in 2013

Interventions:The increasing population in Bulacan puts a strain to its already limited financial resources. At present, the public health sector is in competition with other local public offices for budgetary allocation. While the demand for quality public health service is growing, approved budget is getting smaller. There is a need therefore for the public health sector to take an active role in resource generation outside of its traditional fund sources.

Aside from the usual income retention from operation of health facilities, LGUs shall explore and develop mechanisms to generate new sources of funds. LGUs shall study carefully the feasibility of converting health facilities to economic enterprises. LGUs shall also take advantage of grants and other assistance particularly with respect to capacity building for its health workers. The province shall continue to look for donors to put investments in the Bulacan public health sector.

While the province actively seeks for new and creative sources of health financing, it shall also optimize the efficiency and effectiveness of local financial planning in health by focusing resources on priority programs and implementing performance-based budget allocation. The LGU shall impose such measures in improving efficiency in resource allocation across levels of healthcare (primary, secondary and tertiary) with strong emphasis on public health.

The first step shall be the conduct of a systematic review/study of the various financing options mentioned to include maximizing PHIC capitation funds for the improvement of health services and facilities. Since the capitation/reimbursement was a stable source of health financing in the province, the LGUs shall continue to improve fund management and utilization of the same for the improvement of priority public health programs and projects.

Goal 2: Out-of-pocket spending for health is reduced to 20 percent through increase in local government spending and inputs from SDAH partners in social health insurance.

Objectives: To expand the PhilHealth coverage of the poor from 85.6% in 2008 to 100% in 2013;

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To increase the number of health facilities that are PhilHealth accredited for OPB from 21 RHUs in 2008 to 57 in 2013, for TB-DOTS from 12 RHUs in 2008 to 57 in 2013 and for MCP from 3 RHUs in 2008 to 57 in 2013; and

To develop a Local Health Accounts (LHA) to monitor the impact of local financing reforms

Interventions:In addressing the problems of over-targeting and multiple of enrollments to the sponsored program, the province shall rationalize the selection of beneficiaries by developing an effective means for identifying the eligible population for enrollment. The employment of an effective instrument such as the proxy means test to identify the poor shall help the LGUs in determining qualified and legitimate indigents for enrollment to the program. Moreover, the provincial government will take the lead on increasing the involvement of groups such as cooperatives in the enrollment of informal sector through PhilHealth Kasapi Program. By rationalizing the enrollment, the LGUs can optimize the use of limited resources that can be further utilized for equally important endeavors.

Moreover, the provincial government aims to reduce delays in the remittance of counterpart premium contribution to PHIC by proposing a more equitable cost sharing of the local counterparts between the PLGU and the C/MLGU in consideration of the capacities of LGUs to finance the sponsored program. The provincial government shall take the lead in ensuring that all primary health care facilities comply with the PHIC accreditation requirements by assisting municipalities in facility improvement and staff capacity building. It will also study the feasibility of setting a fixed amount of out-of-pocket expenses for hospital services rendered by the provincial/district hospitals to encourage PHIC cardholders to use government health facilities. It will develop and use local health accounts as an input to the systematic assessment of all health expenditures in the province.

11. Health Regulation

Goal: Access to quality and affordable products and services is assured.

Objective:To ensure access to quality and affordable health goods and services, especially the poor.

Interventions: Strict enforcement of health and health-related national laws and regulations and

enactment of local legislations supporting such mandates Development of a policy-tracking mechanism tool to monitor the implementation of

health and health-related ordinances Establishment of Botica ng Barangay in all identified strategic barangays

12. Health Governance

Goal 1: Installation of a functional local health system at the LGU and ULHS that is responsive to the health needs of the people especially the poor and the marginalized.

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Objectives: Strengthening inter-LGU collaboration in health through the activation and strengthening

of the local health boards Strengthening human resources for health through capability building, promotion and

incentives Strengthening the local health information system as input to decision-making and

legislation

Interventions:To ensure functional local health systems in Bulacan, the following interventions shall be undertaken: Establishment of mechanisms for inter-LGU collaboration through the Provincial Health

Board and the Provincial Development Council as venues to discuss cross-cutting health concerns

Strengthening CSO/NGO/private sector participation in health development Policy formulation on utilization of information technology in routine recording and

reporting Re-orientation on the two-way referral system of public health facilities with primary,

secondary and tertiary hospitals Enhancement of capabilities of health service providers in supervision and monitoring Design and implementation of continuing program to train staff in health sector reform

priorities and strategies Provision of client feedback mechanism Development of plan to address out-migration of health personnel to include incentive

schemes

Goal 2: Efficiency and effectiveness of financial, procurement and logistics management systems to support health program implementation are ensured.

Objectives: To create a positive environment for better financial, procurement and logistics

management systems in the health sector through the appropriate mix of incentives and controls.

To establish innovative approaches in financial, procurement and logistics management systems and strengthening its implementation through collaboration of various providers of health care and integration of the systems among implementing agencies.

Interventions:The critical approaches in improving internal management are the following: Compliance to standard procedures for financial and procurement transactions, and

material management processes Improved systems and tools for financial, procurement and material management

transactions Reduced transaction time and costs

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C hap te r 6 :C r i t i c a l T a rge t s , A c t i v i t i e s and O u tcomes

Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

PPA: DISEASE-FREE ZONE INITIATIVESRabies Elimination Services To decrease by 50% of

8,697 animal bite cases in 2008

Rabies free Bulacan To decrease human

rabies death from 6 to 0

Increase to at least 90% of households practicing immediate washing of bite site with soap and water when bitten by dogs than consult traditional healer

8,697 animal bites seen with 3,377 given post-exposure treatment

6 mortality cases due to human rabies

Poor health seeking behavior: animal bite victims prefer "tandok than seeking medical attention from health facilities

Health Promotion Production and reproduction of campaign materials on rabies control, treatment and management

2009-2013

Increase to at least 90% of households practicing responsible pet ownership

Irresponsible dog owners and unaware of the ordinance

Not all dogs are registered and immunized

Health Promotion Tri-media campaign Public fora and symposia,

community assemblies among others

School campaign Mother’s classes

Strict enforcement of ordinances in all LGUs

Weak enforcement by LGUs of ordinances on: Rabies Control Responsible Pet Ownership

Advocacy and Development Cooperation

Reactivation of Municipal/City and Provincial Rabies Task Force

Monthly monitoring and evaluation of rabies control and prevention program

Ensure availability and accessibility of rabies

Inadequate free dog vaccine Expensive cost of anti-rabies

Logistics Management and

Budget allocation for procurement of anti-rabies

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Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

vaccines for human and animal

vaccines for pre and post-exposure

Resource Generation vaccines for human and animal

Support from NGOs, CSOs, private sector groups, PCSO, DOH and other sources

Procurement of human anti-rabies vaccines

Provision of active and passive anti-rabies vaccines

100% coverage of high-risk animal bite victims given post-exposure treatment

Financial constraints of patients to complete treatment/post exposure vaccination

Procurement of Tetanus Toxoid

Provision of TT

Procurement of ATS Provision of ATSProcurement of haloperidol 5 mg/ampoule

Provision of haldol

Procurement of diazepam10 mg/ampoule

Provision of Diazepam 10 mg/ampule

Capable health personnel on the treatment and management of animal bites

Most health personnel not trained on Animal Bite Treatment and Management

Capacity Building Conduct training on Animal Bite Treatment and Management

Provision of pre-exposure prophylaxis to all health workers

Majority of health workers do not have pre-exposure prophylaxis

Provision of pre-exposure prophylaxis to all health workers

Delayed management of animal bites cases due to inaccessibility to Animal Bite Treatment Center

Facility Upgrading Establishment of RHU-based animal bite center and at the PHO-PH ABC

Strengthened referral system for animal bite cases

Weak referral mechanism for animal bite cases

Health Systems Management

Establishment of referral system for animal bite cases between public and private animal bite centers

To vaccinate 90% of canine population in all municipalities and cities

Presence of stray dogs Procurement of anti-rabies vaccines

Provision of anti-rabies vaccines for dogs

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Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

Leprosy Elimination ServicesTo reduce leprosy cases from 13 cases to less than 1 per 10,000 cases

<1/10,000 population 13 leprosy cases [0.04/10,000]

No training on leprosy for current and newly hired personnel

Capability Building Conduct Basic Skills Training on Leprosy for newly hired and current health personnel [MHOs, RHPs, PHNs, MTs]

Orientation on Actiive Case Finding [Kilatis Kutis) to RHMs and BHWs

To sustain the prevalence rate of leprosy of less than one case per 10,000 population

Social stigma experienced by leprosy patients

Health Promotion Information-dissemination leprosy prevention, detection, treatment and management through community assemblies and house-to-house visits

Availability of drugs: PB, MB, prednisone to leprosy patients

Maintain cure rate at 100% Logistics Management

Provision of drugs: PB, MB, prednisone to leprosy patients and ensure its uninterrupted supply to leprosy patients

Inaccurate data and weak tracking of treatment protocol of leprosy patients

Health Systems Management

Monitoring and evaluation on disease occurrence by using the standard reporting forms and physical assessment forms

Increase of case detection rate of leprosy cases by 50% in 2013

Passive case finding Active case finding for leprosy cases

Conduct home visits of leprosy patients for contact tracing

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Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators;

Strategy][Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

Malaria Control Services

To reduce malaria morbidity from 30/100,000 population to 26.2/100,000 population

Malaria morbidity of 2.6/100,000 population or less

0 mortality from malaria

Annual Parasite Incidence of 30/100,000 population

30 malaria positive cases Malaria Morbidity of

26.2/100,000 populationProvision of universal access to quality malaria diagnosis and treatment services

Only 1 of 5 endemic areas with microscopist trained in malaria microscopy

Capacity Building Conduct training and refresher courses on: Basic Malaria Microscopy Advanced Malaria

Microscopy Training of Barangay

Microscopists Preventive Microscopy

MaintenanceLow awareness of health staff on malaria control, prevention and treatment

Capacity Building Conduct training and refresher courses on: Basic Malaria Management

Training for health workers Training of BHWs on Rapid

Diagnostic Test KitsLow awareness of community members on malaria control, prevention and treatment

Health Promotion Distribution of IEC materials Community assemblies Mother’s classes School orientation “Search and Destroy”

operations of breeding sitesMajority of cases has limited or no access to quality diagnosis and treatment services

Logistics Management

Procurement of malaria commodities, i.e., laboratory re-agents, glass slides, RDT kits, malaria drugs

Facility Development

RCC Sites Stockroom repair

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Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators;

Strategy][Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

Monitoring andEvaluation

Regular validation of smear results [Quality Assurance Microscopy]

Monitoring of therapeutic efficacy for p. vivax and p.falciparum

Evaluation of treatment outcomes

To scale-up vector control to reach 100% of the population in malaria-endemic areas

Low usage of insecticide-treated bed nets of households

Vector Control Procurement of malaria commodities, i.e., bed nets and insecticides

Distribution of insecticide-treated bed nets to identified indigent families through the Agapay sa Barangay Project

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Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

PPA: INTENSIFIED DISEASE PREVENTIONTB Prevention and ControlTo reduce TB mortality from 369 cases [5th leading cause of mortality] to 295 cases [20% reduction]

70% Case Detection Rate85% Cure Rate

TB control program performance of 54% Case Detection Rate and 82% Cure Rate

Preferences of TB patients for private physicians for consultation

Social stigma associated with the disease

Poor health seeking behavior of patients

No treatment partner

Expansion of barangay-based TB Patrol program to cover affected barangays: Organization Training Community mobilization

No standard management protocol and treatment for children with TB

Capability Building Conduct training on Management and Treatment of Children with TB to health workers

Lack of NTP training for newly hired health personnel

Conduct training on MOP for newly hired health personnel

Sputum collection area needs renovation

Facility Development

Renovation of sputum collection area in RHUs

Only 2 LGUs [Hagonoy and San Miguel] with established PPMDWeak referral system from private physicians

Health Systems Management

Expansion of PPMD Conduct PPMD orientation

and NTP enhancement workshop for health personnel

Training of Private practitioner on PPMD

2,088 TB smear positive Logistics Management

Request for the provision of TB commodities: TB drugs for Category I and

III Laboratory supplies, i.e.,

glass slides, re-agents Acid fast stain

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Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

Glass slides Sputum capsRequest for the provision of drugs and supplies for children with children: TB drugs for TB in children

[104 cases] PPD supplies Case finding and treatment of

TB cases among inmates Augmentation of TB Drugs TB drugs kit for cases in the

provincial jail Some government hospital

does not follow standard treatment protocol [preference for chest x-ray rather than sputum exam]

2 [Baliuag and San Miguel District Hospitals with assessment on Hospital-based NTP

Conduct Hospital Base NTP Training

Discrepancies on reports Late submission of reports No regular monitoring and

supervision of the provincial TB coordinator because of inadequate TEV

Monitoring and Evaluation

Conduct regular data validation

Provision of TEV

15% microscopy services do not comply with standard laboratory procedures

33 private diagnostic laboratories not trained in direct sputum smear microscopy

Quality Assurance Refresher course for microscopists not complying with standard

Expansion of TB microscopy through involvement of private diagnostic laboratories

Referral of LGUs for x-ray positive, sputum negative

Health Systems Management

Strengthening of Provincial and local TBDCs to review referrals and recommend

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Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

appropriate treatment management

Strengthen quality assurance through quality control of laboratory procedures

12 out of 57 RHU facilities accredited by PHIC

Facility Development

Compliance to PHIC accreditation requirements through: Facility assessment and

improvement Capacity development of

health workers on TB detection, treatment and management protocols

TB in the Workplace [refer to Health Governance]

Risks of TB exposure among workers in the workplace

TB in the Workplace Identification of commercial establishments with high risk for TB exposure

Coordination with the DOLE for the establishment of TB in the Workplace Program

Training and orientation of employees on control measures in TB exposure in the workplace

Inadequate IEC materialsPoor case detection among the vulnerable groups

Health Promotion Reproduction of IEC materials

Orientation and advocacy meetings with government agencies, non-government organizations and business groups on case detection among vulnerable groups

Institutionalization of CUP Limited participation of private sector and other government agencies in TB control program

Health Systems Management

Reorganization of CUP in Bulacan

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Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

HIV/AIDS /STD/STI Control ServicesTransmission of HIV/AIDS and other reproductive tract infections are contained and impact mitigated

To reduce +GC from 123 to 62 [50%] by 2013 or 0.03/100,000 population

No existing social hygiene clinic5,050 STI cases of +vaginal discharge

Facility Development

Establishment of Social Hygiene Clinics in high risk cities and municipalitiesRisk mapping and assessment of high-risk LGUs

No training of health workers on STI/HIV/AIDS

Capability Building Conduct training on syndromic management

Increasing STI casesNo master listing of high risk groupsPoor recording and reporting systemNo regular monitoring from MHO, PHO and CHD 3

Monitoring and Evaluation

MappingMaster listingData entry and updating of entertainment establishments and CSWs

No legislation on HIV/AIDS /STD/STI control and management

Legislation Training and orientation of local health boards on HIV/AIDS /STD/STIFormulation of proposed legislationApproval and enforcement of ordinanceIncrease budget allocation for medicines, reagent and supplies

Health Systems Management

Organization of AIDS Council in9 high-risks LGUs

Logistics Management

Procurement of medicines for smear +CSWs

Low awareness on the risk of HIV/AIDS /STD/STI cases among CSWs, sexually active men and women

Health Promotion IEC materials, e.g., films, documentaries, case studies, leaflets, among others

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Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

Dengue Control Services To decrease dengue

cases from 1,548 in 2008 to 929 [60% reduction] by 2013

To decrease CFR from <1% to 0 CFR [17 deaths in 2008 to 0 death in 2013]

Communities taking an active in dengue vector control

Inadequate knowledge of health workers and communities on dengue prevention and control

Vector Control Meeting of 50 private and public primary and secondary school principals on formation of Dengue Skul Watch Teams for dengue prevention and control

Formation of Dengue Skul Watch Teams [12 members per team]

Provision of IEC materials to teams

Provision of treated curtains in schools and barangay with clustering of cases for vector control

Identification of dengue-free schools through vector control measures

Vector survey not done regularly

Inadequate surveillance on dengue

Inactive MESU Poor referral system

[public-private]Poor health seeking behavior of dengue suspect/cases

Vector Control Conduct house-to-house and school-based vector survey

Implementation of “search and destroy” operation on schools and barangays

Vector survey and entomology kit

Inadequate knowledge of health workers on dengue treatment management

Capacity Building

Logistic Management

Procurement of dengue control materials and supplies: Larvicides / insecticides 1 unit heavy duty fogging

machine for outbreak areas

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Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

PPA: EMERGING AND REEMERGING INFECTION PREVENTION AND CONTROLAvian Influenza and Other Infections To prevent/reduce

mortality from emerging and re-emerging diseases such as Influenza A [H1NI], Ebola Reston

To maintain a bird flu-free Bulacan

Maintain 0 mortality, 0 Case

To maintain bird and swine flu-free Bulacan

2 morbidity cases of Ebola Reston virus

0 mortality and morbidity incidence from Influenza A [H1NI]

With existing surveillance system

Legislation in place in support of emergency response plan for emerging and re-emerging disease outbreaks

Active and functional PDC and MDCCs

Health Systems Management

Finalization and enhancement of Provincial A1 Manual of Operations by TWG

Table review of drafted Provincial A1 Plan [PAO, PHO-PH, PGB Health Consultant, NGOs, support staff]

Reactivation of BHERTS through consultative meeting and planning with DILG

Implementation of functional surveillance system through MESU/PESU

Implementation of two way referral system [MHO/CHO to hospital and vice versa]

Capability Building Training of health workers, barangay officials and volunteers for CBEWS

Continuing updates on emerging and re-emerging diseases of RHU and hospital staff

Health Promotions Training on communication planning on emerging and re-

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Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

emerging diseases Dissemination of information

through community assemblies on emerging and re-emerging diseases

Production and distribution of appropriate IEC materials in strategic areas and population

Logistics Management

Procurement of PPEs and emergency medicines and other supplies Medicines:

Tamiflu Antibiotics [Amox. Or

Cotri.or Cloxa] Analgesic [Paracetamol]

Laboratory supplies [cotton, alcohol, sanitizer]

Supplies for VTM (viral tube media test, throat swab]

Vehicle to transport specimen to RITM

Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

PPA: CHILD HEALTH

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Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

Expanded Program on Immunization [EPI]Reduction of infant and under 5 mortality from 5.76/1,000 live births to 2/1,000 by 2013

Fully Immunized Children [1 dose of BCG, 3 doses of polio, 3 doses DPT, 1 dose of measles, 3 doses of Hepa B]

Only 2/3 cities and 4/21 municipalities with 95% and above FIC coverage

Newly hired and old health personnel lacks training on Basic EPI

CapabilityBuilding

Training on Basic EPI (with IPC) for MDs, PHNs, and RHMs

Poor follow up of missed children by health workers

Reorientation on the REB Strategy for MDs, PHNs, RHMs and BHWs

Identification of unmet needs on EPI

Inadequate EPI supplies [LGU counterpart not fully complied]

Logistics Management

Computation of cost of vaccines, syringes, needles and other supplies

Procurement of commodities Distribution of commodities Production and distribution of

ECCD cardsProvision of vaccines for immunization from DOH Oral Polio @ 152/ampule DPT @130.83/vial BCG @ 125.44/ampule Measles @ 93.10/vial Hepa B @ 112.7/vial Tetanus -TP X 3.5% @ 46.06

Untimely and irregular distribution of vaccines to LGUs

Monitor availability and follow-up pick up schedule of vaccines

Cold Chain Management

Procurement of vaccine refrigerators

No private sector participation in immunization

Health Systems Management

Orientation of private sector on EPI Protocols

Formalizing Public-Private Partnership (PPP) for EPI

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Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

Program Monitoring and evaluation of

PPPTarget population is higher than the actual number of children for immunization

CBMIS Workshop on CBMIS for health workers and BHWs to identity actual unmet needs

Roll out Reproduction of CBMIS

formsNeglect of mothers/family members for children's immunization

Health Promotion Advocacy on EPI during mothers' classes, bench conferences, video presentation while waiting at the RHU

Mobilization of children during GP events

Exclusive breastfeeding up to 6 months [reported when infant is 6 months old]

85% of mothers breastfeeding exclusively their children for the first 6 months

Low level of awareness of mothers/caregivers on the importance and benefits of breastfeeding up to 6 months

Inadequate information campaign on exclusive breastfeeding

Health Promotions Orientation on breastfeeding during mothers' classes, bench conferences, video presentation while waiting at the RHU

Health Event: Breastfeeding Week

Production and distribution of IEC materials on breastfeeding

Establishment of mother baby friendly barangay

Organization and training of peer counselors for breastfeeding

Health workers not trained on Infant and Young Child Feeding (IYCF)

Capability Building Training on IYCF [5 days live-out training for service providers]; 3 days didactic and 2 days practicum]

Children under 5 years of Maintain 100% coverage LGUs have steady supply of Review and validate records and

122

Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

age with diarrhea seen and given ORS [oresol]

cotrimoxazole 50% of LGUs procure ORS;

if ORS is not available at the RHU, doctor prescribes and instructs clients to purchase at the BnB where it is always available and cheaper

reports during supervisory visits

Children under 5 years of age with pneumonia seen and treated

100% coverage from 94% performance in 2008

Only 2 of 24 LGUs with training on IMCI (LGU-funded); most health workers not trained on IMCI

Capability Building IMCI training [11 days training course for midwives, nurses and doctors]

Health Promotions Include discussion on child health during bench conferences, mothers' classes and individual counseling

Mobilization of BHWs and women's health team in providing health education during home visits

Accomplishment for diarrhea seen and given ORS should not include prescription of ORS; however, some RHUs report it as accomplishment

Monitoring and Evaluation

Orientation of health workers on the proper filling up of health forms

Regular monitoring and evaluation

Children under 5 years of age with diarrhea seen and given reformulated ORS [oresol] and zinc

100% coverage Inadequate oresol in health centers [commonly prescribed] due to limited LGU budget.

Advocacy to LCE for inclusion in the CSR+ plan of reformulated oresol, zinc and cotrimoxazole

Provision of budget and procurement of commodities

Non-availability of reformulated ORS and zinc due lack of local suppliers

Procurement of zinc for sick children in coordination with CHD 3 for local suppliers of Reformulated ORS and Zinc

Under reporting of cases Accomplishment of private

Monitoring and Evaluation

Orientation to the private health sector through the

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Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

clinics and hospitals not integrated in the provincial health reporting system

Private Health Desk on the new FHSIS and other applicable reporting system

Regular monitoring and evaluation

Nutrition Services

Children 6-71 months given 2 doses of Vitamin A capsule within one year

Poor GP implementation resulting to high missed children on Vitamin A capsules and de-worming

Passive attitude of health workers in following up missed children

Monitoring and Evaluation

Conduct monitoring and supervision activities (health promotion included as part of supervisory and monitoring tasks

RCA Forms TEV of supervisor

Children 6-11 months given Vitamin A capsules

95% coverage in 2013 from 84% performance in 2008

Conduct of rapid assessment of performance on coverage

Children 12-59 months given Vitamin A capsules

Maintain 98% performance coverage

Neglect of mothers/family members in ensuring continuity of Vitamin A and iron supplementation for children

Include discussion on child health during bench conferences, mothers' classes and individual counseling

HPC strategy development to reach transient families

Children 60-71 months given Vitamin A capsules

95% coverage in 2013 from 77% performance in 2008

Train and mobilize BHWs and Barangay Health Promotion Officers (HEPOs) in providing health education during home visits

Sick or high-risk children 6-71 months given Vitamin A capsules 6-11 months given

Vitamin A 12-59 months given

Vitamin A 60-71 months given

Vitamin AAnemic infants and

Inadequate LGU budget for procurement of iron and Vitamin A for high-risk children

Logistics Management

Advocacy to LCE for line budgeting and full implementation of Commodity Self Reliance + plans

Procurement and distribution of commodities to RHUs Vitamin A and

iron/ferrous sulfate Provision of GP supplies,

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Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

children given iron supplements 6-23 months 24-59 months

i.e., 2 rounds of Vitamin A Medicines for de-worming Salt Tester

Poor recording and reporting Health Systems Management

Review and validate records and reports during supervisory visits

Households using iodized salt

100% of households using iodized salt in 2013 from 92% in 2008

Low level of awareness on the importance of Iodized salt of some households

Health Promotion Include discussion on child health during bench conferences, mothers' classes and individual counseling

Health Event – GP Dissemination of information

on iodized salt usage to households

Poor compliance on the part of business and commercial establishment

Health Systems Management

TEV for monitoring, assessment and on the spot check [Php 3,000/member]

Non-functional Asin Task Force Reactivation of the Asin Task Force

Poor enforcement of the Asin Law

Strict and full implementation of the Asin Law in all LGUs

Monitoring and evaluation of business and other establishments' compliance to Asin Law

Conduct random/on-the-spot check of salt sold in the market and used in the households

Monitoring and Evaluation

Quarterly consultative meeting of PPHO and LGU technical working group

Dental ServicesOral Prop for pre-school children

Increase percentage of children practicing oral

No PPHO-Dental Health Program

Dialogue with LCEs for the creation of a dental program

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Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

health care to 80% in 2013 from 59.1% [47,220] in 2008

No dentist to head the unit No position for Provincial

Dentist and not included in the new PPHO structure

division, hiring of dentists at the PHO and LGU levels

Coordination with Hospital Senior Dentist to extend TA to LGU dentists

No direction of dental health program

Municipal dentists need support and guidance from the PPHO

LGU dentists do their own programs but no one in the PPHO integrates/oversees efforts and initiatives

Development of a comprehensive dental health program for the province and LGUs

Inadequate dentist to population ratio of 1 dentist:67,952

Dentist is stationed in the main RHU and conduct scheduled dental clinics in the barangay

Conduct dental outreach services in every barangay

Preventive: oral exam and oral prophylaxis supplies

Curative: tooth extraction, supplies and medicines

Low level of awareness on the importance of oral care among pre-school children [2-6 years old]

Health Promotions IEC materials production and distribution

Newborn Screening

Increase to 40% of women undergoing newborn screening from 3,429 [17%] in 2008

8 government hospitals with NBS services

Health Systems Management

Dialogues with LCEs and other stakeholders for the enrolment of indigents to PHIC to avail of the NBS procedure

Mobilize BHWs and women's health team in encouraging informal sector to enroll in PHIC

Clients have low level of Health Promotions Include discussion on

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Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

awareness on the importance of NBS

newborn screening during bench conferences, mothers' classes and individual counseling

Mobilize BHWs and women's health team in following up newborns for NBS during home visits

Clients are financially constrained to avail of NBS (Php 650-750 per test)

Conduct PHIC orientation at the municipal and barangay levels

Inadequate NBS kit at the hospitals

Logistics Management

Review of existing logistic andprocurement system

Conduct regular inventory of stocks and review of utilization report

Prepare annual procurement plan with provision for buffer stock

Mother-Baby Friendly Initiative100% of all hospitals are designated Mother-Baby Friendly facilities

7/8 hospitals are Mother-Baby Friendly facilities

Poor implementation of milk code and Mother-Baby Friendly Hospital Initiative

Some health practitioners do not adhere to the Milk Code and Mother-Baby Friendly hospital initiative because of incentives derived from patronizing the milk products

Monitoring and Evaluation

Enforcement of MBFHI Conduct of random visits in

hospitals and OB wards during supervisory visits

Some mothers have low practice on the early initiation of breastfeeding

Health Promotions Include discussion on breastfeeding during bench conferences, mothers' classes and individual counseling

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Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

Health Event - Breastfeeding Week

Development and production of CD for presentation on IYCF

Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

PPA: MATERNAL HEALTHBEmONC/CEmONC Facility

Reduction of maternal mortality from 6.82%

19 Lack of health facility to provide BEmONC services

Facility Development

Conduct Facility and Capability Assessment for

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Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

to 1.71% (2) by 2013 From 44 cases to 11

cases of maternal deaths by 2013

BEmONC Procurement of health

equipment, furniture and fixtures

Renovation and improvement of infrastructure/building

3 RHU facilities are MCP-accredited

Health Systems Management

Compliance to requirement of PHIC for MCP accreditation of RHUs

Health workers not trained on emergency obstetrical and newborn care and other safe motherhood trainings

Capacity Building Conduct training courses on: BEmONC [11 days] for

doctors, nurses and midwives Life Savings Skills (LSS) for

RHMs

Women’s Health Team 24 LGUs oriented and

trained onWHT

Creation of WHT in 14 municipalities/cities with 83 traditional birth attendants

Health workers and LGUs have limited understanding on the concept of women's health team

Capacity Building Orientation to health workers and LGU officials on Women's Health team

Training on Women's Health Team

Contraceptive Self RelianceIncrease CPR 50% in 2013 from 42% in 2009

100% LGUs with plan CSR+ plan not fully

implemented 19 LGUs with specific FP

budget but only 17 had actual procurement

Advocacy, Communicationand Social Marketing

Meeting with LCEs, SB/SP on Health, and Local Health Board to CSR+ Plan implementation

24 LGUs with procured FP commodities

17 LGUs with actual procurement of FP commodities

Formulate local CSR+ policy in 3 LGUs [Paombong, San Miguel and Malolos City]

Conduct participatory monitoring and evaluation of CSR+ Plan implementation

129

Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

Follow-up activitiesInsufficient budget for CSR logistics and procurement

Capacity Building LGU orientation on MNCHN Grant

Prepare distribution/allocation list of FP commodities for LGUs

Logistic Management

Procurement of FP commodities, i.e., pills, IUD, injectables

Distribution of FP commodities to LGUs

Transportation expenses for CDLMIS

No client segmentation Supply is good while it lasts

[First come, first served basis Not all LGUs have safety net

for the poor

Capability Building Reorientation of BHWs and RHMs on CBMIS

Reorientation of RHMs on LMIS

Distribution of forms and actual experience

Conduct of regular CBMIS and LMIS

Preference of couples to use traditional natural family planning methods [withdrawal, rhythm, calendar] due to convenience, no cost, and used to the method.

Health Promotions Include discussion on modern FP methods during bench conferences, mothers' classes, pre-marriage counseling and individual counseling

No training for newly hired and old midwives, doctors and nurses on CBTFP Levels 1 and 2, inter-personnel communication and counseling and informed choice and volunteerism

Capability Building Conduct of CBTFP Levels 1 and 2 [5 days per level] for midwives, doctors and nurses

Conduct of 3-day Family Planning Action Session (FPAS) for RHMs and PHNs

Other Reproductive Health Programs

130

Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

Pregnant women with at least 4 antenatal visits attended by skilled birth attendants [doctors, nurses and midwives]

Increase to 90% performance in 2013 from 84% in 2008

Delay in seeking prenatal care due to initial reaction of denial

Low awareness on its importance

Inconvenience in traveling to health facility

Financial constraints Perception that pregnancy is a

normal occurrence and there is no need to consult health workers

Advocacy, Communicationand Social Marketing

Development and production of IEC materials, e.g., flyers, leaflets, comics, Mother and Baby Book among others

Distribution of materials during health events

Pregnant women had at least 2 doses of tetanus toxoid immunization

Increase to 80% performance in 2013 from 71% in 2008

Non-compliance of some hospital physicians on TT immunization protocol

Advocacy, Communicationand Social Marketing

Conduct orientation and/or re-orientation/updates on TT immunization protocols to health workers during ULHS meetings, among other venues

Some pregnant women have fear of side effects of the vaccine to the unborn child

Health Promotions Dissemination of information during consultations and household visits by RHM and BHWs

Birth deliveries attended by skilled health workers, i.e., doctors, nurses and midwives

Some pregnant women still prefer traditional birth attendants

Capability Building Conduct Training on Community Managed Maternal and Newborn Care for midwives and nurses

1 batch of training for midwives from Balagtas, Baliuag, Bulacan, Malolos City, Meycauayan City, Obando, Pandi, Paombong, Plaridel, San Ildefonso, San Miguel, San Rafael, Santa Maria, Marilao and Hagonoy

1 batch from PHO budgetDeliveries at health Increase to 80% Preference of mothers to deliver Advocacy, Increase enrollment to PHIC and

131

Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

facilities [hospitals, private clinics and health centers]

performance in 2013 from 38% in 2008

at home due to convenience, distance of health facility and financial constraints

Communicationand Social Marketing

encourage pregnant women to deliver in PHI-accredited public health facilities

Pregnant women with complete dosage of iron supplementation – at least 6 months (reported after the 180 tablets)

Increase to 90% performance in 2013 from 68% in 2008

Inadequate iron and vitamin A supply for pregnant and lactating mothers in some LGUs

Logistic Management

Prepare Annual Procurement Plan for micronutrient requirements

Procurement of micronutrients for augmentation

Accomplishment of complete iron and vitamin A dosage not evidence-based (some were only prescribed; health workers rely only on feedback from clients)

Health Systems Management

Assessment of current recording and reporting system (include during supervisory visits)

Validate improved recording and reporting tool

On-the-job training of PHNs on improved recording and reporting system for micronutrient supplementation

Outreach activities for GIDA communities (services) - go for reaching areas with poor access and those with indigenous people

Postpartum Women given complete iron dosage 90 tablets

Increase to 90% performance in 2013 from 72% in 2008

Low level of awareness of mothers on the importance on micronutrient supplementation [iron and Vitamin A]

Advocacy, Communicationand Social Marketing

Development and reproduction of IEC materials

Maternal Death Review 7 functional ULHS MDRCs

6 of 7 ULHS with organized but not functional MDRCs

Non-functional ULHS; turnover of committee members without proper endorsement and no orientation to new members

Health Systems Management

Organization and strengthening of MDRCs in all municipalities and cities

Orientation on MRDC role Conduct regular maternal

death review

132

Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

No provincial MDRC No local policy on the

development of Provincial Maternal Death Review Committee

Legislation Advocacy to LCE for the creation of Provincial MDRC through an Executive Order

Conduct regular maternal death review

Poor monitoring and evaluation of maternal deaths

Line listing of maternal deaths

Conduct of Clinical CaseConference / maternal death review

Other Health Programs: Dental HealthImproved access to dental health program

Increase to 95% performance in 2013 from 89.2% [31,932] in 2008

Lack of dentist in the LGUs and provincial level (PPHO-Dental Program Division)

Advocacy, Communicationand Social Marketing

Dialogue with LCEs for the creation of a dental program division, hiring of dentists at the PHO and LGU levels

Coordination with Hospital Senior Dentist to extend TA to LGU dentists

Development of a comprehensive dental health program for pregnant women and mothers

Inadequate dental supplies Provision of critical logistics for the essential oral health care packages

Low level of awareness on the importance of oral care/dental health among pregnant women and mothers

Development of IEC materials

Collaboration and linkages with other health partners for integrated approach to oral health

Other Health Programs: Adolescent Reproductive HealthIncreasing cases of abortion admissions in hospitals with 2,688 patients in 2008

Health Systems Management

Conduct of study on causes and factors of increasing trends of abortion

133

Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

Development of programon teen pregnancy

Low awareness of the teens and young adults on the reproductive health

Health Promotions Increase awareness on adolescent reproductive health through the conduct of Responsible Youth towards Life Ready for the Future [RYT Life] in partnership with PYSEACO

Private Health Desk to provide orientation courses to [schools and universities on adolescent reproductive health

Formulate curriculum for Adolescent Reproductive Health [ARH]

Lobby with the School Board/ Board of Regents on the integration of Adolescent Reproductive Health in the school curriculum

Conduct health education and promotion on adolescent reproductive health in schools and universities

Lack of knowledge and information of health workers on ARH

Monitoring and Evaluation

Refresher Course on M&E for Public Health Nurses

Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

PPA: HEALTHY LIFESTYLE AND MANAGEMENT OF HEALTH RISKSAdvocacy Campaigns for Risk Behaviors

134

Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

Reduced mortality and morbidity due to non-communicable diseases

No comprehensive provincial and local Non-Communicable Diseases Control and Prevention Program

Service Delivery Creation of Provincial NCD Technical Working Group [4 PPHO, 1 PPDO, 1 PSWDO, 1 NGO, 1 PNP, 1 PA, 2 academe, 2 Hospital, 1 PHTO, 1 PPAO, 1 PIA, 1 ABC, 1 SB on Health, 1 LMP, 1 DepEd]

3-day NCD Control Program Implementation Review and planning workshop

Designation/Assignment/Hiring of municipal/City NCD Control and HL Coordinator

Organization/Creation of Municipal/City NCD Control and HL Core Team

Inadequate information on lifestyle-related diseases and health risks among health workers

Capacity Building Orientation on the installation of NCD Control and HL program at the province and municipal/city levels

2-day NCD orientation/planning workshop to Municipal/City HL Core team [doctors, PHNs, HEPO designate, RSIs]

Orientation/Re-orientation on NCD Control and lifestyle-related diseases

Stress Management seminar among health workers

Training on the conduct of community stress de-briefing

Training on diet counseling program

135

Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

Regular update on NCD and related Diseases for Diabetic Club Members

Advocacy to allocate funds for NCD program as well as the procurement of NCD medicine

Unhealthy practices (because of peer, family pressure), "instant lifestyle"

Conduct Kabarangay HL Forum

Continuous health teachings and bench conferences at RHUs and communities

Logistics Management

Procurement of supplies for provision to organized diabetic clubs and BHWs

Not all LGUs with Cancer, DM, HPN, Redcop Registry

Health Systems Management

Training for MHOs/RHMs/BHWs in the conduct of NCD Registry [24 MHOs, 300 RHMs, 569 BHWs for a total of 893]

Reproduction of monitoring forms

Regular monitoring and evaluation and validation

Monitoring and Evaluation

Development of HL monitoring evaluation tool based on HL indicators

Pre-testing Orientation to health workers

on the use of NCD reporting tool

Collection and collation of data

Limited NCD prevention and control services

Health Systems Management

Strengthen provincial referral system

Review and validate Bulacan Health Referral system (note:

136

Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

part of disease surveillance) Orientation on Bulacan health

referral system Implementation of Bulacan

health referral systemPhysical Activity [HATAW]

Not all LGUs conduct Hataw Exercises and diet counseling

Organization of provincial, municipal/city HATAW core group (10 members/24 teams)

Roll out HATAW activities in all municipalities and cities

Conduct of regular HATAW exercises at municipal/barangay level

Smoking Cessation Non-passage of local ordinances supporting anti-smoking

Advocacy, Communicationand Social Marketing

Advocate for the passing of municipal/city ordinance adopting Clean Air Act/anti-smoking campaign

Lack of knowledge of health workers on smoking effects

Capability Building RSI orientation on Smoking Law and its enforcement

Training of doctors and nurses on counseling on substance abuse

Health Systems Management

Integration of anti-smoking campaign to elementary and high school curriculum

Ensure adequate supply of human blood for medical needs of the population

Voluntary Blood Donation Only 3 LGUs with active municipal blood council

Capacity Building Training/Orientation on Local Blood Council Guidelines (21 Blood Council)

Province-wide donor registry is not updated

Health System Management

Set-up of Integrated Blood Banking Information system (IBBIS)

Set-up of Internet Connection Procurement of Computer and

Printer Orientation on IBBIS

137

Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

implementation Re-activation of Samahan ng

Magkakadugo [donor registry at the barangay level)

Completion of Dugong Bagong Bulakenyo [registry/master list of voluntary blood donors]

Mobilize LGU Blood Team to organize blood typing activity [10,000 per year]

Logistic Management

Procurement of blood typing equipment and materials Typing sera a Typing sera b Typing sera d Slides (72s), Lancet (200s),

Toothpick (50s), Alcohol, Cotton among others

Number of Blood Units Collected

Insufficient blood collection (50% of actual collection)

Lack of awareness on voluntary blood program

Social Marketing and Blood Forum with NGOs, private business establishments, military camps, academe among others

Quarterly mobile blood donation at RHU level and government hospitals and regular

Mobile blood donation at community level, academe, establishments, offices, etc

Strengthen community donor recruitment through the Usapang Magkakadugo sa Barangay

No out reach blood letting Organize municipal and

138

Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

activities (centralized at RHU) barangay blood coordinatorsInsufficient manpower for advocacy and promotion

Capacity Building Training on Blood Donation and Donor Recruitment for 24 blood coordinators

Training on Basic Phlebotomy

Provincial blood team can only accommodate 4-5 MBDs in a week

Expansion of Blood Donation Team to 3 remaining LGUs and MBD partner agencies and organizations

Logistics Management

Procurement of blood-letting commodities and supplies: blood bad single, vacuette, globes, folding beds, pillows and pillow cases,

HBsAg 100/test kit, HIV, 100 test (1750 kits), HCV 1 & 2 972 boxes, HBsAG 36 test/kit [972 kits], N95 mask, BP Apparatus, tackle box, TV set for blood donors, squeeze ball, red and violet taps

Hospital Blood Transfusion Committee is inactive

Training of Blood Transfusion Committee on the guidelines and protocol on blood transfusion

Monitoring of blood transfusion committee

Quality of Blood No provincial ordinance or policy on "no replacement”

Advocacy meeting with SP on "no replacement" ordinance through the Bulacan Local Blood Council

Only 4 public hospitals with blood refrigerators

Procurement and Logistic Management

Purchase of blood refrigerator for the remaining district hospitals (BMCH, SDH, EGPDH, GPDH and Blood

139

Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

Center] Purchase of 1 unit plasma

freezer and I unit blood refrigerator for the Blood Center

Procurement of additional equipment for Blood Center: tube sealer, fax machine, 3 units plasma separator stand, emergency light and digital timer

No regular reporting and monitoring on blood utilization at hospital level

Monitoring and Evaluation

Regular monitoring on blood utilization

Risk Factor ScreeningTo improve knowledge, attitude and practice of health workers on the risk factors, control and prevention of lifestyle diseases

Health workers not trained on Risk Factor Screening/Healthy Lifestyle

Capacity Building Training on BP taking for BHWs

Training for health workers and BHWs on self-examination for breast and cervical cancers

Training and orientation on Risk Factor Screening/Healthy Lifestyle for health workers

Service Delivery Regular breast examination at RHUs and barangays

Regular acetic acid wash/pap smear at RHUs and barangays

To improve community knowledge, attitude and practice on the risk factors, control and prevention of lifestyle diseases

Inadequate knowledge, poor attitude and low practice of the community on the risk factors, control and prevention of lifestyle diseases

Health Promotions Reproduction off IEC materials

Tri-media campaign Conduct community

assembliesLogistics Procurement of materials and

140

Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

Management supplies for local risk-factor screening: droplight, examining table, slides (72s slides), vinegar, cotton pleb

Water and SanitationHouseholds with sanitary toilet

100% of households with sanitary toilets in 2013 from 91% in 2008

17% or 103,107 households have no sanitary toilets

Service Delivery Survey of households without sanitary toilet and access to safe water

Masterlisting of households with sanitary toilet facility and access to safe water sources

Allocation of budget for the construction of toilet facilities [estimate of 15% of barangay households have no sanitary toilets

Construction of toilet bowls Indigent households identified

through the Agapay sa Barangay’s Oplan Bantay Palikuran

Households with access to safe and potable water

100% of households with sanitary toilets in 2013 from 87% in 2008

13% or 71,381 households with no access to safe and potable water

Legislation Advocacy to local officials for increased coverage of households serviced by LWUA or BSWA

Reduced morbidity and mortality from diarrhea

Diarrhea cases of 500/100,000 population

Diarrhea cases of 740/100,000 population

Service Delivery Conduct water samplings and examinations of existing water sources for potability (PHC/bacti bottles, water sampling kit, laboratory examination fee)

Mortality due to diarrhea at <1 death/100,000

Mortality due to diarrhea with 0.06/100,000 population

Disinfection of positive water sources and newly constructed water supply sources with chlorine granules

Cases of cholera, typhoid, Maintain 0 morbidity and Maintenance of safe and potable

141

Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

paratyphoid fever outbreaks confirmed by NEC-DOH

mortality water on households and resettlement area through the use of tablet disinfectant [utilization in 1% of households, 100% in resettlement areas]

Health Systems Management

Data Management Validation of EHS reports as

to access to water, with sanitary toilets, sanitary compliance of food establishments among others through the PIR

Enhancement of EHS reporting form to include report of EHS-related diseases

Formalization of partnership through MOA with BWSA/LWUA for regular water testing; RHU copy furnished with laboratory results

Capacity Building Training of newly hired RSI and MHOs/RHPs on EHS program

Re-orientation and updates on EHS for existing staff

EHS orientation for local officials (SB on health, ABC, LMP)

Training course for operators and owners of water refilling stations

EHS Sanitation Course for RSIs

Refresher course on Sanitation Laws and its IRR

142

Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

[PD 856 and PD 522]Food establishments complying with minimum sanitary standards

Increase to 100% minimum compliance in 2013 from 89% in 2008

10,527 out of 11,806 or 89.2% of food establishments with sanitary permit

28,498 out of 31,953 or 89.2% of food handlers with health certificates

Service Delivery Inspection of food establishments by using standard inspection forms

Issuance of sanitary permits Issuance of health certificates Province-wide

implementation of SSRS Enhancement of SSRS rating

guidelinesFood handlers trained and practicing sanitary procedures

Inadequate knowledge on sanitation of food handlers

Capacity Building Training of Food Handlers Training on HACCP

Food trade regulated No ordinance on food trade Legislation Regulation of street food trade

Consultative meeting with local officials

Orientation/community meeting and dialogue on street food trade with municipal and barangay officials

Developed EHS Manual of Operations

No EHS manual of operations Health Systems Management

Development of EHS operational guidelines

Reproduction of PD 856 and PD 522 IRRs for newly hired RSI and MHOs/RHPs

Improve the health surveillance system of the province on toxicology and heavy metal contamination

Toxicology Project No recorded cases on heavy metal contamination but Meycauayan City, Obando and Marilao with heavy metal contamination on its river water ways

7 additional LGUs considered high-risk

Inclusion of Bulacan under

Capability Building Basic Training on Toxicology Health Surveillance Training

for Health Practitioners

143

Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

WQMA needing waterways clean up

Increase awareness of health workers on heavy metal contamination

Low awareness of health workers on issues surrounding heavy metal contamination

Advocacy, Communicationand Social Marketing

Development of handbook on heavy metal contamination and basic toxicology for local health officers

Publication of handbook/manual

Reproduction of handbook for dissemination to local officers and other stakeholders

Service Delivery Conduct of health survey and health assessment

Consolidation, analysis and reporting of survey results

Consultation and referral of suspected cases with heavy metal contamination

Monitoring and follow-up of identified cases

Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

PPA: SURVEILLANCE AND EPIDEMIC MANAGEMENTTo prevent, control and manage the occurrence of outbreaks on reportable, immunizable disease and other emerging and re-

Creation of functional Epidemic and Surveillance Units [PESU and M/CESU at the province, municipalities and cities]

Health personnel not updated on standard protocols on clinical management of diseases [outbreak risks]

Lacks training/updates on the

Capacity Building Training on Basic Epidemiology

Training on PIDSR

144

Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

PPA: SURVEILLANCE AND EPIDEMIC MANAGEMENTemerging diseases ff: basic epidemiology,

emerging and re-emerging diseases, PIDSR, dengue vector survey

Only 50% of LGUs are trained in MESU MESU not established in 12 LGUs

Health Systems Management

Installation of MESU to 12 remaining LGUs and re-activation of MESU on 12 LGUs

Setting up of MESU within the RHU

Designation of Surveillance Coordinator and Surveillance Officer

Strengthened referral system

Weak referral system with the private health sector

Lack of coordination with private clinics and hospitals on reporting of notifiable diseases

Dialogue with private clinics and hospitals through continuing updates on reportable/notifiable diseases every quarter

Monthly submission and collection of reports from private clinics and hospitals

Strengthened information system

Poor reporting and investigation of diseases under surveillance

No standard investigation forms on some diseases

Delayed investigation and surveillance

Monitoring and Evaluation

Procurement of office furniture and equipment

Reproduction of prototype investigation and reporting forms

Weekly update of report to MHO/PESU/RESU

Updates to MHOs and PHNs Monitoring and supervision

of C/MESU and Private hospitals and clinics by PHO-PH Surveillance Coordinator

Creation of Provincial No provincial epidemic Legislation Development of

145

Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

PPA: SURVEILLANCE AND EPIDEMIC MANAGEMENTEpidemic Management Committee

management committee Comprehensive Provincial Epidemic Management Plan

Legitimization and approval of the Comprehensive Provincial Epidemic Management Plan through the LHB

Endorsement of the Comprehensive Provincial Epidemic Management Plan through an Executive Order

Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

PPA: DISASTER PREPAREDNESS AND RESPONSE SYSTEMTo reduce mortality from 0 mortality from Some MHOs/CHOs not Health Systems Formulation of a Provincial

146

Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

disasters [natural and man made disaster]

disasters 1 Provincial Health

Emergency Preparedness Response and Recovery Plan

included in disaster preparedness planning

MHOs not informed on standard protocol on declaring state of calamity

Lack of coordination of MDCC to MHO/CHO [Marilao]

Management Health Emergency Preparedness, Response and Recovery Plan Creation of a TWG for the

drafting of Health Emergency Plan

Writeshop on the formulation of Plan to include data gathering and review

Public hearing/stakeholders meeting for finalization of Provincial Health Emergency Preparedness Response and Recovery System

Legislation Passage of Provincial Health Emergency Preparedness, Response and Recovery Plan through the LHB with an Executive Order

LGU Orientation on the approved Provincial Health Emergency Preparedness Response and Recovery System Plan

Provincial Health Emergency Network established and functional

Lack of training of health personnel on basic life support and first aid

Capacity Building Refresher Course on First Aid and Basic Life Support in coordination with Red Cross and PDMC

Training on Disaster Preparedness Response and Recovery System

No stock pilling of logistics for emergency use

Logistics Management

Procurement of medicines [antibiotics, analgesic, anti-diarrhea, anti hypertensive, vitamins] for disaster-stricken areas

147

Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

Lack of ambulances and communication equipment for mobilization during rescue and response

Provision of vehicle for Provincial Emergency Disaster Preparedness

24 LGUs and 7 hospitals submit complete, accurate and timely FHSIS reports

Inadequate FHSIS Reporting forms

Late submission of quarterly FHSIS report

Monitoring and Evaluation

Request for the provision of sufficient standard FHSIS reporting forms

Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

PPA: HEALTH PROMOTION AND ADVOCACY

148

Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

90-95% of the citizenry are health conscious and increased access to public and private health facilities

Government health facilities delivering quality health care with satisfied clientele

Poor health seeking behaviors of clients

Preference for private health facilities

Misconceptions on health and health practices

Unavailability of health information materials

Lack of health promotional activities

Health Promotions Conduct of special events focusing on different health issues and concerns: “May K sa Health Center

(Kalinga, Kakayahan, Kalinisan, Kaalaman sa Kalusugan)"

Health Caravan Bulacan Health Expo Kalugan sa Kalusugan (Move

for Health) Sportsfest BHPP - Healthy Settings Dengue Skul Watch Health Summit BHW Congress

Increased awareness on public health programs

Poor health seeking behavior of clients due to pre-occupation with economic concerns, peer pressure, fast-paced lifestyle among others

Monthly Health Initiatives: January: Cancer (registry) February: Heart, Dental (BP

taking at all establishments, listing of patients with HPN

March: TB, Rabies, Women's Health (Rabies Congress, pap smear)

April: Garantisadong Pambata (GP Exhibit, motorcade)

May: Safe Motherhood, Brigada Eskwela

June: Dengue, Redcop (Motorcade, hanging of streamers, barangay and school visits)

July: Diabetes, Nutrition, Blood

August: Lung, Breastfeeding, NBS

149

Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

September: Health Expo showcasing HL services

October: GP 2nd Round November: FF Day, Diabetes

Day (forum with DM patients December: World AIDS Day

[candle lighting ceremony and forum with at risk groups]

Health Systems Management

Conduct of Participatory Action Research to low performing LGUs

Training of enumerators for the survey for 6 priority health programs

Improved KAP of health workers in health promotion and advocacy

Lack of KAP on health education and promotion, organizing health events, IEC development, IPC and BCC

Capacity Building Training of Trainers on Interpersonal Communications and Counseling

Training of Trainers on Community Mobilization

Training on Message Development

Training of Service Providers on IPCC

Lack of organized groups to support health education and campaigns in the 24 M/C LGUs

Training of BHWs on IPCC Training on Community

Mobilization for BHWs, NGOs, and BNSs

Organization, orientation and mobilization of target groups

Social Preparation for health events

Monitoring and supervision Roll-out training for service

providers on IPCC

150

Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

Lack of involvement of tri-media on health promotion

Networking and Alliance Building

Masterlisting of media partners

Inadequate skills of health personnel on health promotions

No manual for health educators

No baseline data on the number of health information advocacies rendered by health workers

Capacity Building Orientation on the use of health promotion manual (ACSM Manual)

Development and production of IEC materials

Procurement of tri-media Equipment at PHO-PH for use at Health Caravan

Training on Health Promotion Advocacy Tracking System

BHW as frontline health promoters

Inadequate incentives for BHWs for health promotion activities

Health System Management

Allotment of BHW incentives

To ensure that all IEC advocacies are being conducted on the ground

No plantilla position for HEPOs in municipalities and cities

Assign a designated HEPO

Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

PPA: HEALTH FACILITIES DEVELOPMENT

151

Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

Rationalization of Local Health FacilitiesAccessible, efficient, effective quality health services provided and delivered to community

100% health facilities are SS-certified and PHIC- accredited

53 RHUs are SS-certified 7 PGB Hospitals are DOH-

accredited 1 RHU is MCP-accredited 21 RHUs are OPB-accredited 12 RHUs are TB-DOTS-

accreditedNo existing BEmONC facility Bulacan is not pilot for BEMoNC.CEMoNC

Facility Development

Establishment of BEmONC/CEmONC through facility improvement and repairs

Capability Building Orientation of health personnel on BEmONC/ CEmONC

Training of health personnel on emergency obstetrics care

Legislation Establishment of BeMOC/CeMONC facility through an Executive Order

Allocation of budget for the procurement of equipment, logistics and supplies

Health Systems Management

Implementation of 2 way referral system from RHU to BEmONC to CEmONC

No birthing station Facility Development

Establishment of Birthing stations

Upgrading of existing birthing stations for accreditation

Procurement of equipment, supplies and materials to comply with PHIC standards

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Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

for accreditation Maintenance of birthing

stationsLack of RHU/CHU including health personnel complement

Legislation Advocacy to LCE for compliance to health facility to population ratio

Advocacy to SB for the creation of health plantilla positions

Lack of equipment and supplies Allocation of budget for the procurement of equipment and supplies to sustain operation of RHU/BHS

CHU/RHU not recognized in Meycauayan City, Marilao and Santa Maria

Coordination with SB for the endorsement of RHUs to PHO to CHD 3 and DOH for recognition as official health reporting units

Coordination with PHO and CHD 3 for inclusion of RHUs in the master list of recognized RHUs

Existing RHUs not yet accredited for TB-DOTS, OPB and MCP

Quality Assurance Maintenance of existing PHIC-accredited TB-DOTS Centers, OPB and MCP

Compliance of RHUs to pass all PHIC accreditation requirements for delivery of benefit packages

Standard facility mapping guidelines not yet implemented in Bulacan

Coordination with CHD 3 on standard facility mapping guidelines

Review of Bulacan facility map

Conduct facility rationalization workshop

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Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

Development of facility rationalization plan, write up to come up with facility mapping manual

Strengthened primary health care and referral system

Bulacan referral system manual not implemented

Re-orientation on the Bulacan referral system manual

Endorsement of manual to SP for approval and utilization

Reproduction of manual for distribution to 7 hospitals and 24 MHOs/CHOs

Draft referral form not utilized Utilization of standard referral form

Weak public to public, public to private referral system

Recording and reporting of referrals to PHO - public health

Training on Bulacan referral system for public and private practitioners/clinics/hospitals

Some defective and replaceable communication equipment and ambulance transport

Allocation of budget for the procurements of communication and mobilization equipment

Some RHU needs repair/construction

Appropriation of budget for construction and repair of RHUs and BHS

Procurement of equipments and supplies for the operation of RHU

Health facility-to-population ratio not met (lacks 50 BHSs to comply with 1:5,000 ratio)

Advocacy to mayor for the budget for the construction of BHS facility

Allocation of budget for the construction of BHS

Procurement of equipment and supplies for the operation of BHS

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Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

No official Public Health Building [office is located at the OPD building of BMC]

Construction of PHO-Public Health building

Provision and procurement of equipment, logistics for the PHO-Public Health Building

Health Human Resource Provision/Capacity Building

Health personnel population ratio not met [lacks 85 doctors, 100 dentist, 85 nurses, 91 RSIs, 50 midwives and 106 medical technologists]

Lobby with the mayor/governor for the hiring of health personnel

Provision of budget for the creation of plantilla position for health personnel needs

Lack of training on health programs by RHU and hospital personnel

Capability Building Training on strategic management and continuing quality improvement for municipal and City Health Officers and Provincial Program coordinators

Refresher course on priority public health programs for local health workers

Training of local health workers on data collection, compilation, validation and analysis for policy and program evaluation

Orientation of decision makers and other stakeholders on health sector reform

Hospital ServicesEffective and efficient hospital services delivery

100% client satisfaction on hospital service delivery

Limited manpower, equipment and service infrastructure at the Bulacan Medical Center

Facility Development

Expansion of ancillary and clinical servicesIncrease manpower

High cost recovery but no Plan for BMCH to become a

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Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

corporate structure for hospital corporate hospitalBed population ratio inadequate with the present set-up (RMMMH-all hospital)

Upgrading of hospital level + bed capacity + staff for RMMH and BDH

No installed computerized database network and reporting system (BHIS) in district hospital

Full installation and institutionalization of the system (BHIS)

Poor lay out of current hospital facilities and services

Establish satellite pharmacy and cashier in new building

Accessible, efficient, effective health service delivery to stakeholders with 100% clients satisfaction

Integration of Wellness Services in Hospitals

Integration of hospital services in health teachings

Close linkage with LGU for financial support

Maternal Health: antenatal and post natal care

Delayed referral of high risk pregnancies

Financial constraints Attitudinal problem of clients

Strengthen referral system Capacity building for health

workers on post natal care

CEmONC/BEmONC No follow-up after orientation Request CHD 3 for follow up orientation on CEmONC/BEmONC

Increased access to nutrition services in hospitals

No malnutrition ward in hospital Creation of malnutrition ward (BMCH)

Identification of needed equipment for malnutrition ward

Personnel requisition Provision of supplies for

supplemental feeding and iron capsules

No standard management for pathologic and infectious waste (hospital)

Establishment of autoclave and treatment facility

Establishment of a liquid waste disposal facility in

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Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

district hospitalsHospital compliance with DOH Standard for continuous quality improvement

Expansion of ancillary and clinical services

Increase in manpower

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Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

PPA: HEALTH REGULATIONEnforcement of and Compliance to National Health Legislation and StandardsImplementation/ enforcement of health and health-related laws

100% enforcement and implementation of health and health-related laws and standards by the end of 2013

No local ordinances on important health and health-related programs

Low level of awareness of stakeholders on health and health-related laws

Lack of systematic and institutionalized evidence-based participatory legislation and policy making at the local level

Advocacy, Communication and Social Marketing

Develop a policy tracking mechanism tool to monitor the implementation of health related ordinances [Milk Code, Mother-Baby Friendly Hospital, Asin Law, ECCD, Sanitation Code among others]

Regular LHB meetings at the provincial and municipal/city levels

Regular dissemination of health updates through flyers, news bulletin among others to all sectors

Orientation to decision makers and other stakeholders [LCEs, SPs, SBs, NGOs, CSOs] on health sector reform

Compliance to PHIC accreditation standards for health facilities

80% RHUs are OPB-accredited by the end of 2013

39% or 22 out of 57 RHUs are OPB accredited

No PHIC enrollees Difficulty in accreditation

process and renewal of license

Advocacy on sustainability and universal coverage

Increase level of sponsorship for enrollees

Regular consultation with PHIC

Resource mobilization80% of microscopy centers are TB-DOTS-accredited by the end of 2013

30% or 12 out of 40 sputum microscopy are TB-DOTS accredited

100% of birthing stations/RHUs are MCP accredited by 2013

11% or 1 out of 9 birthing stations are MCP accredited

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Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

Legislation of health-related laws at the local levels

Passage of ordinances supportive to health program initiatives

Inadequate information on national laws on health and health-related programs

Weak advocacy by health officers to local legislators

Advocacy, Communication and Social Marketing

Regular dissemination of information on health programs

Activation of LHBs Monitoring of programs that

need legislative support Development of Provincial

Health and Sanitation Code

Enforcement of and Compliance to National Health Legislation and StandardsIncreased access to low-cost quality drugs and commodities

1 BnB per barangay Low access of households and communities to low-cost drugs and commodities

Resource Generation Localization of botika ng barangay

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Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

PPA: HEALTH FINANCINGExpansion of National Health Insurance ProgramInvestments in health are increased and efficiency and equity in resource allocation are improved

Universal coverage 85% of the total

population 80% of informal sector

covered

Low PhilHealth enrollment among informal groups

Development of strategies for easy enrollment of informal sector

Organization of informal groups

100% 0f indigent enrolled to NHIP

93% indigents enrolled to NHIP

Not all LGUs have enrollments to NHIP

No budget allocated for PhilHealth enrollment

Resource Generation Orientation of local officials on the benefits of PhilHealth

Systematic review of various options and recommendations for mobilizing additional resources for health

PhilHealth accreditation of public health facilities

80% of RHUs with PhilHealth accreditation

100% of licensed hospitals with PhilHealth accreditation

Not all RHUs with PhilHealth accreditation

100% of licensed hospitals with PhilHealth accreditation

No PHIC enrollees Lack of fund to comply with

requirements Difficulty in the accreditation

process and renewal of license

Health Systems Development

Short listing of health facility for assessment

Facility mapping and assessment of candidate RHUs for PhilHealth accreditation

Orientation of LCEs on PhilHealth accreditation requirements for health facilities

Upgrading of health facilities for accreditation

Rationalization of PHIC reimbursement

20% for administration and 80% for facility improvement and MOOE

No guidelines on the use of PHIC reimbursement

Utilization of capitation at the discretion of LCE

Advocacy to Policy Makers

Orientation of LCEs on proper management and utilization of capitation fund

Formulation of guidelines with approval by SB

Increase LGU investments for health

Increased percentage of budget allocated for health programs

Less than 5% of total budget allocated to health

LegislationResource Generation

Systematic review of various options and recommendations for mobilizing additional resources for health to include PhilHealth financing,

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Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

user fees, grants and loans, public enterprise, and improving efficiency.

Orientation to various stakeholders (LCE, SP/SB, etc.) of the various options

Development of a resource mobilization plan for health

Local policy development on fund management and utilization of PhilHealth capitation fund

Establishment of Local Health Accounts

No Local Health Account Programs

Advocacy work on the use of LHA for local health financing reforms

Orientation on Local Health Accounts

Formation and capacity building of provincial team to develop the LHA

Formulation of local health accounts

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Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

PPA: HEALTH GOVERNANCELocal Health Systems DevelopmentFunctional local health systems are institutionalized in the context of local autonomy

100% of ILHZ are functional by the end of 2010.

6 out 7 ILHZ organized Poor coordination of reform

activities and programs and integration of these reforms to ILHZ

Inactive LHBs to respond to development imperatives of the local health system through the ILHZ

Limited networking and collaboration between private and public health sectors

AdvocacyProgram ReviewPolicy Development Capacity Development

PHO to meet with LMP Assessment and planning Recommend policy to

integrate private health system with the public health care system with SP resolution/ordinance as official mandate

LHB assessment and recognition of outstanding LHB

100% of RHUs are SS-certified

53 out of 57 RHUs are SS certified

Lack of funds to comply with the inclusion criteria of SS Movement

Poor monitoring and supervision

AdvocacyMonitoring and EvaluationPolicy Development

LHB Meetings Workshop for the

development of monitoring tools

Recognition and awards RHUs and BHSs

Increase participation of the private sector in public health initiatives

17 SMEs, 11 private midwives, 23 private sector are partners with PHO Private Health Desk

Lack of policy to integrate private provision of health care with the public health care system

AdvocacyPolicy DevelopmentCapacity Building

Establishment of Private Health Desk

Consultative meetings Workshop on program

integration Orientation/Training on

program development Mapping of facilities and

service providers Installation of public health

programs in the workplaceLocal Human Resource Strengthening

Knowledgeable and skilled No human resource development Capability Building Training on Strategic

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Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

health workers Plan Management and Continuing Quality Improvement for MHOs/CHOs and Provincial Program Coordinators

Refresher Course on Supervision and Monitoring for PHNs

Training of newly-hired local health workers on public health programs

Refresher Course on priority public health programs for local health workers

Training of data collection, compilation, validation and analysis for policy and program evaluation

Training on Behavior Communication Change

Training on Basic advocacy, communication and negotiation skills for public health staff and municipal health officers

Health Worker's ConferenceAddress fast turnover of health personnel

Lack of opportunities on upgrading skills and training in development managementNo annual training plan

Implementation of relevant training activities to enhance managerial and technical competence of health workers at all levels

Overworked health staff with case overload

Implementation of standard proportion of health workers to the population (hiring of additional health personnel to reach the standard ratio)

Implementation of Magna Carta for Health Workers

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Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

Implement the Service Delivery Excellence in Health (SDEXH) and Client Feedback Mechanism

Out-migration has caused shortage in health care workers, disproportioned resources needed for training, inadequately trained personnel.

Follow standard guidelines in personnel promotion and provision of incentives

Development of a HR plan to address out-migration of health workers to incentive schemes, reorganization of delivery system, HHR substitution among different types

Local Health Information System Development / UtilizationInstitutionalization of CBMIS

Health workers not familiar with CBMIS

Re-orientation and updating of CBMIS for PHN, RHM and BHW

Implementation of revised FHSIS

Health workers not familiar with revised FHSIS

Orientation on the revised FHSIS

Roll-out to RHMImprove local health information systems for planning, monitoring, supervision, program evaluation and policy development

High level of computer illiteracy

Lack of computers Lack of training

Automation of routine recording and reporting system at the RHU

Interfacing FHSIS with the reporting systems installed for TB, EPI, Malaria and other programs

Installation of monitoring systems to track AOP implementation, CSR, MNCHN and PhilHealth Implementation

Regular conduct of service delivery implementation review

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Component Targets Situational Analysis Intervention Implementing Strategy(ies) Timeline[Goal/Outcome] [Performance Indicators; Strategy] [Gaps and Deficiencies] [Interventions] [Activities] [Timeline]

Monitoring and Evaluation of PIPH Implementation Creation of local

implementation and coordination team (LICT)

Planning, monitoring and evaluation

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C hap te r 7 :C r i t i c a l I nves tm en t s

The total cost of investments from 2009 to 2013 amounts to Php 2,926,054,176. This is the projected amount of investments that the Province of Bulacan has generate in order to achieve the public health sector goals of better health outcomes, more responsive health system and equitable health care financing.

Of the full amount of investments allotted, 1% shall be spent for the implementation of disease free zone initiatives, 2% for intensified disease control programs, 41% for management of child health, 3% for maternal health, 17% for healthy lifestyle and management of health risks, <1% for strengthening the surveillance and epidemic management system, 1% for disaster management and 2% for health promotion. A big chunk of the budget shall be devoted to health

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facilities development to include facility upgrading for hospital and public health services with 31% of the total cost of investments. Health regulation, governance and financing has 1% each.

For more details on the complete budget for the 5-year investment plan, please refer to the costing tables in the Annex of this document.

1. Disease Free Zone Initiatives

The cost of investments for the implementation of rabies and leprosy elimination services and malaria control services is Php 17,029,900 which covers expenses of the Provincial Health Office and the rural health units for capacity building of health personnel, improvement of microscopy and laboratory services, production of IEC materials, drugs and medicines and capital outlay.

Rabies Elimination Services

Towards the elimination of rabies as a public health threat, the province needs Php 14,987,600 as investment in compulsory dog immunization as part of responsible pet ownership and dog bite victim immunization. It shall also cover cost of anti-rabies vaccines and production of IEC materials.

Leprosy Elimination Services

The province shall maintain a high leprosy cure rate and pursue active case finding towards the elimination of the disease. With an investment of Php 364,450, the province will ensure that MDT medicines are available; health workers are well equipped in terms of KAP on leprosy surveillance and case management, and access of the community on IEC materials is improved.

Malaria Control Services

Eliminating malaria mortality shall be aggressively pursued in the province through vector control and early detection through improved malaria microscopy. The province shall invest Php 1,677,850 for disease surveillance at the community level through the use of RDT kits, ensuring availability of anti-malaria drugs, and organization of malaria management committee among the most susceptible sector and promotion of the use of insecticide-treated bed nets. It shall also invest in the organization of community “search and destroy” operations to rid mosquitoes of their breeding sites.

2. Intensified Disease Prevention and Control

Total health investment Tuberculosis Control Services, HIV/AIDS/STD/STI Control Services, Dengue Control Services and Emerging and Reemerging Infection Prevention and Control Services for the 5-year period is Php 51,340,749.

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Tuberculosis Control Services

To attain the national standard in TB case detection rate and cure rate, the province shall invest Php 45,748,049. Said amount will be utilized for the production of IEC materials for community awareness on TB prevention and control leading to increase in case detection rate, establishment and strengthening of PPMD units and hospital-based TB-DOTS facilities, capacity building for health workers on TB-DOTS treatment protocols, improvement of sputum collection areas and upgrading of TB microscopy units, training on children with TB for doctors and nurses, procurement of anti-TB Category 1, 2 and 3 drugs, monitoring and supervision of the TB provincial coordinator for quality assurance.

HIV/AIDS/STD/STI Control Services

Health investment for HIV/AIDS/STD/STI Control Services is Php 776,550. This amount covers capacity building activities, e.g., HIV/AIDS Case Management on Syndromic Approach for health workers in HIV/AIDS/STD/STI high-risk areas. Development cooperation and advocacy with LGUs for the mapping and assessment of high-risk areas shall be conducted in an effort to pinpoint potential outbreak areas and contain procedures are instituted. Social Hygiene Clinics shall also be established with partner LGUs. These Clinics shall make available supplies for serological tests, drugs and medicines, and skilled counselors.

Dengue Control Services

The province shall pursue the reduction of dengue morbidity and mortality. The amount of Php 2,260,900 shall be utilized for intensified mosquito vector control, effective surveillance system in the control of dengue, capacity building of health personnel in the management, prevention and control of dengue infection, advocacy work, development of a dengue epidemic contingency plan for emergency response and health promotion activities. All municipalities/cities shall aggressively pursue vector control procedures, activate its Epidemic and Surveillance Unit and mobilize community-based dengue vector control activities. School classrooms shall regularly be defogged to ensure safety of children, and cleaning and clearing of suspected mosquito breeding sites.

Emerging and Reemerging Infection Prevention and Control Services

The province of Bulacan shall invest Php 2,555,250 for the prevention and control of bird flu [avian influenza], Ebola Reston virus and swine flue [Influenza A[H1N1]. It shall be utilized for the production of IEC materials, procurement of flu vaccines, Oseltamivir and PPEs. Capacity building shall be conducted from among health workers on the various emerging and re-emerging diseases leading to improved early diagnosis and management. It shall also invest in strengthening disease and surveillance procedures at the community and provincial levels. Public health centers shall also be improved in terms of facilities and equipment to handle these infections. Partnership with the private health sector will be strengthened.

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3. Child Health

The province shall invest the amount of Php 1,214,718,822 in an effort to reduce infant and under 5 mortality from 5.76/1,000 live births to 2/1,000 by 2013 through the expanded program on immunization, integrated management of childhood illnesses, nutrition, dental and oral health among others. It shall vigorously implement the Reach Every Barangay strategy accompanied with appropriate health promotion activities. A community-based, user-friendly monitoring tool shall be developed to track health progress of every child in the province.

Expanded Program on Immunization

The province shall pursue to attain the national standard on expanded program on immunization. This means universal coverage of all children, particularly the poor of vaccines, vitamin A and other micronutrients. Capacity building of health personnel on basic EPI shall be conducted. The province shall ensure the procurement and availability of vaccines, micronutrients and essential medicines for this program.

Integrated Management of Childhood Illnesses

Capacity building on IMCI will be conducted for new health workers and refresher courses and updates will be provided regularly at the different health care facilities. Health promotion activities will be conducted at the household level encouraging mothers, parents and guardians to seek immediate medical attention at public health facilities for their children. Health workers will also be trained on IMCI with the corresponding treatment protocols. Critical medicines and commodities for sick children, anemic and diarrheic children shall also be ensured.

Nutrition Services

The province shall pursue the reduction and/or elimination of third-degree malnutrition among children. As such, it shall ensure the procurement of drugs and medicines, weighing scales, micronutrients, supplemental feeding needed for this program. Parallel activities like health promotions and capacity building of health workers and BHWs/BNSs will be conducted.

Dental Services

The province shall also pursue the increase of children of school age practicing oral care. In this regard, it shall pursue to establish a provincial dental health program to take the lead in dental care in the province. IEC materials will be distributed in the schools and day care centers to encourage children and their parents to start practicing oral care.

4. Maternal Health

The province of Bulacan aims to reduce maternal mortality from 6.82% to 1.71% (2) by 2013 or from 44 cases to 11 cases of maternal deaths by 2013. A total of Php 79,875,441 is needed to implement interventions critical for the improvement of maternal health services.

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Safe Motherhood

The province shall pursue to continuously improve the quality of pre-natal and post-natal care to ensure women’s reproductive health. The establishment of BEmONC/ CEmONC facilities in selected strategic sites in the province is one intervention in ensuring safe delivery of babies. In this connection, health personnel shall undergo capacity building seminars, e.g., BEmONC and Life saving Skills, on the management of these facilities.

Facility-Based Deliveries

Pregnant women shall be encouraged to deliver in the health facilities most accessible to them to ensure safe and uncomplicated deliveries. Professional-trained doctors, nurses and midwives staff these facilities and are ready for any emergency. LGUs shall be encouraged to establish birthing homes from within the RHU/BHS facility or covert the RHU into a BEmONC facility to handle emergency obstetric procedures.

Women’s Health Team

The province and the LGUs shall organize Women’s Health Team (WHT) to take the lead in ensuring the implementation of the safe motherhood program. It will be responsible for pregnancy tracking, birth planning, facility referral, maternal death reporting, and proper newborn care to include breastfeeding, nutrition and immunization, outreach activities for family planning, counseling and replenishment of FP supplies.

Maternal Nutrition

The province shall it shall ensure the availability of adequate Vitamin A capsules and iron supplements for pregnant and lactating women.

Contraceptive Self Reliance

The province shall ensure the availability of and access to modern birth spacing methods through the installation of CBMIS in all LGUs to determine unmet needs and securing financing for free contraceptive commodities to the poor, efficient procurement and distribution of contraceptive commodities and supplies, continuing education and training of health personnel on interpersonal communications skills, FP counseling, FP modern methods among others, promotion of responsible parenthood and parenting, strengthening system of referral, and expansion of private sector sources of FP services and commodities.

5. Healthy Lifestyle and Management of Health Risks

The province shall pursue the reduction of morbidity and mortality due lifestyle-related diseases by 5-10% in 2013. Total budget requirement is Php 494,848,978. The amount will be utilized to intensify public awareness on lifestyle-related diseases and create consciousness on the importance of healthy lifestyle behaviors, ensure full implementation of ordinances and programs related to healthy lifestyle, to ensure availability of diagnostic services and treatment

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procedure on lifestyle related disease especially to the poor, and to improve knowledge and skills of health workers on risk factor screening and management of lifestyle-related diseases.

Advocacy campaigns for risk behaviors and Risk factor screening

The province shall intensify its advocacy and education campaign encouraging people to engage in physical activity, balanced nutrition, and smoking cessation and decrease risk factors due to lifestyle. It shall maximize the use of tri-media and other IEC materials to educate the community on lifestyle-related diseases. Health workers shall also be trained on risk factor screening and healthy lifestyle promotion. Water and Sanitation Programs

The province shall ensure that environmental hazards, disease and deaths are reduced due to compliance to environmental sanitation programs, policies and procedures. Activities include increasing access of households to safe and potable water sources, and households with sanitary toilet facilities. Heavy metal contamination shall also be closely monitored in the high-risk waterways of Bulacan. LGUs shall also hire and train rural sanitation inspectors to take the lead in ensuring safety of water sources and sanitary surroundings.

Blood Donation Services

The province shall intensify advocacy and information and education campaign through the conduct of tri-media campaign on the importance of blood donation. In strengthening the program, LGUs shall pass ordinances for the creation of Municipal Blood Council. Health personnel shall also be capacitated on donor recruitment, retention and care, blood storage and cold chain. Medical technologist shall be trained on Phlebotomy.

6. Surveillance and Epidemic Management System

The province shall pursue to attain a responsive and functional integrated Surveillance and Epidemic Management System. Total investment is Php 8,733,610 that will be utilized to build the capacity of all 24 LGUs in performing disease surveillance and response and increase utilization of disease surveillance data for decision-making, policy-making, program management, planning and evaluation at all levels. Other activities include the establishment of M/CESUs in all LGUs, establishment of a functional two way referral system in surveillance, and capacity building of health workers on basic epidemiology, logistics management, management information systems, planning and monitoring systems.

7. Disaster Preparedness and Response System

Reducing the impact of disaster to families and communities is the goal of disaster prepared and response system being established in the province of Bulacan. The amount of Php 22,548,144 shall be utilized for the formulation of a comprehensive disaster management plan at the province and LGU levels, strengthening of disaster coordinating councils at all levels, installation of measures to mitigate the effects of disaster life and property, and to increase the

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coping capacities of families and communities after a disaster. Referral systems between and among the public and private health sectors shall be enhanced. Communications and transportation equipment shall also be procured to assist in disaster management.

8. Health Promotion and Advocacy

The province shall improve the quality and quantity of its health promotion activities leading to good health-seeking behaviors of the population. Total investment needed is Php 63,822,060 that will finance capacity building activities on basic health promotion techniques and behavioral change communication, acquisition of audio-visual supplies and equipment, IEC material development and tri-media campaign.

9. Health Facilities Development Program

The total cost of facility improvement for hospitals and primary health centers is Php 912,461,324. It will cover the expenditures for the establishment of additional barangay health stations and the upgrading and maintenance of hospital facilities. Part of the investment requirements shall also be devoted to personal services and continuing capacity building of health personnel and other hospital staff.

Health Financing

Total investment needed for health financing is Php 27,662,300 that will cover efforts to generate resources outside of its traditional fund sources, optimize the efficiency and effectiveness of local financial planning in health by focusing resources on priority programs and implementing performance-based budget allocation, studying of options in improving efficiency in resource allocation across levels of healthcare (primary, secondary and tertiary) with strong emphasis on public health.

Health Regulation

The province shall ensure access to quality and affordable health goods and services, especially the poor. It shall pursue to strictly enforce health and health-related national laws and regulations and enactment of local legislations supporting such mandates, develop policy-tracking mechanism tool to monitor the implementation of health and health-related ordinances, and establish Botica ng Barangay in all identified strategic barangays. Total investment in this aspect is Php 12,673,098.

Health Governance

The province shall invest Php 20,339,750 for the strengthening of the local health service delivery systems and management support systems in health which include interventions and activities on the development of inter-LGU cooperation mechanisms for health, public-private partnership and networking, capacity building for local health board, enhancing local human resource system, improving health information system and harnessing sectoral management and internal management systems and approaches.

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C hap te r 8 :F inanc i ng

Local Government National Government Grants

P/LGU M/LGU Other Sources DOH Regular PHIC/PCSO Other

Sources DOH ECCD Global Fund HealthGov TB Linc HealthPRO

1. Disease-Free

Rabies 2,864,300 3,688,800 3,262,500 2,436,000 2,436,000 300,000

Leprosy 203,650 100,800 60,000

Malaria 96,250 345,200 700,000 142,000 394,400

2. Intensified Dis.

Tuberculosis 21,899,900 4,057,000 75,700 14,195,749 50,000 5,469,700

HIV/AIDS 421,250 355,300

Dengue 1,324,500 271,300 509,100 156,000

Emerging 631,900 1,598,400 210,200 114,750

3. Child Health 12,269,100 74,139,356 1,127,073,416 1,112,700 124,250

4. Maternal Health 13,678,200 29,890,275 1,185,000 32,641,966 1,000,000 27,000 190,000 863,000 400,000

5. Healthy Lifestyle

HL Lifestyle 59,249,245 194,160,000

180,000,000 8,000 188,000

Water 4,518,390 27,918,255 24,387,550 4,219,538 200,000

6. Surveillance 1,715,560 6,504,650 443,400 70,000

7. Disaster 1,698,900 18,955,200 1,547,094 346,950

8. Health Promotion 43,181,400 15,378,560 714,800 1,019,700 906,000 60,000 2,561,600

9. Health Facilities 440,271,424

325,726,700

88,663,200 36,000,000 21,600,000 200,000

Health Regulation 10,485,998 1,640,600 546,500

Health Financing 7,262,300 8,400,000 12,000,000

Health Governance 10,035,200 5,069,500 800,000 3,495,050 940,000

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C hap te r 9 :T ime t ab l e

The Plan will be implemented over a five-year period from 2009 to 2013. The PIPH implementation will undergo the following phases:

1. Start up Phase or Pre-Implementation Phase. Upon the approval of the PIPH by concerned local legislatives councils, the province of Bulacan, through the Bulacan Provincial Health Office shall begin the setting up of the PIPH management structure, preparation and approval of the 2009 operations plan and consultation meetings with various local stakeholders in health.

2. PIPH Implementation Phase. The province together with the component cities and municipalities shall implement the 2009 PIPH Operations Plan. It is during this phase that proposed interventions and activities are undertaken.

3. Sustaining Phase. Periodic review of the PIPH implementation shall be undertaken. The province shall initiate various resource generation and mobilization activities to continuously finance the critical investments that are crucial in the attainment of set goals as expressed in this plan document.

The following is the breakdown of cost of investments per PPA from 2009 to 2013 that shall be the basis of tracking the implementation of the PIPH in the Province of Bulacan.

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PPA 2009 2010 2011 2012 2013 Total [5 Yrs]

1. Disease-Free Zone Initiatives

Rabies Elimination Services 962,100 3,723,400 3,618,400 3,585,600 3,098,100 14,987,600

Leprosy Elimination Services 21,600 178,250 31,200 102,200 31,200 364,450

Malaria Control Services 429,000 543,850 235,000 235,000 235,000 1,677,850

2. Intensified Disease Prevention and Control

Tuberculosis Control Services 5,928,620 14,817,170 14,317,970 7,138,070 3,546,220 45,748,049

HIV/AIDS/STD/STI Control Services 64,500 532,050 60,000 60,000 60,000 776,550

Dengue Control Services 778,200 728,800 251,300 251,300 251,300 2,260,900

Emerging & Re-Emerging Infection Prevention & Control Services 860,550 592,400 551,150 551,150 2,555,250

3. Child Health 53,324,117 266,238,186 282,063,811 296,733,194 316,359,513 1,214,718,822

4. Maternal Health 7,683,288 16,027,159 24,910,320 15,070,111 16,184,564 79,875,441

5. Healthy Lifestyle and Management of Health Risks

Healthy Lifestyle and Management of Health Risks 47,524,015 96,328,025 97,329,375 94,442,615 97,917,315 433,605,245

Water and Sanitation 2,847,689 18,644,814 13,082,804 13,105,068 13,563,358 61,243,733

6. Surveillance and Epidemic Management 1,210,050 3,725,740 1,148,940 1,174,440 1,174,440 8,733,610

7. Disaster Preparedness and Response System 3,956,000 4,838,224 5,643,074 4,143,074 3,967,774 22,548,144

8. Health Promotion and Advocacy 9,064,600 19,023,810 10,741,000 11,152,900 13,839,750 63,822,060

9. Health Facilities Development 50,100,000 342,894,924 178,283,650 164,779,800 176,402,950 912,461,324

Health Regulation 513,498 3,458,100 2,836,500 2,836,500 3,028,500 12,673,098

Health Financing 5,100,000 6,066,050 5,806,250 5,345,000 5,345,000 27,662,300

Health Governance 2,359,800 5,135,450 4,606,300 3,886,300 4,351,900 20,339,750

Percentage 1% 27% 22% 21% 23% 100%

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C hap te r 10 :P l an Managem en t

The Provincial Planning Team for the PIPH created by Governor Jonjon Mendoza shall evolve into the Provincial Implementation and Coordination Team [PICT].

The LICT shall have the following roles and responsibilities:

Formulate policies and guidelines for PIPH implementation at the LGU level; Approve the Annual Operational Plan; Ensure that counterpart funds are appropriated in the Annual Budget; Cause the cooperation of component LGUs and other key stakeholders; Recommend systems and processes for better coordination and implementation of

local health service delivery; Hold meetings at least once every quarter to assess the progress of implementation.

The LICT shall be supported by two Technical Working Groups to review and recommend solutions to key policies and operational issues presented by the PHO. The TWG on PIPH Operations to be composed of representatives from Office of the Governor, CHD, PHO and MHO. It shall ensure that the PIPH activities support the National Objectives for Health. It shall also assess the outcomes of programs identified in the PIPH. The TWG on PIPH Financing shall be composed of the Provincial Planning and Development Officer, Provincial Budget Officer, Provincial Treasurer, Provincial Accountant, Provincial General Service Officer.

It shall ensure the sustained financing of key intervention identified in the PIPH. It shall integrate operational plans in the local development plans and annual investment programs of the Province and its component LGU. It shall review financial management systems, guidelines and procedures for the efficient and effective management of PIPH resources including reforms to strengthen procurement, logistics and warehousing.

The Provincial Health Officer shall be assigned concurrently as the PIPH Coordinator. As such he shall be responsible in performing the day-to-day activities to ensure that key programs, systems and other PIPH details are executed effectively and efficiently. Subject to the concurrence of the LICT, the PIPH Coordinator shall set up a PIPH Management Office with reasonable number of staff to support implementation.

The PIPH Coordinator shall have the following roles and responsibilities:

Coordinate and manage PIPH implementation of the Province and its component LGUs; Submit for LICT approval an organizational structure necessary to support efficient PIPH

implementation; Coordinate the implementation of the program with all the key stakeholders;

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Ensure that all annual physical and financial requirements as defined in the approved PIPH are accordingly prepared and integrated to the LDP, AIP and Executive Budget of the Province and component LGUs;

Facilitate policy and procedural dialogue to discuss key issues and problems affecting the implementation;

Submit periodic physical and financial accomplishment reports to the members of the LICT and the CHD.

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