TOWARDS AL TERNA TIVE APPROACHES TO HEALTH DEVELOPMENT IN UNDERSERVED AREAS THE DESIGN AND DEVELOPMENT OF A MONITORING SYSTEM FOR HEALTH IN RURAL COMMUNITIES A RETROSPECTIVE ANAL YSIS
RESEARCH AND DEVELOPMENT ( R &. D) PROJECT CARIGARA CATCHMENT AREA (CCA) LEYTE, PHILIPPINES ... 1977 - 1982
*
A Joint Project of the Institute of Health Sciences, Health Sciences Center, University of the Philippines System; Ministry of Health, Region VIII; Ministry of Local Government and Community Development; and the Provincial Government of Leyte in collaboration with the World Health Organization.
iii
FOREIVORD
The health status of the rural population is inextricably linked with the socioeconomic problems found in the rural areas. In our efforts to improve the health of our people, we, the health professionals have for too long avoided the problems related to maintaining and improving health. The effort to do so requires new ways of thinking, new methods of work, new skills, all of which require in each of us a need for change. Yet, without addressing the socioeconomic factors which influence the health of our people, we cannot hope to be effective and carry out our responsibility to our country and to our society. In 197/i, the University of the Philippines - Institute of Health Sciences (UP-IHS) Committee began to look for new approaches to health development. The result was an experiment in health manpower development in the rural areas based on a ladder-type curriculum. By 1977, the Institute had graduated its first class of barangay health workers (BHIVs), and at the same time, the Ministry of Health in Region VIII began experimenting with new ways of improving the effectiveness of health care delivery. The interests of these two institutions were merged and found expression in a joint effort of research and development (R & D) in health care. The Carigara R&D project, which began in early 1977, was innovative not only in its assumption about health and the relationship between the health services and the community but also about the participative approach used in the research. In this case, the participants included the community health workers, professors, international consultants, health administrators, political leaders, all of whom, at one time or another made invaluable contributions to the development of new knowledge. The results of these efforts have provided important tools and insights about the organization of health care, the training of health workers and the relationship between the community and the health system. For the first time, the health professional working in the rural areas of our country now has the means to lead and contribute actively to community health development by providing the community, the health services and other sectors
iii /
wi th a practical method for designing health programmes. These health progrdmmes address the cause of ill health and at the same time encourage the development of individual and community self-reliance in health. This is not only an important contribution to the field of health systems development but also a significant contribution of the profession to our society as the findings address the fundamental issue of social development. More than 100 people have been involved directly and indirectly in this study. The absence of anyone of them would have undoubtedly affected the quality of the outcome. In addition, the support of national and international institutions have been essential not only in providing funding and technical expertise but also in contributing to the momentum and providing the encourage·ment needed.· A, few individuals. and groups should be mentioned• . .-<"-
To begin with, we are grateful to the people and leadel'ship of the Carigara Catchment Area for without their involvement and support, the Study could never have been undertaken. Second, we must give recognition to the health officers in the Carigara Catchment Area and their staff for their willingness to take the risk in exposing the practices of the health care system, their perseverance in conducting the R&D and their commitment to the goal of improving the health of the people. We must also, at this point, recognize the leaders and the staff of the health system in Region VIn wi-.thOlft· . whose support and understanding, the project would not have been successful. These include Dr A. Banzon, who was Regional Director of Region VIII and concurrently Director of the IHS from 1976 to 1980, and her successor, Dr M. Roxas. We must also acknowledge the contribution of the IHS staff directly involved in the R&D. We must also recognize and express. our gratitude to the international organizations who supported the Study, particularly to the WHO Regional Office for the Western Pacific, the Danish International Development Agency (DANIDA), the Swedish International Development Agency (SID A), the United Nations Children's Fund (UNICE.F), the Nelly Kellog Van Schaick Charitable Trust, the Telengtan Foundation and the Population Center Foundation (PCF) for the financial aid extended to us.
iv /
We cannot overemphasize the crucial need and importance of this work by the R &: D Committee of the Institute of Health Sciences. Here for the first time is a feedback mechanism wi th which those who "intrude" into the even tenor of rural life in the name of progress and development may validate and justify such intrusion. As Chancellor, I wish to congratulate those who worked and prepared this monogram on a monitoring system for health in the rural communities and strongly endorse this monogram to national health planners and decision makers. I wish to make special mention of Dr Gunawan Nugroho of WHO and Mr George L. Dorros of WHO, both of whom, although without official re~onsibility to the Institute of Health Sciences, were unstinted in their contribution to this work. They were motivated solely by the love of service to fellowmen.
Chancellor University of the Philippines Manila
2~.~~~
v
EXECUTIVE SUMMARY
Tne major! ty of the people living in developing countries reside in the rural areas. F or this reason, heal th development and research activi ties had, in the past, emphasized the expansion of an effective and efficient delivery of basic health services to the rural health population. In recent years, however, conditions in the Philippines, as well as in other developing countries in Asia, have changed. While the size of the rural population has grown, the ability of the Government to provide services to meet health needs has diminished. At the same time, government activities and socioeconomic activities in the rural areas, as well as international events, have had repercussions on the health status of the people. Wi thout the ability to monitor and anticipate the effects of these changes on the health status of the people in the communities, the health resources of the Government cannot be effectively utilized to meet the increasing demands of the peopl e. This study undertook the task of establishing such a monitoring system. It did so by applying innovative methods of health systems research and new approaches to health care delivery which emphasized the development of a working partnership between the community, the health service and other government sectors. Tne people involved in the research included members of the community in the research areas, health workers in hospitals and health centres who are responsible for health care in these areas, as well as health administrators and academicians. Because of these innovative approaches, the research process was ecclectic rather than systematic. Yet, in the end, the effort produced effective methods and techniques for decision making, planning, organizing and evaluating health development programmes which link the communities, health sectors and other sectors in a continuous process of managing health development. Without these or similar methods and techniques to relate problem-solving and decision-making procedures of the communities to the health system, there is little hope of effectively using health resources to manage health development in a rapidly
vi
changing socioeconomic environment. The information from this partnership can oe used for the design of health manpower or health promotional and preventive programmes which are relevant to the changing needs of the rural population. For these reasons, the findings of the Study imply significant changes throughout the govemment health system if the partnership approach to achieving health for all by the year 2000 through primary health care is to be achieved. Since this research was oased on the fundamentals, principles and assumptions embodied in primary health care and in the goal of health for all by the year 2000, it offers the intemational community of public health professionals some insights to, and implications of, these major national and international policies .which have been translated into practice in a rural setting.
Vi1
CONTENTS
FOREWORD
ii
EXECUTIVE SUMMARY
v
CHAPTER I. THE EXISTING SITUATION
I.
Historical perspective Health and socioeconomic profile of Region VIII The Work of the Ministry of Health in Region VIII The need for research and development 4.1
I
2. 3.
2 3
4.
4 4 5
4.2 5. 6.
The University of the Philippines Institute of Health Sciences (UP-HiS) The rural health services in Region VIII
Funding and support for research and development Focus of the report
5 6
viii
~
CHAPTER II.
THE PROJECT
7
I.
Objectives 1.1 1.1 The primary objective Specific objectives
7 7 7 7 8
2. 3. 4.
Research design The conceptual framework Criteria for the development of a monitoring system 4.1 4.2 The monitoring system Design criteria for the lay reporting system Specific criteria for the design of methods and procedures for planning and evaluating community health programmes at the pri mary level
II II
12
4.3
12 12
5.
Procedures 5.1
5.2 5.3 6. 7.
Preliminary stage (6-12 months) Implementation stage (J 2-36 months) Development stage (ongoing)
12
13 13 13
Method of analysis Duration Significance of the study Descri ption of the study area
14
S. 9.
14 15/16
ix
CHAPTER IlL ORGANIZATION AND MANAGEMENT OF THE PROJECT
19
I.
Overview Stage I: 2.1 2.2 Central Project Management (February 1977 - June 1978)
19 19 19 21 22 23 23 24 24
2.
Proposed organization of the project Operations of the Central Project Management Transitional Project Management (July 1978 - December 1979) Regional Project Management (January 1980 - February 1982)
3.
Stage II: Stage III: 4.1 4.2 4.3
4.
Creation of the Regional Research and Development Committee (RRDC) The RRDC in operation Variation of RRDC management
CHAPTER IV.
THE IMPLEMENT ATION OF RESEARCH AND DEVELOPMENT: AN EXPERIENCE IN EVOLVING METHODS, PROCEDURES AND APPROACHES FOR HEALTH SYSTEMS RESEARCH
31
I.
The phases of implementation Phase I: Reorientation of the Health Workers (]977-1980)
31 32
2.
x
3.
Phase II: 3.1 3.2 3.3 3.4
Community organization and development activities (l978-198J)
36 36
Social preparation of the communities Community organization Community development Expansion activities Introduction and initial analysis of the community health information system (I979-198J) Development of a planning and evaluation procedure for community heal th
37 39 41
4.
Phase RI:
42 44
5.
Phase IV:
6.
Principal technical support activities to R &. D
45
CHAPTER V. THE DEVELOPMENT AND USE OF HEALTH TECHNOLOGIES
47
I.
Phase I: 1.1 1.2 1.3
Methods of reorientation of health staff
47 47 48 li8 li9
1.4 2.
The health management questionnaire The quick survey form The individual problem analysis and plan of action The community profiles Methods of organizing community health development programmes
Phase II: 2.1 2.2
49 49 50
Developing a community health programme model A common framework for intersectoral collaboration
xi
3.
Phase 1lI: 3.1 3.2
Methods for lay reporting
50 50
The family information sheet The growth chart Methods for planning and evaluation of health programmes
51 52 52
Phase IV: 4.1
The "epidemiological approach"
CHAPTER VL FINDINGS
55
I.
The community 1.1
55 55 55
1.2 2.
Background Findings
The health services in Carigara 2.1 2.2 Background Findings
57 57 57 60 60 61
3.
The management of the project 3.1 3.2 Background Findings
CHAPTER VII.
CONTRIBUTIONS TO HEALTH SYSTEMS DEVELOPMENT
65
I.
The communities in Carigara 1.1 The health services in Carigara
65 65
xii
Page
2. 3. 4. .5.
Provincial health system The regional health system The Ministry of Heal th At the international level
66 67 68 69
CHAPTER VIII. CONCLUSIONS
71
I.
General The community The health system Health manpower Management of R&D
71 72
2. 3. II.
73 711 7'+
5.
CHAPTER IX.
RECOMMENDATIONS
77
REFERENCES
79
- x iii -
LIST OF ANNEXES
Page ANNEX I ANNEX 2 ANNEX 3
-
MAP OF REGION VIII (EASTERN VISA VAS, PHILIPPINES) THE PHILIPPINE HEALTH SERVICES SYSTEM THE UNIVER SITV OF THE PHILIPPINESINSTITUTE OF HEALTH SCIENCES: AN INNOVATIVE STRATEGY FOR HEALTH MANPOWER DEVELOPMENT AND DISTRIBUTION HEALTH MANAGEMENT QUESTIONNA IRE QUICK SURVEY FORM BARANGAY NETWORK THE FAMILY SHEET THE GROWTH CHART MANAGEMENT OF THE INFORMATION SYSTEM FOR THE COMMUNITY HEAL TH PROGRAMME THE "EPIDEMIOLOGICAL APPROACH" SAMPLE FRAMEWORKS/INSTRUMENTS FOR HEALTH PROGRAMME ANAL YSIS USING THE "EPIDEMIOLOGICAL APPROACH" PROGRAMME STRATEGY OUTLINE SOCIOECONOMIC HEALTH PROFILE
83/84 85
-
97
ANNEX 4
-
103 107 113/114 115 125
ANNEX 5 ANNEX 6 ANNEX 7 ANNEX 8 ANNEX 9
127 129
ANNEX 10
-
ANNEX IO-A -
137 139/140 143
ANNEX 10-BANNEX 10-C-
- xiv -
Page ANNEX 10-D ANNEX 1O-E ANNEX 10-F SPOT MAP PROBLEM STATEMENT OUTLINE FORMULA nON OF A PRIMAR Y HEALTH CARE PROGRAMME THE CARIGARA CATCHMENT AREA (CCA) MODEL FOR DEVELOPING A BARANGAY HEALTH PROGRAMME COMMUNITY PROFILES COMMUNITY PROFILE OF BARANGA Y ST A. ROSA COMMUNITY PROFILE OF BARANGA Y BALUD COMMUNITY PROFILE OF BARANGAYBARUGAHAYNORTE COMMUNITY PROFILE OF BARANGA Y JUGABAN COMMUNITY PROFILE OF BARANGA Y HIAGSAM COMMUNITY PROFILE OF BARANGA Y CANAP CARIGARA MODEL FOR DEVELOPMENT OF BARANGA Y HEAL TH PROGRAMME PROFILE OF CHANGE 147/148 149
-
157
ANNEX 10-G -
171 175
ANNEX 11
-
ANNEX l1-A -
177
ANNEX II-B ANNEX 11-(; -
183
191
ANNEX II-D -
199
ANNEX ll-E
-
205
ANNEX ll-F
-
213
ANNEX 12
219/220 227/228
ANNEX 13
-
xv
LIST OF MAPS
Page MAP OF CARIGARA CATCHMENT AREA (CCA) MAP OF REGION VIII (EASTERN VISA VAS, PHILIPPINES)
17/18 83/84
- xvi -
LIST OF Cf-l AR TS
PROFDSFD R &: n ORGANIZATION CHART FOR TRANSITIONAL PROJECT 'v1ANAGFMENT REGIONAL RESEARCH AND DEVELOPMENT COMMITTEE (RRDC) ORGANIZATION STRUCTURE ORGANIZATION CHART - HEALTH REGION NO. VIII ORGANIZA TION CHART - PROVINCIAL HEAL TH OFFK:E ORGANIZATION CHART - MUNICIPAL HEALTH OFFICE BARANGAY NETWORK THE GROWTH CHART
25/2(, 29/30 89/90 91/92 93/94 113/114 125
xvii
LIST OF TABLES
Page
TABLE J. FUNCTIONS OF THE RRDC UNITS TABLE 2. PILOT BARANGA YS, MAJOR PUBLIC HEALTH PROBLEMS AND POPULATION SIZE
27 13
TABLE 3. ORGANIZATION AND FUNCTIONAL REQUIREMENTS OF A NATIONAL COLLABORATING CENTRE FOR HEAL TH DEVELOPMENT
219
xviii
LIST OF FIGURES
FIGURE I. THE LADDER TYPE CURRICULUM STR UCTURE OF THE UNIVERSiTY OF THE PHILIPPINES - INSTITUTE OF HEALTH SCIENCES FIGURE 2. RECOMMENDED MANAGEMENT PRIORITIES (PROBLEM AREAS) OF THE DIFFERENT LEVELS OF THE HEALTH SYSTEM
101/102
135/136
xix
LIST OF ABBREVIA nONS USED
AP - married couples of reproductive age APC - academic programme coordinator BAExt - Bureau of Agricultural Extension BAG - Barangay Advisory Group BAI - Bureau of Animal Industry BC - Barangay Council BF AR - Bureau of Fisheries and Aquatic Resources BHS - barangay health station BHW - barangay health worker BMR - basal metabolic rate BN - barangay network BNS - barangay nutrition scholar BP - blood pressure BPI - Bureau of Plant Industry BSCH - Bachelor of Science in Community Health CSC - cell blood count CCA - Carigara Catchment Area CEH - Carigara Emergency Hospital CHHC - community hospital and health centre CHN - community health nurse CHW - community health worker
xx
cm. - centimetre
co - community organizer CRC - Catholic Relief Services CTPA - cholera/typhoid/paratyphoid antigen CV A - cerebrovascular accident DANIDA - Danish International Development Agency DAP - Development Academy of the Philippines DCW - day-care children's worker DOS - domiciliary obstetrical service OPT - diphtheria/pertussis/tetanus DZRMH - Daniel Z. Romualdez Memorial Hospital ECG - electrocardiogram EH - emergency hospital EPI - expanded programme on immunization FMT - farm management technician FTOW - full-time outreach worker HMT - home management technologist lBRD - International Bank for Reconstruction and Development IMR - infant mortality rate IVP - intravenous pyelography KB - Kabataang Barangay KBN - Kadiwa Brigade Network K UB - kidney, ureter, bladder
\1
•
xxi
MA - Ministry of Agriculture MCRA - target group for follow-up of family planning acceptors MD - Doctor of Medicine; medical doctor MECS - Ministry of Education, Culture and Sports MEDICARE - Philippine Medical Care Commission MHO - municipal health officer MLGCD - Ministry of Local Government and Community Development MHS - Ministry of Human Settlements MSSD - Ministry of Social Services and Development MW - midwife NACIDA - National Cottage Industry and Development Authority NEDA - National Economic Development Authority NlE - method of rehabilitation of malnourished children NNCP - National Nutrition Council of the Philippines NMYC - National Manpower and Youth Council NPAS - new performance appraisal system OPT - Operation Timbang PC - puericuJture centre PCF - Population Center Foundation PHN - public health nurse PHO - provincial health officer POPCOM - Population Center Foundation PT A - Parent-Teacher Association
xxii
R &. D - Research and Development RHCDS - Restructured Health Care Delivery System RHO - Regional Health Office RHP - rural health physician RHPP - Rural Health Practice Programme RHTC - Regional Health Training Center RHM - rural health midwife RHU - rural health unit RHU-MHC - Rural Health Unit-Main Health Center RRDC - Regional Research and Development Committee RSI - rural sanitary inspector SEAMIC - South-East Asia Medical Information Centre SID A - Swedish International Development Agency sq. km.- square kilometres TLC - tamarind-Iuya-calamansi solution UNICEF - United Nations Children's Fund UP - University of the Philippines UPCM - University of the Philippines College of Medicine UP-IHS UP-IPH University of the Philippines - Institute of Health Sciences University of the Philippines - Institute of Public Health
UR TI - upper respiratory tract infections
CHAPTER I THE EXISTING SITUATION
I. Historical perspective Up to 1970, the Philippines had been losing 500 physicians a year to the United States. This was approximately half of the country's annual medical graduates. During the same period, the brain drain from the State Medical School was even worse than the national average of 50% it was 63 % I. The physicians were also unevenly distributed, and 73 % of the population did not benefit from the average national physician-population ratio of 1:3222. Of the country's estimated 15 000 physicians, only 421 or 3 % were in public health. These statistics show that there were too few physicians to deliver basic health services to 70% of the Filipinos living in the rural areas. Many medical educators dismissed the problems of brain drain and maldistribution as being caused by economics and, therefore, as insoluble. It was claimed that the medical graduate had spent so much time, effort and money to be a physician, that he or she therefore had a right to expect the best return for his or her investment. This was, however, more of a rationalization than a true assessment of the situation. More crucial factors than economics contributed to this desire to go abroad or practise only in the urban areas. Foremost was the fact that almost all educational institutions for medical and allied professions in the Philippines followed a curriculum oriented towards a western system of health care delivery, with many features not relevant for practice in the rural areas. Consequently, most graduates of medical and allied professions developed skills, knowledge and attitudes which were not oriented towards the health needs of rural Philippines.
I Estrada, Horacio R. "The Realities of Philippine Medical Education", in Development of Health Manpower for the Rural Areas (Proceedings of the Scientific Session, 32nd World Medical Assembly (1978), Manila). Quezon City: Unladlahi Foundation, 1979. pp. 22-23.
-2-
This disturbing health picture prompted faculty members of the University of the Philippines College of Medicine (UPCM) to discuss developing a medical curriculum designed to meet the health manpower needs of the country. rhus, the "Extraordinary Curriculum Committee" was created in 19711 to prepare a medical curriculum geared towards heal th care delivery in underserved and unserved rural areas. The Committee was composed of medical educators and faculty members from other units of the University, such as the Colleges of Arts and Sciences and of Engineering. The new ideas generated by the Committee were later implemented. rhus, the concept of an Institute of Health Sciences (IHS) was proposed and submitted to the Board of Regents of the University of the Philippines (UP) System on I April 1976. Subsequently approved, the Institute formally opened its doors on 28 June 1976 1 in Tacloban, Leyte. Because of its location, a majority of the first group of students who enrolled came from the provinces of Leyte, Samar and Biliran. These provinces make up a central administrative area called Region VIII. 2. Health and socioeconomic profile of Region VIJI Region VIII (see map in Annex I) is the home of 2 799 534 2 rural Filipinos. In a land area covering more than 21 1t31.7 square kilometres (sq. km.), there are only 7259 kilometres (km.)3 of passable roads providing limited access between major population centres. Such poor inirastructure has sharply reduced the potential social and economic growth of the population which is compelled to adhere to subsistence farming and fishing as a way of life. This "survival" existence level for most of the population is perpetuated by the lack of educational and employment opportunities, as well as an average family income of Pesos 4 834.00 per annum. This
I Banzon, A mparo. "1\ Partnership Approach to Health Care", I October 1978. 2National Census and Statistics Office, Region VIII figure for 1980. 3National EconomIc and Development Authority figure for 1978.
- 3-
income in turn is being constantly eroded by as much as a 10.87% I annual rate of inflation, further diminishing family purchasing power for basic commodities. The situation has inhibited the Government's development efforts in the region. The major causes of morbidity and mortality in the region are: gC'.stroenteritis, influenza, pneumonia, tuberculosis, heart disease and schistosomiasis. Neither the pattern nor the rate of these diseases had changed significantly during the previous years, even with considerable government effort to improve the conditions and respond to human suffering. 3. The worK of the Ministry of Health in Region VIII The Ministry of Health officially opened its Regional Health Office (RHO) in Tacloban City in February 1973. At that time, provincial and city health offices, including hospitals and a number of rural health units (RHUs), were already established and serving an estimated 41.7% of the population 2 • (For a description of the Philippine Health Services, see Annex 2.) The Ministry of Health acknowledged that the region was still largely an underserved part of the country. It embarked on a strategy of expanding its peripheral services through RHU-main health centres and barangay3 health stations (BHSs) and developing adequate health manpower to serve the needs of the population. These efforts were undertaken through nationwide RHU programmes, which later were reorganized into the present Restructured Health Care Delivery System (RHCDS) and the Rural Health Practice Programme (RHPP). The RHCDS developed the peripheral infrastructure of the ,vlinistry of Health in the region by constructing additional facilities and deploying retrained midwives. By 1979, health services were available to 72.7 % of the mostly unserved and underserved population. To provide additional medical care to this population, the R '-IPP was designed to expose new medical and nursing graduates to
rural services experience as a pre-licensure requirement. This programme, also known as the "Underboard Programme", required every
I National for 1979.
Census
and
Statistics
Office
Region
VIII
Figure
2 Keg ional Health Office No. VllI estimates. 31'.arangay is a village of 1000 to 2000 population.
- 4-
medical/nursing undergraduate to serve six months in the RHU before being allowed to take a licensing examination. At the same time, as part of an overall national effort, the Ministry of Health embarked on a programme to provide greater access to health services by recruiting and training local barangay volunteers. Known as barangay health auxiliary volunteers, these people were assigned to selected municipalities of Leyte during the early 1970s in cooperation with public schools and the Leyte Chapter of the Red Cross. Auxilliary volunteer workers were trained later in coordination wi th development projects initiated by the Visayas State College of Agriculture for the surrounding municipalities and by the Leyte Sab-a Basin Authority. The last recruitment and training programme for volunteers was initiated in 1979 and held in situ for the seven municipali ties of eastern Samar. All these training sessions for the health volunteers were carried out oy the RHO staff and the respective provincial health staff including some from the local hospitals. Some health workers in special programme areas, such as tuberculosis and "Leader-Health Workers", were trained in some parts of the region oy private agencies and local church groups in coordination wi th the RHO. The recently introduced national training programme of barangay nutri tion scholars was also initiated in the region. The Daniel Z. Romualdez Memorial Hospital (DZRMH) School of Nursing established in 1971, the Ministry of Health's Underboard Programme and the University of the Philippines Institute of Health Sciences (UP-IHS) established in 1976 were formalized approaches to the problem of heal th manpower in Region VIlI. 4. The need for research and development 1i.1 The University of the Philippines Institute of Health Sciences (UP-IHS) The UP-IHS was designed as an experiment in medical education for the purpose of producing a oroad range of health manpower including community healtn workers (CHlVs), midwives, nurses and physicians who, upon graduation, would return to serve their rural communities. (For a description of tne lHS, please see Annex 3.) Both the objectives and the deSign of the curriculum oi the institute represented major departures fro,n traditional medical and nursing schools in the country. In addition, students enrolled in the
-5-
institute's programme came from the rural communities and did not have the same academic background as their more economically fortunate peers who had received their education from the major urban areas of the country. Because of this, it was necessary to prepare teaching materials and adjust teaching methods more suitable to students whose IiIe experience had been predominantly rural. To meet this challenge, the faculty of the Institute had to develop new teaching skills and adapt a creative posture in every aspect of their work. Nevertheless, they faced two major obstacles. One was their limited knowledge of rural community life. Second was the lack of available information on the relationship between socioeconomic factors and health in these communities. 4.2 The rural health services in Region ViII
For its part, the Ministry of Health in Region Vlll had made a major effort between 1973 and 1977 to ensure that health services were accessible to the majori ty of the population in the rural areas. As the Ministry of Health was committed to the reduction of health problems particularly among the rural population, health officials in Region Vlll started turning their attention to the question of effectiveness of health programmes. For this purpose, the underlying cause of health problems, the health practices of rural families and the relevance of approaches used by the Ministry of Health should be understood. For the above reasons, the IHS Committee-Manila and the Regional Director of the Ministry of Health, Region Vlll, accepted the idea of developing a monitoring system for health development in the rural areas as proposed by a WHO Consultant who had more than 12 years of experience developing such a system. This decision led to the initial steps to plan a Research and Development (R & D) programme conducted jomtly by the UPCM and the Ministry of Health in Region VIIl. 5. Funding and support for research and development The R&D project, which began in February 1977, was technically supported by the World Health Organization's Regional Office for the Western Pacific. It was funded by the Danish International Development Agency (DANIDA) and the Swedish International Development Agency (SIDA) through WHO.
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Additional organiza tions: (a)
assistance
was
extended
from
the
following
The United Nations Children's Fund (UNICEF) in the form of sea and land vehicles for the transportation needs of the project; The Nelly Kellog van Schaick Chari table Trust also for "seed" money to start the operations of the IHS in general; The China Medical Board of New York, Inc., for the "seed money" for the first year of operations of the Underboard Programme; The Telengtan Foundation for gathering information about the involvement of the health service staff; and The Population Center Foundation (PC F) of the Philippines for some funds for the project operations during the second year of the project.
(b) (c)
(d) (e)
6. Focus of the report This final report focuses on the R&D experience in Carigara in the context of the achievement of the project's main objectives. The broader implications and effects of this project are described in Chapter VII, "Contribution to Health Systems Development".
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CHAPTER II THE PROJECT
I. Objectives 1.1 The primary objective
The primary objective of the R &: D project was to develop a monitoring system which would enablel (a) (b) the UP-IHS to plan curricula and develop training/teaching methods relevant to the needs of the rural population; and the Ministry of Health Region VIII to design and implement rural health programmes relevant to the changing needs of the population.
1.2
Specific Objectives (b) To develop methods and approaches for reorienting health staff in providing basic health services and the management of community health development programmes; To develop methods for participate in health work; organizing communities to
(b) (c)
To develop methods for lay reporting on family health; and To develop methods for planning and evaluating health programmes with the community.
(d)
2. Research design Given the developmental nature of the research, it was essential to select a research design which would allow the active participation of the community and the health staff in the development and maintenance of a monitoring system.
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The research desIgn selected is commonly known as action research I. This design requires both researchers and irnplementors to solve operational problems and answer research questions following a particular sequence of steps: Step [ Step [J Step Step Step Step Step IU IV V VI VII jointly formulating a problem statement developing hypothesis related to the solution of the problem generating cri teria for designing the solution jointly designing and developing a solution testing the solution sharing of findings and conclusions redefining new problems arising from the solution
This is a cyclical research design and is therefore a continuous process. It not only develops solutions and answers to research questions but also develops the problem-solving and technical skills of all participants. 3. The conceptual framework The conceptual framework was to establish a continuous flow of relevant information between the community and the health system which could later be used as the basis for decision making and redesigning health programmes. This project was developed 011 the basis of a number of assumptions about health and the relationship between the health system and the community in the rural areas of developing countries. These assumptions were: (a) That communItIes in the rural areas are dynamic, i.e. reflecting seasonal changes, changes in the socioeconomic patterns oi the population and the effects of development activities on living condi tions, etc. (b) That the -naintenance and improvement of good health of the individual, the family and the community requires adequate food, water and shelter.
ICohen, Louis and Menion, Laurence, Education". Croom Helm, London 1980.
"Research
'vlethods in
- 9 -
(c)
That improvement of health requires the development of a partnership among the health system, the communities and other health-related organizations.
(d) That a partnership with communities could be developed through health development projects jointly planned, implemented and monitored by the health system and the community. (e) That the changing health needs of the community could be continuously monitored by individual families in selected communities. (f) That information on the changing health needs of the communities could be used by the health system to redesign health programmes. (g) That the IHS could have access to relevant information for its teaching needs through a close working relationship with the Ministry of Health. The development of an information system at the community level was to be based on the following sequence of problems and the hypotheses for their solutions. This sequence was developed during the course of project implementation. Problem I The health staff in RHUs implemented health programmes according to accepted technical procedures. They did not moni tor the effectiveness of the intervention in the context of the local situation. Hypothesis I The problem-solving skills of the RHU staff could be maintained by integrating the development of these skills as part of the process of continuous assessment of the effectiveness of selected health programmes at the community level. In addition, the staff could identify what information was required from the community and how this infor ma tion could be obtained on a continuing basis. Problem II The ineffectiveness of a specific health programme was seen as largely due to socioeconomic factors in the community. The RHU staff believed that unless the community could participate in defining and solving the socioeconomic problems related to health, the effectiveness of ongoing health programmes would remain marginal.
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Hypothesis II If the RHU staff could develop skills and methods necessary for organizing their respective communities, then those communities in turn would be able to develop and implement their own health programmes.
Problem III The health staff perceived two major problems in sustaining community organizations and health-related programmes. The first was that the structure of the community's organization they had helped to develop conflicted with existing or proposed government structures, and that the community was unable to benefit from intersectoral support for their heal th-rela ted programmes. The second problem was that since the communities involved had low incomes, their active involvement in the preventive and curative aspects of certain health programme of the RHU could not be sustained. Hypothesis III (a) If government agencies working at the community level could agree on a common framework for organizational structures, their intersectoral support could be given more effectively to community heal th development programmes. (b) If the community's active participation in the preventive and curative aspects of health programmes of the RHU was to be sustained, the RHU staff should ensure access to essential and affordable drugs and medical supplies. Problem IV No appropnate methodology for analysis was available at the RHU lete! to enable the health staff to use family health data to assess and redesign community health programmes. Hypothesis IV If a procedure for Jomt planning and evaluation of health programmes with the communi tie, were developed, then effective community participation could be sustained. As a resul!, effective health services and relevant manpower training programmes could be designed.
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4. Criteria for the development of a monitoring system As the project developed, various sets of criterta were evolved and used as a basis for designing other components of the monitoring system. The criteria used in the following areas are described below: 4.1 The monitoring system (a) The system should enaole the communities to: identify their changing health needs; assess the results and effects of community-organized health activities; and identify actual and potential resources available in the communi ty for health activities. (b) The system should enable the health services at the primary level to: icientify the changing causes of ill health in the community; assess the influence of socioeconomic development programmes and other factors on the health of the people; identify the changing indicators for health; identify actual and potential roles and resources of other agencies for intersectoral support of health activities; and identify relevant health technologies which could be applied to prevailing health problems. (c)
Tne system should institutions to:
enable
heal th
manpower
training
iden t lfy the changing causes of ill health in the community; analyse and describe the changes in the contents of health programmes; identify the changing emphasis on the various roles and functions of the health staff and the level of skills required; identify the successful health technologies used and their applications; and identify problem areas for relevant research in health services and manpower development.
- 12 -
4.2
Design criteria for the lay reporting system (a) The basic unit of reporting should be the family.
(b) A consolidated report should be developed for various aggregations of families up to the community level using data collected by the families. (c)
The data to be recorded should include: health status socioeconomic status home environment general data
.
(d) Information forms should be designed in such a way that they could be easily completed by any member of the family and collated at various levels of aggregation. 1f.3
Specific criteria for the design of methods and procedures for planning and evaluating community health programmes at the primary level (a) Methods and procedures should enable the community, the health services and other sectors to plan and evaluate health development programmes jointly. (b) Methods should facilitate identification strategies for health at the community level. (c)
of
intersectoral
The application of these methods and procedures should result in health programmes which are relevant, acceptable, essential, effective and at a cost which both the community and the Govern ment can afford. 5. Procedures The procedures for this research had to be evolved over the entire duration of the Study. However, a basic framework was developed at the beginning of the project as a guide. 5.1 Preliminary stage (6-12 months) (a) Establishment of bases for operations (i) Hospital and RHU staff were socially prepared, oriem"d towards the objectives of the Study and introduced to the principles and ideas behind the Study.
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(i j) The hospital and/or the RH U staff would be recrui ted as members of the field staff. (iii)
The field staff would be technically prepared and introduced to a plan of action, to epidemiological surveillance and to the development of a health information system. Entry into barangays
(b)
Social preparation would consist of using barangay captains and councils to introduce plans and ideas to members of the communities. (i) (ii)
BHWs would be trained when required. Baseline data would be gathered.
(iii)
(iv) An information system would be developed at the primary level. (v) The researchers would make trial runs and adjustments. 5.2 Implementation stage (l2-36 months)
This would consist of carrying out retrospective studies of participating communities; defining the resources utilized for carrying out health programmes; developing new programmes and/or modifying existing ones; and, based on acquired experience, supporting the training programme for rural health personnel by the Regional Health Training Center (RHTC). 5.3 Development stage (ongoing)
Through prospective studies, the researchers were to investigate the impact of alternative programmes; operations would be expanded to other areas, possibly outside Region VIll. 6. Method of analysis In order to achieve the objectives of the Study, it was deemed necessary: (a) To review the administrative, managerial, and operational procedures and policies of the present health care system especially at the community level.
- Ii> -
(b) To examine and analyse the effects of the health care system on various community institutions and, in turn, to show how these insti tutions affected the system. (c)
To examine the extent of inter-agency coordination at the community level in health-related matters. (dl To examine the responses of the community to health care programmes and to measure the effect of the community's contribution to, support of, and participation in, such programmes. (el To develop and test alternative approaches to, and strategies of, health care and health technology for the communities in the underserved areas. (f)
To engage selected groups in the community and in the health service and other sectors In problem-solving, planning and developmental activi ties related to the project. (gl To interview various groups in the communities and observe changes in behaviour and practices. (h) To analyse the consistency and relationship between content and findings.
7. Duration: The project began in February 1977 and ended in March 1982. 8. Significance of the Study The R &: D project was a new experimental part of the UP-IHS, and a service to the Ministry of Health. Through the project, the I.,tltute sought to validate some of its new ideas and also to generate and use new ideas. Moreover, the project's monitoring system ensured that both the Institute and the Ministry of Health would be in constant touch wi th the residents in the rural communities which they were designed to serve, thereby increasing their effectiveness by improving the quality of health manpower and health services. As such, this R&D effort should be seen as part of the .~ational effort to develop an effective and efficient health care system. It attempted to find truly Filipino solutions to Filipino health problems. Its achievement could form a model for societies similar to tne PhilippiCles. Thus, this research might represent the Philippines' contribution to the solutions of problems common to developing countries, particularly the area of heal th manpower development.
- 15/16 -
9. Description of the study area The Carigara Catchment Area (CCA)I (see page 17/18) is c0mposed of approximately 135 000 people scattered in the municipalities of Barugo, Capoocan, Carigara, Jaro, San Miguel and Tunga. The municipalities of Barugo, Carigara and Capoocan are coastal settlements along the Carigara Bay, while Jaro, Tunga and San Miguel are inland municipalities. The area is fairly typical of rural Leyte with an economy based mainly on agriculture (rice and coconuts) and fishing. It is classified as socioeconomically depressed as evidenced by a low income level. This is also reflected by the prevalence of infectious diseases such as pulmonary tuberculosis and gastroenteritis, as well as schistosomiasis, which has pockets of endemicity in the area. These leading causes of morbidity and mortality are compounded by poor environmental sanitation and malnutri tion. The leading health facility in the area is the Carigara Emergency Hospi tal (CEH), a 25-bed government hospital. The Government also maintains an RHU in each of the six municipalities. Except for Tunga, each of these Units is headed by a municipal health officer (MHO) who is a physician) Because of its small size, the Tunga RHU is run by a public health nurse under the supervision of the Jaro MHO. These government facilities constitute the major portion of the health infrastructure in the area. There are only a few private clinics in the larger town centres (poblacions).
I A catchment area in this report denotes a geographical boundary served by a hospital and its satellite health centres. 20 t her members of the RHU staff were: a public health nurse, a sanitary inspector and several midwives. On the average, an RHU, which constitutes the major health infrastructure in each town, serves approximately 20 000 people. (See Annex 2 about the Philippine Health Services System.)
- J7 -
MAP OF CARIGARA CATCHMENT AREA (CCA)J
JFrom "Ormoc City", P.C.G.S. 2525. Coast and Geodetic Survey - J~76.
Published by the Philippine
- 18 -
Health Facilities in the Pilot Barangays: Sta. Rosa Balud Jugaban Barugohay Norte Hiagsam Canap Barangay Health Station Barangay Health Station Barangay Health Station Carigara Emergency Hospi tal Barangay Health Station No Barangay Health Station (a t the start of the project)
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CHAPTER III ORGANIZA TlON AND MANAGEMENt OF THE PROJECt I. Overview This chapter describes and analyses the original management structure and its evolution during the project. The management changed, in the five years of the project's duration, not only in personnel but also in structure. Three main stages of management can be distinguished: Stage I. Stage IL Stage Ill. Central Project Management (February 1977 - June 1978) Transitional Project Management (July 1978 - December 1979) Regional Project Management (January 1980 - February 1982) ement
2.1
Proposed organization of the project As originally proposed, the Study was to be carried out at three levels: (a) (b) (c)
The IHS Committee of the UPCM The IHS Tacloban R&D Committee R&D field staff
2.1.1 The IHS Committee of the UPCM The IHS Committee of the UPCM in Manila would be project proponents with the following function s: (a) (b) (c)
(d)
Overall design and planning, allocation and disbursement of funds, determination of directions and strategies for the Study; Supervision and direction of field operations in coordination with the IHS Tacloban R&D Committee; Utilization of infor malion for modification of IHS programmes; Coordination and cooperation with concerned government agencies at the national level;
- 20 -
(e)
(f)
Coordmation and cooperation WI th concerned international agencies and non-governmental agencies; and Communication of information to other agencies when necessary or appropriate.
Z.I.2 The IriS Taclooan R &: 0 Committee Tne R &: D Committee of IHS Tacloban would have the following functions, (a) (b) ,-~oordination of IHS faculty activities with the operations of the R &: 0 field staff; and Channelling of field information to IHS faculty for modifying IHS training programmes.
<'.'.3 The R &: 0 field staff Tne R Sf. l) Held staff would be the field coordinators for each study area of the IHS faculty. One person would be appointed project director. The field staff would include :\llinistry of Health personnel in the area and other IHS faculty members. The functions of the field staff were~
(a) (b) (c)
To develop study designs and implement strategies for field operations; To coordinate and supervise field operations; and To coordinate with the RH U or the hospi tal base of operations and the IHS in the recruitment of necessary personnel.
In order to function effectively, the R &: 0 Committee of the IHS w::JJid be composed of both field staff and members of the IHS 1: .... icubrn Committee. '\', ali thre>e levels, communication and cooperation with "",spond",", levels ot the Ministry of Health were maintained in the (a)
_,Ie
~~,) i r)Wlng ~nannf..:r:
,\t tne national level, the UPCM Comrnittee worked with the DepartlT,ent 01 Health.
(b) At the regIOnal level, the K 6: iJ Tacloban Comrnittee coo,di"dteu Nltn tne Ministry of Hedlth RegIOn,,! Office. (cJ At the field level, the field staff worked closely with field units such as the local hospital or the RHU.
- 21 -
2.2
Operations of the Central Project Management
The R &: D project was initially centrally managed by the IHS Committee in Manila, through the R &: D proponents. This was necessary while the lower operational levels were being organized and developed. For approximately two years, from February 1977 to almost the end of 1978, individual or several members of the IHS Committee based in Manila travelled to Tacloban once a month to supervise, direct or redirect and coordinate the implementation of Phases I and II of the R &: D project. With the permission of the Ministry of Health Regional Director, the R &: D proponents spent the first four months organizing the MOHs and the chief of the hospital in the CCA into a working group, reorienting them to new assumptions to "new" health care, carrying out situational analysis, developing new skills and initiating community health development activities. At the same time, provincial and regional health staff were being informed about the R &: D programme through meetings with the R &: D staff. Selected faculty members of the IHS were also involved as members of the R &: D field staff. This small core of faculty members and several R &: D field staff gradually assumed the management of the project with guidance from the IHS Committee. Since the R&D Study was concentrated in only one area (CCA), the R&D field staff also assumed the role and responsibilities of the R&D Committee of IHS Tacloban. The project organization was not strictly implemented as conceptualized. As of April 1978, the R&D field staff consisted of two IHS faculty members, one of whom was appointed coordinator; a sociologist, whose main responsibility was documentation; a Sri tish Overseas Volunteer, who assisted in documentation; and three community organizers (COS), whose main function was to assist the health officers in the entry and organization of rural communities at the barangay leve I. The staf f developed its ability to direct and manage research by exposure to field situations, regular meetings with health personnel, IHS faculty and IHS Committee members. The principal functions of the R &: D staff were to initiate, facilitate and document the interaction between health workers and communities at the barangay level. In addition to the technical staff, the R &: D was supported by two full-time clerKs and two driver-mechanics. The project staff was also provided wi th continuous technical support by IVH O.
- 22 -
3.
Stage II. Transitional Project Management (July 1978 - December 1979)
In early June 1978, a three-day seminar-workshop on the organization of R &: 0 in the field of health for the region was held at the Las Arenas !:leach Resort, Tacloban, attended by faculty members of the IHS, Ministry of Health field personnel involved in the CCA Study, staff members of the RHO and members of the IHS Committee (Manila). A WHO consultant and a BANCOM (a bank then engaged in farming and c:ornrnunity organization activi ties) consultant acted as facilitators. The principal result of the workshop was the agreement on an approach t:> organize R &: 0 at the regional level. It was envisioned that all R &: D activities in the region would be coordinated by the Regional K, &: 0 group which would De assigned the foJlowing duties: (a) (D) (c)
(d) (e) (f)
f eam building of R &: D personnel Processing and evaluating data ChanneJling of information to appropriate consumers (IHS faculty, ,V\inistry of Health or the IHS Cornmi ttee) Planning and programming Staff supervision Administration of funds in facloban
Tne support staff, consisting of a field team of COs, writers, clerks and other per sonne I, was to be administered by the Regional R &: 0 group. It was responSible for supporting and coordinating with tnose IHS faculty memoers engaged in R &: D activities. See page 25/26 for the proposed Organization Chart. In July I :178, the Regional R &: 0 group and its support staff were orgClnlzed to represent fully the interest of the IHS Committee-Manila, an,;; WI th Its Clelp and guidance, to further develop and strengthen the (I(),: ",nenttitJon arld reporting system of the group. In early 1979, full ,,'F.L ,agernem of tile R &: D project was endorsed to the Regional R &: D ,;coup. From then on, the IHS Committee only acted as liaison in both technical arid fmancial matters and as an advisory body to the project. However, it was periodically informed of the status of the project.
- 23 -
4. 4.1
ement Creation of the Regional Research and Development Committee (RRDC)
The Transitional Management of the R&D project continued through 1979. When the COs were being phased out once their terms of reference for the project had been accomplished, it was decided that the participating health officers and their respective staff would take over the COs' work. Technical assistance would be provided by the members of the evolving R&D Committee. While the IHS Committee-Manila was gradually phasing out its direct supervision over the project and developing the Regional R&D group as its local representative, the Ministry of Health Regional Office began to realize the importance of the R&D project as an integral part of its operations and not as a separate component. This was observed when the Ministry of Health attempted to evolve an organization structure which would take over the management of the project and thereby involve more Ministry of Health personnel in R&D activities. After a series of monthly meetings and a one-day workshop held in September, the RRDC evolved out of the Regional R&D group towards the end of 1979. The RRDC was created as the overall manager and support system to the three separate R&D components, namely: the Internal R&D of the IHS; the External R&D or the CCA Study Area; and the Underboard Programme. The RRDC was chaired by the Ministry of Health Regional Director and composed of the following units: planning, administration, technical supervision, monitoring/evaluation and documentation. (See page 29/30 for the RRDC organization structure and pages 27 and 28 for the functions of the RRDC uni ts.). The RRDC specified the composition of each unit. They were composed of technical staff from the Ministry of Health Regional Office, the IHS faculty and the field health staff in the CCA. Project operations in both the IHS Tadoban assigned to separate coordinators responsible for conjunction with the IHS faculty and CCA health were then sUbmitted to RRDC for discussion and and the CCA were project planning in offices. The plans approval. The IHS
-
2~
-
was managed by an academic programme coordinator (APC), while the CCA project was under a research coordinator. The RRDC met monthly to discuss the progress of the project, problems encountered, recommendat:ons and redirection of programmes. 11.2 The RRDC in operation
The RRDC was only operational and viable until the end of 1980. Several factors contributed to its dissolution. First, since it was a large committee with 25 members, it therefore became increasingly more difficult to assemble the entire group for meetings. When it did meet, there were too many to allow for constructive discussions and it was difficult to get a unanimous agreement on decisions. Second, the standards and procedures of RRDC were so rigid that they hindered R &: D activities at the CCA instead of facilitating them. The RRDC was an attempt to standardize an entire R &: D process by creating a single structure staffed by the Ministry of Health personnel. This single structure proved to be inflexible to meet the needs of the type of research being conducted. 11.3 Variation of RRDC management
In order to maintain an efficient administrative organization for the R &: D project, the R &: D action officer, with the concurrence of the RRDC Chairman, decided to organize a small core of staff from the R ROC, which would be guided by the needs and functions of the Transition Management Structure presented on page 25/26. The other members of the RRDC were available for consultation as needed.· This for,n of management style lasted from January 1981 until the end of the five-year period in March 1982.
- 25/26 -
Pro.Pa5ED R&D ClGINlZATICN 0lARl' FOR TRANSITICNAL pRlJECr ~
Ministry of Health Region VIII
I
rns (Tacldlan)
rns
I
Faculty (Manila)
Hegiooal R&D Group Provincial Health Offiae 2 - IllS Faculty nerbers 2 - Ministry of Health Regiooal staff
Support Staff I
J
I \
I I
\
\ \ \
RlU/Hospital e.g. Carigara
I I
I
I,' Catmmity R&D Activities
,
Faculty R&D Camti.ttee
I Internal R&D Activities
- 27 -
TABLE I. FUNCTIONS OF THE RRDC UNITS
A.
Administrative Unit
0) (2)
Organizes and supervises R &: 0 staff: monitors (3), clerks (3), driver
0).
Oversees financial operations:
(a) (b) (c) (d)
records disbursements prepares disbursement documents audits documents manages disbursements
(3)
Manages office operations: (a) (b) (c) (d)
record-keeping communications requisition and control of equipment and supplies typing, photocopying
(If)
Provides administrative support for the programme Manages transport system
(5) B.
Technical Supervision Unit (1)
Analyses on-going programmes/projects for: (a) (b) strengths and weaknesses supervision required
(2)
Provides technical support through: (a) (b) (c)
regular trips to project site provision of reference materials provision of consultancy services
C.
Planning Uni t (1)
Sets direction of the programme Meets with project/programme coordinators for formulation of plans
(2)
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D.
Monitoring/Evaluation Unit (1)
Plans, organizes, implements monitoring/evaluation scheme at the R 6c D level Collects and analyses data Informs appropriate staff of evaluation results
(2) (3)
E.
Documentation Unit (1)
Report writing: (a) (b) (c)
minutes of meetings periodic project reports process insights
(2) (3)
Editorial work Production of training and support/materials (journals/papers) Information for press releases
(4) F.
Action Officer (I)
Acts as the overall coordinator to: (a) (b) identify gaps between uni ts channel information to appropriate units
(2)
Acts as liaison officer to: (a) (b) maintain links wi th other agencies brief visitors on R 6c D
G.
Secretary (l)
Records minutes of meetings Takes charge of communication between uni ts Works closely with the actiOn officer
(2) (3)
- 29/30 -
REGIONAL RESEARCH AND DEVELOPMENT COMMITTEE (RRDC) ORGANIZATION STRUCTURE MINISTRY OF HEALTH
I REGIONAL R&D COMMITTEE I-CHAIRMAN
IHS COMMITTEE
~~ILA
-----
ACTION OFFICER SECRETARY
I ADMINISTRATIVE UNIT
I TECHNICAL SUPERVISIO UNIT
I PLANNING UNIT
I MONITORING EVALUATION UNIT
I DOCUMENTATION UNIT i
j
EXTERNAL R&D (CeA Coordinator) --
UNDERBOARD PROGRAMME (Coordinator) ~ ~
INTERNAL R&D (IHS Coordinator) ~---
----
~
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CHAPTER IV THE IMPLEMENTATION OF RESEARCH AND DEVELOPMENT: AN EXPERIENCE IN EVOLVING METHODS, PROCEDURES AND APPROACHES FOR HEALTH SYSTE.MS RESEARCH
I. The phases of implementation The monitoring system conceptualized by the R&D programme was implemented in the following phases, each of which took into account the seven assumptions cited in Chapter II, "The Design Criteria and The Procedures for Research". Phase I Phase II Phase 1lI Phase IV Reorientation of health workers (1977-1980)1 Community organization activities (1978-1981)1 and development
Introduction and initial analysis of the community health information system (1979-1981)1 Development (1981-1982)1 Part I. of the monitoring consisting of two parts: the and system
Monitoring reorienting programmes
community and rephasing health
Part 2.
Monitoring the effectiveness and efficiency of the health care delivery system in response to changing community needs
A description of the development of each phase of implementation follows.
I The time phases are approximates. At certain periods during the project, all the phases of implementation were happening simultaneously.
- 32 -
2. Phase I: Reorientation of health workers (1977-1980) In February and March 1977, the R&D proponents and the Chief of the CEH discussed the possibility of developing community health programmes using the hospital as a base. It became evident that the project had to include both the CEH and the MHOs of the RHUs in the CCAI. The proponents therefore decided to invite the MHOs of Barugo, Capoocan, Carigara, Jaro and San Miguel to participate in the programme. Starting April 1977, monthly meetings were held with the Chief of the CEH and the five MHOs in the hospital catchment area (by then organized as a group) for the following purposes: (a) to evolve a method for initiating and participating in the development of community health programmes in specific areas; and to prepare and strengthen the health infrastructure as a support system for community health programmes.
(b)
In the reorientation of the municipal health personnel, the R&D proponents carefully avoided the usual scheme of issuing them with a pre-packed programme for implementation. They hoped each participating health officer would develop his own progra mme based on his insights and experiences. At first, the participating health officers decided to select public health problems as the focus of a community health programme. Then, after studying the RHU and hospital records, each health officer identified a major public health problem in his municipali ty. He then selected a pilot barangay on the basis of: (a) accessibility; (b) receptivity of the people; (c) population size; and (dl the highest m'''lber of cases of major public health problems. The pilot areas selected by the group, including the major public health problem and population size of each barangay, are shown in Table 2.
I Refer to footnote on page 15/16.
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TABLE 2. PILOT BARANGA YS, MAJOR PUBLIC HEALTH PROBLEMS AND POPULA nON SIZE
Municipality
Pilot Barangayl
•
Major public heal th proble m (as of 1977) schistosomiasis pulmonary tuberculosis gastroenteritis pulmonary tuberculosis pulmonary tuberculosis pulmonary tuberculosis
Population of bara!:!8a~ I 08li 2 691 829 I li73 I DOli li73
Barugo Capoocan Carigara (CEH)
Sta. Rosa Balud Barugohay Norte
Carigara (RHU) Jugaban Jaro San Miguel Hiagsam Canap
As a first step, the MHOs and the Chief of the CEH filled in a questionnaire (see Annex li) on the procedures they were using to deal wi th the health problems. Moreover, since the proponents 2 were concerned with the R &: 0 process, each health officer also agreed to keep a daily record of his activi ties for the duration of the programme. This initial activity made the health officers aware that they had been involved primarily in carrying out procedures for implementing health programmes which were designed at a higher level of the health system. During the initial exercise, it was noticed that MHOs and the
I For the profiles of the municipalities and the pilot barangays, refer to Annex II. 2This consisted initially of a part-time medical officer consultants from WHO and some professors from the UPCM in ManiL.
- 34 -
chief of hospital were not accustomed to designing their own programmes freely. Some were even temporarily reluctant to participate in R &: D activities. However, the group of health officers realized that they individually and as a group would have to find new ways of solving old problems. At the same time, the participation of the staff of the Ministry of Health in the Study was made official through a memorandum order issued from the Ministry of Health Regional Office. When the participating health officers, together with some of their staff, first entered the selected barangays, they conducted a quick survey of each community to gather baseline data. They made house-to-house visits and used a survey form provided by the R &: D proponents (see Annex 5). The survey covered health, socioeconomics and culture. The participating health officers, in their meetings with the proponents from May to October 1977, analysed the data, made spot maps and community profiles and determined how to use the information in planning the health programmes. During these meetings, it gradually became evident that the perceptions of the communities constituted an indispensable contribution to the planning process. However, it was not clear how to generate, validate and incorporate this community input into a viable health plan. Thus the proponents agreed to continue discussions with each health officer and the barangay concerned. This procedure was incorporated into the individual plans which were developed later. [n late September 1977, the group met with participating health officers for three days at Palo, Leyte, to develop individual and group plans of action. They arrived at a planning outline, and two weeks later the individual and group plans were finalized, directed mainly at approaches to anticipated problems common to the individual plans. This ,)lan featured the following points: a mechanism for sharing personnel, facilities and expertise among the RHUs and the CEHj a programme for the continuous development and improvement of the existing resources of the RH Us and the hospi talj and an outline for a common approach for each barangay when involving external agencies (both government and private).
- 35 -
In January 1978, the first R &. D evaluation was held. The MHOs and the chief of the hospital reported on the progress made since the start of the R &. D. One of the major topics discussed during the session was their opinions about the R &. D programme. Initially, all the health officers had negative reactions to R &. D. It seemed to be an additional burden to their "already overloaded" staff. R &. D, they claimed, was very demanding on their time. They had to adjust some of their routine activities to R &. 0 and spend some of their evenings in the communities, which was uncalled for in their functions as health officers. However, the health officers admitted that R &. 0 had gradually become a regular part of their activities. They realized that in order to work with the people, personal time would have to be sacrificed. A positive finding was that the MHOs and the chief of the hospital agreed that they had developed a closer relationship in both their personal and professional interactions. A serious problem during the initial stages of the R &. D programme was that the health officers had problems relating directly to theIr barangays. This was attributed to the nature of their medical training and background. As products of the conventional approach to health care, they believed tha t the role of a heal th officer was to cure and prevent disease. The R &. D approach was quite opposite to the conventional one and involved an integrated approach to comrnunity health developrnent. The health officers were sent out of their clinics to the community to enable them to par tic ipa te with the people in community-based development projects. The health officers also expressed feel ings of anxiety over their lack of adequ"te skills to implement the R &. D programme. They felt they needed support in the aspects of the programme concerned with community development. A need arose for COs to assist the health oificers in their community work. In response, the R &. 0 office in Tacloban recruited and hired three COsl and fielded them in the pilot barangays. These COs would later play a primary role in assisting the health officers in the social preparation of the communities and sensitizing and motivating community members to participate in the R &. 0 programme.
I The COs were three young female graduates of UP facloban (major in community development), who were assigned to two pilot barangays each.
- 36 -
By the end of 1978, the health officers and the COS felt that the participation of the people in community activities was still minimal, especially in programme evaluation. This was a result of different points of view and attitudes toward health problems as seen by the health professionals and by the community. However, by mid-1979, increased participation in implementation and planning activities by the barangay network (BN) leaders and to a certain extent by the people, was reported. Although the lack of participation in programme evaluation was identified as a constraint during the mid-year evaluation, no suggestions were made on how to improve this situation. In January 1979, the health officers discussed and prepared a plan of action for a community health development programme. Towards the middle of 1979, all the community organizers resigned because they laCked understanding of their role in the programme. 3. Phase II. Communi to organization and development activi ties 1978-1980
This phase of the R&D programme consisted of four sub-phases: social preparation of the community, community organization, community development and expansion activi ties. 3.1 Social preparation of the communities The initial entries into the pilot baranga~s were made during the reorientation flhase of the MHOs and the chief of the hospital. To prepare the community, the MHOs and the chief of the hospital first approached the captains and councils of the pilot baran~ays to inform them about the rationale and Objectives of the R de D an the identified priori ty health problems. Records were reviewed, and an initial survey was carried out to find out what people considered to be their priority problems. Although people did consider health to be a problem, the health officers were disappointed to discover that the priority felt needs were primarily economic. I\t the ensuing barangay assemblies, the health workers attempted to convince the people that health should be a priority problem. Subsequent meetings were mainly brainstorming and planning sessions for future act ivities. It was noticed that fewer and fewer people attended these meetings.
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This situation prompted the respective health officers, in consultation with their barangay captains, to create a task force in each barangay that would disseminate health information from the RHU to the people and vice-versa. The task forces consisted of several volunteer opinion leaders from each of the barangays. Further consultations with the barangays convinced the health officers that a health development programme in the community would be viable only if it were made part of an integrated development programme. Therefore, instead of implementing their individual health programmes immediately, the health officers decided to participate in socioeconomic and cultural development programmes and to integrate their health programmes at the appropriate time. Thus, other government agencies such as the Ministry of Local Government and Community Development (MLGCD), the Ministry of Education, Culture and Sports (MECS) and the Ministry of Agriculture (MA) were involved at the local level. 3.2 Community organization The task forces were considered too small to set up the health programme so a more formal organization called the BN (see Annex 6) evolved. COS I were recruited to help spread information about the network and make the community receptive. They also helped the MHOs and the chief of the hospital meet with the community leaders, the barangay captains and identify existing structures within the barangays which might be used for carrying out a programme. Each health officer used a different approach in setting up the network. In Jugaban, the .V1HO and the barangay captain SCheduled a barangay assembly to introduce the R &: D and to identify those who would serve in the network. After explaining the function of the network, the assembly divided the barangay into three "puroks,,2 and elected a leader for each. The purok leaders were elected according to different cri teria in each barangay. Each pur ok leader grouped families in his care into units of 10 to 14 families. A unit leader was elected by the families using selected criteria such as trustworthiness, literacy, good public relations, etc. The barangay captain, as network head, coordinated activi ties of the puroks, while ~ leaders coordinated the
ICOs are professionally trained to work with the communities in establishing community organization for community development. 2A conventional sub-unit of a barangay.
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unit activities. The unit leaders and the captain decided that the leaders' functions would be: (a) to ease the way for unit activities; (b) to motivate the people to attend meetings and ''pintakasi'' (voluntary group activities); (c) to refer patients to the RHU; and (d) to participate in identifying tuberculosis cases. (The MHO added this function.). In Balud, the MHO used the existing barangay nutrition network. The purok leaders were all appointed by the barangay captain on the basis of criteria he had evolved: literacy and being an ex-officer of the barangay. Each Pfrok leader was responsible for about 20 families. The barangay captain acilitated all activi ties in the respective puroks. The MHO understood that all the leaders would help him find pulmonary tuberculosis suspects. Later in 1981, the MHO increased the number of p'uroks and purok leaders from 17 to 30 so that he could better coordinate and monitor ~ activities. This time, each purok leader became responsible for about 10-15 families. In Canap, the MHO presented his plan and the purpose of establishing a network during a barangay assembly. The network consisted of puroks wi th 10 families each and the cri teria for the selection of purok leaders were decided by the assembly. The community organizer met one ~ at a time for the selection of leaders. The barangay captain coordinated activities and presided over meetings of the network. Purok leaders disseminated information to members, initiated activities and referred pulmonary tuberculosis suspects to the MHO. In Barugohay Norte, the chief of the hospital and the barangay captain held a barangay assembly immediately after a Sunday mass in order to introduce the R de D programme. The people elected purok leaders, who in turn appointed uni t leaders according to the criterion of trustworthiness. The ~ leaders were expected to coordinate the ,_·,cctivities of unit leaders, while the latter disseminated information to tileir members and motivated them to attend meetings and activities. In Hiagsam, the MHO reactivated the barangay nutrition network and established a core group known as the Barangay Advisory Group (BAG), which was headed by the barangay captain, and also comprised the school prinCipal, the Parent-Teacher Association (PTA) president, Kabataang Barangay (KB) chairman and the MHO. The BAG "ppointed two purok leaders and two teacner-coordinators who, in turn, helped select unit leaders who would each take charge of 20 families in
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uni t leaders who would each take charge of 20 families in their puroks. The BAG coordinated the activities of the network with the help of the purok leaders, teacher-coordinators, uni t leaders and member families. In 1978, the unit leaders suggested subdividing the units into two, so as to achieve better supervision of unit activities and to promote closer relationships between the purok and unit leaders, and member families. Sub-uni t leaders were elected to take charge of the other 10 member fa milies in each unit. In Sta. Rosa, the MHO used the existing barangay nutrition network. The barangay captain and the MHO divided the barangay into 12 puroks. Five barangay councilmen living in identified puroks were appointed as purok leaders, while the other seven were elected using the following cri teria: permanent residence in the barangay, literacy, acceptance by the people and CIVIC consciousness. A teacher-coordinator was assigned to each purok. The BN was headed by the barangay captain. The purok and uni t leaders generally liaised between the RHU and the community and promoted such health activities as immunization, sanitation campaign, weighing of preschool children, etc. Wi th the establishment of the BNs, the MHOs and the chief of the hospi tal considered their entry into their respective barangays completed. The table of organisation for a barangay network structure described above appears in Annex 6. 3.3 Community development In January 1978, an evaluation workshop reviewed past activities and prepared plans for the future. The MHOs and the chief of the hospital felt that, up to then, the communities had partiCipated in the implementation but not in the planning and evaluation of projects. It seemed unrealistic to expect full participation from a community that had been conditioned to be passive reCipients of pre-planned programmes. As a result of the evaluation, the health officers decided to implement and follow-up activities to strengthen community participation, to make sure that planning began with the people, to tap existing resources and to join wi th other government agencies for the sharing of resources.
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Various community projects to solve problems and meet the needs as perceived by the people were implemented between 1978 to 1981. These activities may be grouped into health and health-related community activities and economic activities such as food production. 3.3.1 Health activities (a) A communitywide nutrition survey, Operation Timbang (OPT), was undertaken to determine the nutritional status of preschool children in the area. This led to deworming of children, distribution of milk and establishment of feeding centres for second and third-degree malnourished children in all pilot barangays. Pood distribution and feeding centres, however, were not maintained owing to lack of resources. (b) Identification of tuberculosis cases and follow-up treatment and immunization using BCG were activities regularly undertaken in Balud, Canap, Jugaban and Hiagsam. (c)
A community health workers' programme was set up in Jugaban and Canap to train nine barangay network leaders to help the RHU staff in dispensing basic drugs and rendering first aid.
(d) A Botica sa Barangay (village pharmacy) was established in Sta. Rosa to solve the problem of inaccessibili ty to drug stores and as an income-generating activity. (e) Deworming, immunization conducted in Balud. 3.3.2 Other communi ty activities (a) Water pipes were installed in Jugaban after one purok reported in a community assembly that the water problem was urgent. Consequently, local water resources were tapped, and each family agreed to contribute annually to the maintenance expenses. (b) In Canap, drains, water disposal system, and water-sealed toilets were built. The construction was initiated by the village civic action group and the Rural Improvement Club. and health education were
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(e)
A beautification programme to implement a presidential decree (PO 13) was undertaken in all the pilot barangays. This included fencing individual lots, constructing flower boxes and controlling stray animals.
(d) Funds were raised through benefit dances and donations to finance the construction of mUlti-purpose halls. The multi-purpose halls in Jugaban and Canap were completed; the people participated in their planning and implementation. 3.3.3 Food production and other economic projects (a) Home gardening was initiated in Canap. Communal gardening was a continuing activity in Hiagsam. (b) The R &: D management made two Pesos 5 000 loans each as initial capital investments for income-generating activities. One loan was for 20 families in Jugaban and the other for 20 families in Balud. The residents of Canap initiated a training course on mat-weaving. The course was conducted and funded by the National Cottage Industry and Development Authority (NACIDA) and the National Manpower and Youth Council (NMYC). Out of the 40 trainees, the 25 who completed the training elected their officers in July 1979. The group expressed interest in turning mat weaving into an income-generating activity. The NACIDA promised them assistance. (c)
3.4 Expansion activi ties It took longer for the programme to expand outside the pilot barangays. After two and a half years, the programme was still only established in the six pilot barangays. Conscious of the delay, the health officers took steps towards expansion such as orienting the barangay captains of neighbouring barangays about R &: 0 and inviting them to observe barangay meetings and visit community projects. At the end of July 1979, during the mid-year evaluation, the health officers agreed on a strategy to expand their activities based on the experiences and insights from the pilot barangays. By the end of 1979, the health officers had expanded the R &: 0 efforts to 12 more barangays.
In mid-1980, the Ministry of Health Regional Director decided to extend the project to 80 more barangays. The health officers and the ir staff conducted a feasibility survey and socially prepared the
communities by holding a series of community assemblies, conducting socioeconomic surveys, developing a BN within the community and training the BN leaders. At the end of 19&0, 57 of the 80 barangays had been socially prepared and organized and were considered ready to proceed into the next phase of the R &: 0 programme. The nomenclature of the BN was changed to Kadiwa Brigade Network (KBN) to fulfill a government requirement to organize Kadiwa brigades (a programme of the newly-created Ministry of Human Settlements (MHS» in each barangay. The structure and func tions, however, were basically the same. By March 1982, at the end of the five-year period, R &: 0 efforts had been implemented in a total of 95 barangays in the CCA. 1<.
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Phase III:
Introduction and initial analysis of the community health information system (1979-1981)
To enable the people to make continuous assessment of their problems and resources and make decisions and changes in the health development programme, a system for collecting information was designed early in 1979. The system was based on gathering data through information sheets. The R &: D proponents gave their field staff and the participating health officers the format of the information sheets devised by a WHO consultant. The researchers modified the information sheets to suit the local situation. With the BN's help, the researchers used the sheets as a basis for obtaining data from each family in the pilot barangays in the CCA. The sheets were simplified and called for the minimum of information that would enable periodic assessment of the health of the families and com munities in relation to changes in socioeconomic conditions. The first sheet, the development sheet (see Annex 7), recNded information on the socioeconomic status of the family and changes that might have occurred. The second sheet, the health sheet (I\nnex 7), served as a monthly record of the illness, treatment and results for each family. Both sheets, called the family information sheets, provided primary data of the barangay which were processed and channelled to the RHU at the municipal level, then to the provincial and regional levels. A third sheet, the growth chart (Annex 8), which served as a record of the nutritional status of children under six years of age, supplemented the two other sheets.
A two-day live-in workshop was held in April 1979 with participants from the RHUs, the provincial health offices (PHOs) and RHOs to develop a coding system for filling out the information sheets. The BN leaders were informed about the coding workshop and were asked to suggest ways to clarify the sheets. The RHU staff also gave the unit leaders of the pilot barangays two days of practice in filling out the forms. Likewise, the unit leaders conducted workshops in their respective units to teach the families how to fill up the forms. As a result of the health sheet, the RHU identified 30 symptoms of diseases in their respective barangays to be monitored and recorded. Later, these were reduced to the symptoms of the most prevalent diseases in the pilot barangays, namely. gastroenteritis, pulmonary tuberculosis, schistosomiasis and malnutrition. The symptoms were. fever, cough, cold, diarrhoea, pain and night blindness. In mid-1979, the family information sheets were pre-tested in the pilot barangays for three months. The first evaluation showed that most of the families did not make an entry during the second and third months. The reasons given were; first, the families were left on their own to record data without the assistance of the unit leaders and, second, the forms were in English. It was difficult for them to express themselves in a language they were not completely comfortable in. The test was useful because it aroused the curiosity of the people and because it indicated how the sheets should be modified to suit their level of understanding. The family information sheet was translated into the local dialect and pre-tested again for nine months. The second evaluation showed additional problems. The people were inconsistent in entering data, and still many did not record information during the second and third quarters. Lack of motivation was a possible reason. The families demanded a checklist style on the sheets so that writing would be minimized. The family sheet was revised again. In mid-lnO, the family health information system was formally implemented in the pilot barangays under the close guidance of unit leaders and midwives. During the first year, the unit leaders saw to it that every family sheet in his unit had been completed. The data for the 12 months were collated by the RH U staff and the unit leaders. Results showed that almost one-half of the families in the pilot barangays did not complete the information entry for a whole year.
The reasons given were: (a) some people did not yet understand the importance of the information system; (b) others were mainly motivated to fill out the sheets in the expectation that the RHU would give free medicine in exchange; (c) others were not interested in the information system because it did not guarantee immediate and tangible results which could alleviate their immediate needs, which were economic, not health; and (d) others said they lacked time because of their tight farm schedules. These exercises have produced the guidelines for the management of information system for community health programmes as presented in Annex 9. 5. Phase IV: Develo ment of a lannin and evaluation procedure for community health 1981-1982)
By early 1981, initial health and socioeconomic data for a 12-month period had been consolidated from the completed information sheets. Although the RHU staff in theory knew that the purpose of implementing the information system was to enable the people to assess continually their health programmes and to engage in community decision making, the methods for using this information had not been developed. In August 1981, a one-week workshop was held for all the CCA personnel: MHOs, nurses, rural sanitary inspectors (RSIs) and midwives who were involved in the activities in the pilot barangays. Assisted by the RRDC staff, the WHO consultant addressed the workshop and introduced the "epidemiological approach" to the participants. Planning and problem-solving frameworks were drawn up using the health and socioeconomic data consolidated from the information sheets and from data available in the RHUs or from the RHU personnel. These included socioeconomic health profiles (the graph charts), spot maps, directional outlines and programme strategy outlines (see Annex 10). Then, the RHU teams carried out actual problem-solving and planning exercises in their respective pilot barangays. In Nove mber 1981, the R R DC conducted a one-week seminar-workshop for district hospital staff on the "Integration of Hospital and Public Health Services Using the Epidemiological Approach". Using the barangay experience as a model, a framework was developed for designing a monitoring system for the provincial level that would suit the needs of innovative health services delivery in Region VIII - the integration of hospi tal and public health services.
The seminar was supposed to develop a monitoring system at the PHO level. The development objective was not achieved because the planned period of the R&D ended in March 1982. 6. Principal technical support activities to R&D
The technical support activities consisted of seminars, workshops and training programmes for RHU staff and participating health officers. (a) RHU staff were trained in sputum microscopy, because tuberculosis had been selected as the target health problem in four barangays. The MHO of Sta. Rosa was sent to a special WHO workshop on schistosomiasis. (b) Health officers continued to attend education programmes in cooperation with the Postgraduate School of the UPCM. (c)
Two consultants from Indonesia conducted a two-week workshop in April and May 1979 to discuss community organization with the RHU staff of the CCA.
(d) A three-day workshop on diarrhoeal disease control was held in June 1979 to inform the health officers at the provincial, regional and municipal levels of the latest developments in the treatment and control of diarrhoea. This was followed by another three-day workshop on the development of a plan of action for emergency diarrhoeal disease control and environmental sanitation. (e) In September 1977, a WHO consultant held a management seminar for the health officers on the development of plans of actions. The Ministry of Health Regional Director agreed to follow this seminar by a series of management training courses involving various levels of regional health staff. They would then be able to assist the Regional Health Staff in strengthening the RHO in the implementation of community health development activities throughout Region VIll. The first training course, projected to last for more than a year, was held in November 1979. Between November 1979 and February 1980, four health management workshops were conducted and supplemented by a series of technical workshops that lasted throughout 1980.
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These management and technical workshops focused on inter- and intrasectoral coordination, community organization and community development, tuberculosis control, maternal and child health including family planning and nutrition, epidemiology and laboratory services. (f)
The CEH established a formalized referral system with the DZRMH. This was initiated through a "linkage seminar" between the Ministry of Health, the IHS and the regional hospital. A dispersal programme allowed resident physicians from the regional hospital to visit the CEH periodically to give technical training to the field health staff.
(g) Another "linkage seminar" was held between the IHS and the MLGCD. It resulted in a Memorandum of Agreement whereby the MLGCD agreed to help the IHS cooperate with other government agencies at the municipal level in the R &: 0 areas of activity. In addition to these seminars and workshops, the participating heal th officers and the R &: D staff and COs conducted monthly meetings and mid-year evaluations to discuss procedures regarding community participation in the planning, implementation and evaluation of programmes. At the intersectoral level, the participating health officers held informal meetings with representatives of government agencies working in the communities. In addition, the MHOs and the chief of the hospital established regular informal meetings to evaluate their experiences and share their inSights.
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CHAPTER V THE DEVELOPMENT AND USE OF HEALTH TECHNOLOGIES
This chapter briefly describes the use of health technologies as components of the monitoring system. Examples of each technology are provided in the annexes. I. Phase I: Methods of reorientation of health staff During this phase of the project, there was a need to develop various interrelated techniques which could be used by the health office and its staff to monitor the effects of their programme. Within this context, the level of health of the community could be diagnosed to provide a baseline of the socioeconomic si tuation where the health programmes were being implemented. 1.1 The health management questionnaire The health management questionnaire (See Annex 4) was designed as a tool for situational analysis of the health care delivery system in the eCA at the start of the project. This questionnaire was completed by each of the participating health officers during their initial meetings with the R &: D staff in April 1977 • 1.1.1 Use of the health management questionnaire This questionnaire dealt with the existing procedures for dealing with the identified health problems. Completed questionnaires became the initial entries in the health officers' clinics. Analysis of the answers led the participating health officers to the early conclusion that they were mainly involved in the implementation of pre-planned programmes. 1.1.2 Limitation of the health management questionnaire The MHOs remarked that the questions in the questionnaire were complicated and difficult to answer, especially budget and costing aspects.
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1.2 The quick survey form The quick survey form (See Annex 5) was used by the participating health officers, their staff and the R &. D field staff to gather baseline health data and generate infor mation about the selected pilot barangays. This survey was conducted by means of house-to-house visits. Data gathered covered not only health but also other aspects of communi ty life, particularly socioeconomics and culture. 1.2.1 Use of the quick survey form The data formed the basis for the formulation of the community profiles (See Annex 1:1). Although the quick survey form could also have been used to collect more comprehensive community data and to improve an existing 1977 Ministry of Health survey form, this was not done during the project. 1.2.2 Limitations of the quick survey form Upon evaluation of the results of the quick survey form, the following constraints were ci ted: (a) For maximum results, the health staff had to be properly oriented and must understand the structure as well as the limitation of the survey method. (b) Assessment of water supply sanitation and housing conditions was delegated to the nurses, midwives and sanitary inspectors. Standardization of results was considered a problem. (c)
The form needed to be adapted to local conditions.
1.3 The individual problem analysis and plan of action The R&D participating health officers were provided with an outline for individual problem analysis and action plan during a management workshop held in late September 1977. The workshop aimed primarily at developing the planning and problem-solving skills of the R &. D staff. Its specific objectives were: (a) to review and assess current plans and activities of the R&D; and (b) to develop an individual and group plan of action for R & 0 activi ties. The skills developed during this workshop provided a oasic structure and a com mon method for subsequent technical and managerial problem-solving activities throughout the project.
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1.4 The communi ty profiles The community profiles (See Annex 11) of the different CCA municipalities and barangays were formulated utilizing the data taken from the quick survey for m, from inter views and meetings with selected barangay residents, from a review of the RHU and from municipal records. 1.+.1 Use of the community profiles Community profiles were initially useful as orientation documents for health administrators and supervising staff. At a later phase of the project, they were to become valuable in the context of an appropriate planning system at the community level. 1.4.2 Limitation of the community profiles An apparent lack of understanding of the use of the quick survey form resulted in incomplete community profiles. 2. Phase II: Methods of organizing community health development programmes
During this phase of the project, the health officers and their staff developed various methods for organizing their pilot communities as well as initiating communi ty health development projects with the help of the COS. The need to expand the R &: D activities to other areas forced the health staff to document the development of these programmes in order to guide other health staff in the implementation of similar programmes. 2.1 Developing a community health programme model The CCA model used to develop a community health programme, which is shown in Annex 12, includes the sequence of activities required to develop a continuing community health development programme. The phases include social and technical preparation of the implementing health staff, preparation and organization of the community, implementation and evaluation of health and related programmes, and documentation and monitoring of community activities. 2.1.2 Limitation of the method
The effective use of this method assumed that health staff serving in the rural areas had undergone a similar reorientation as the health staff involved in the R &: D.
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2.2 A common framework for intersectoral collaboration Representatives of MHS, MLGCD, the Ministry of Health and the R &: D field staff met monthly for a series of intersectoral coordination in the CCA in order to for mulate a common framework for intersectoral collaboration so that line agencies would be provided wi th a common working structure and organiza tion at the community level. 2.2.1 Limitation of the framework The common framework for intersectoral collaboration was a local agreement at the CCA level. It was never fully implemented because each line agency had different priori ties and requirements. A request for legitimization by other agency representatives of this agreement at the provincial and regional levels was pursued but never approved. 3. Phase III; Methods for lay reporting Once the communities were organized and implementing their health development programmes, a technique for collecting information had to be designed so that the families would become interested in their own health, and in particular, so that mothers would become more aware of the health of their children. At the same time, the teChniques would provide the health worker with a simple tool for measuring changes and improvements in the health status. 3.1 The family information sheet The family information sheet, consisting of the development sheet and the health sheet, was intended to record information and changes in the socioeconomic status of the family. 3.1.1 Use of the development sheet The development sheet contained general information on the family such as (a) membership, size, sex, age, etc.; (b) maternal and child health history; (c) home envIronment; housing, water supply, waste disposal and energy sources; and (d) economic status; assets, income, and family expenditure. Collated data from the family sheets on a communi tywide basis would be valuable for planning appropriate community health programmes.
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3.1.2 Limitations of the development sheet
The major constraints on the use of the development sheet (and the health sheet described below) were the form of presentation and the reluctance of the community to complete the form without knowing what the information would be used for. The participating health staff could not explain to the community how the information would be used in a community health development plan. Nevertheless, as a result of the community's willingness to make a contribution to the implementation of the health information system and the more frequent interaction with the health staff in the barangay, the participation of most community families was sustained for a period of 18 months. Various reV1Sl0ns were made to simplify the development sheet. However, translating it to the dialect and presenting it in a checklist style lengthened the development sheet, requiring a more frequent reporting of once a month instead of quarterly. Many information sheets were either not completed or were lost because this method of collecting family data ran counter to the oral and visual culture of the communities. The health sheet reflected the monthly and annual health status of each family. This included morbidity, mortality and health service demands. Compared to the development sheet, the community had shown more interest in the health sheet. This could be seen th rough its willingness to fill out the health sheet and openly discuss the entries with the health staff and/or with their neighbours and BN leaders. 3.2
The growth chart The growth chart used was the WHO model (WHO 30396/30397).
3.2.1 Usefulness of the growth chart
The growth chart was useful in recording the nutri tional status and growth of children under six years of age in the pilot baranga ys.
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3.2.2 Limitation of the growth chart The limitation of the growth chart lay not in its use and format but in the inability of the BN leaders and the health staff to sustain related support activities such as food distribution and feeding programmes for undernourished children. It. Phase IV: Methods for planning and evaluation of community health programmes
Using the criteria established for the overall monitoring system and health programme development, a problem-solving and decision-making procedure for utilization of health resources was designed. Its aim was to enable the health workers and the community to learn from past experiences, apply their respective knowledge of technoiogy to problems and make effective use of lay reports. The method developed was initially labelled the "epidemiological approach" by the research field staff principally because its analytical framework reflected the basic principles of epidemiology. It. I
The "epidemiological approach"
The framework and procedures of the "epidemiological approach" is described in Annex 10. A sample of the health programme developed by this method IS provided in Annex 10-F. 1t.1.1 Limitations of the "epidemiological approach" The use of the "epidemiological approach" assumed that: (al The health staff in the community health development. area had been reoriented to
(b) The midwife had a basic knowledge of epidemiological factors related to the most common health problem in the community. The midwife had access to a continuous flow of health and socioeconomic information from the families in the communities. (c)
(dl The users could read, understand related factors.
write,
analyse,
syntheSize
and
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(e) The midwife and public health nurse would organize meetings with the communities and other sectors and facilitate problem-solving discussions. The midwife and the public health nurse possessed the skills (f) to identify and assess the effectiveness of organizations in the community.
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CHAPTER VI
FINDINGS
The multifaceted nature of the research project generated a wide variety of information on health in the rural areas. Since it is neither possible nor practical to present everything that has been learned in one report, only the results, outcomes, responses and perceptions of the community and the health services directly resulting from the overall developmental approach undertaken by the project are recorded here. Findings about the management of action research as a method for health systems research are also included. I. The community 1.1 Background One of the principal underlymg assumptions of the Study was that a partnership between the health services and the community which they served had to be developed and sustained if health care were to be affordable and effective in improving the health status of the communi ty. ~sed on this assumption, the six barangays or communities in the study area were "awakened" and engaged in a process of solving problems, making decisions, sharing resources and responsibilities and taking action jointly with the health services on issues related to their health.
1.2 Findings The communities had various reactions to the project when it was initially presented. Some silently resisted involvement. Others could not relate health problems to their own economic needs. Yet, whether out of curiosity or simple obedience to the call of their leaders and the respect for their health officers, each community established an organization which opened a new channel of communication on health work and enabled health care to be coordinated by the community. These organizations also enabled the community to collect and exchange health information in return for health resources and technology from the heal th centres. While structurally sound, the most important limitation of the communities involved, in terms of their capacities for self-reliance and partnership with the health services, was their lack of management
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skills. Reaching consensus on alternative approaches to problems, the dbility to document or otherwise communicate plans to outside agencies for support, the ability to monitor their own progress in implementing their own plans, the ability to identify information needs for decisionmaking and implementation of plans were some of the important management skills which needed to be developed to sustain a viable partnership wi th the health services. Conversely, when instructed by the heal th staff as to the procedures required for certain aspects of health care management such as tuberculosis, sputum collectmg, criteria for patient referral, environmental samtation, etc., the community using its new health organization proved to be both effective and efficient. Some of the resul ts of the heal th programmes undertaken by the community and the health services are as follows: (a) In Barangay Sta.. Rosa where a schistosomiasis programme was implemented, initial examinations showed that 247 residents were infected wi th S. Japonicum. About 246 of the infected residents were treated wi th the new drug, Praziquantel. Three months later, in February 1982, examination results showed that about 90 % of those treated were negative for schisto ova. (b) In BdI"angay Barugohay Norte where a diarrhoeal disease control programme was introduced by the chief of the CEH, the records of the hospi tal outpatient department from 1977 to 1981 showed that fewer patients wi th this prOblem were diagnosed. (e) In Barangay Jugaban, 18 new tuberculosis patients were identified at the beginning of the programme in 1977. Five years later, of the 18 patients, four were cured, three died and the remainder either stopped taking medication or left the barangay.
(d) In Barangay Hiagsam, 35 cases of tuberculosis were identified at the beginning of the programme in 1977. By early 1982, 24 were still active and 11 cases were negative. Cri tical factors which were also found to determine effectiveness of the community health organizations were; (a) (b) the
the re la tionship between the local leaders and the health staff; and the interest and commitment of political leaders.
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2. The health services in Carigara 2.1 Background When the project began, the health services in Carigara were operating according to prevailing Ministry of Health practices. The CEH was understaffed and dilapidated. Patients coming from communities wi thin walking distance of the hospital would by-pass the facility and willingly pay for their transportation to Tacloban 50 kms. away. The RHUs in the Carigara area had a full complement of staff, and some new facilities had been constructed under a World Bank loan project, which had also provided additional technology and training to the health centre staff. There was neither any existing working relationship between the hospital and the RHUs nor among the MHOs in the area. The health staff in both the hospital and the RHUs had been trained and accustomed to the practice of seeing themselves as providers of health care and the communities as passive recipients. 2.2 Findings The reorientation of health officers in the CCA to new assumptions about health and concepts about their roles and practices proved to be no less traumatic than it had been for the pilot communi ties they had engaged in the Study. Their own assessment of the effectiveness of the health care programmes they had been implementing for several years, e.g. tuberculosis and schistosomiasis, allowed them to internalize the limitation of health teChnologies and identify the crucial relationship between socioeconomic factors and changes in the health status of the community. Having assessed their effectiveness, the health officers concluded that future impact on the health problem could only be achieved by organizing a community health programme. It was this effort in initiating community involvement and facilitating the development of a community organization and health programme that a clearer description of the role of the health services could be reached. Annex 12 provides a comparative profile of the principal change in roles and functions of both the health services and the community operating under new health assumptions and practices.
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As individuals, the health officers emerged from this experience with: a better understanding of community dynamics; a better understanding of the role, potential resources and problems of other sectors; improved informal linkages wi th other sectors; improved planning, problem-solving and communication skills; a method for more efficient approach to organizing community health programmes; a realization that health programmes needed to be integrated with other developmental programmes in the community; and an awareness of the role of the health worker as a technical consultant to the community in this process. However, the experience also highlighted the health officers' initial lack of specific managerial skills needed to sustain a partnership with the communities. As their involvement in the Study evolved, they were able to develop further both technical and managerial skills such as group problem-solving, decision making, facilitation, presentation including oral and written communication, and assessment through a continuous process of team consultation and participation in management and technical workshops at different levels throughout the life cycle of the Study. More important, however, was that the decision-making procedures and problem-solving methods in use at the RHU and district hospitals emphasized a procedural approach to delivery of health programmes ra ther than a participative problem-solving method which involved the health staff and the community in designing and monitoring health programmes jointly. The "epidemiological approach" was a decision-making framework designed to address this problem. The application of this deCision-making procedure provided some important insights about the practical aspects of managing community health programmes. These were as follows: (a) There were many more cases of diarrhoea, fever, upper respiratory infections than had been recorded by the health centre. (b) The time, location and individuals affected by these health problems could be identified.
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(c)
It became possible to assess the probable effects of past health activities on each problem as it related to the individual, the family and the community.
(d) The assessment also helped to identify the specific social or economic activity or event in the family or in the community which contributed to the health problem. (e) Given the information generated as a result of the assessment and knowledge about opportunities in the communities and in the other sectors, it became possible to develop an effective solution appropriate to the time, place and individuals affected by the health problem. By defining the problem and determining the solution, the midwife, the community and the participating sectors could specify the support they required to implement the programme; describe how to coordinate their activities; and set their indicators to monitor the progress of their efforts. (f)
Wi th regard to the process of planning using this framework, three important observations were made by the midwives and the public health nurses who applied it. First, they had difficulty synthesizing and writing the various ans wers to the ir anal ysi s. Second, they expressed the need for more technical training in the field of maternal and child health and communicable disease control using a problem-solving approach. Third, they felt that the outcome of the exercise resulted in proposals which were substantially different from what they had been doing in the past. The difference was that health intervention could now be designed for the specific needs and circumstances of each community, taking into account variations in the time a health problem occurred; the group which was most affected; the specific local contributing factors to the problem; and the people and institutions involved in the solution. These were elements which were not considered in the design of the health programmes they were currently implementing under the instructions from the higher levels of the health services.
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Efforts to make this planning framework part of the management system of the BHSs and the RHUs encountered problems because: existing planning and health programming procedures and practices in the Ministry of Health were established on what appeared to be the assumption that an effective mixture of health technologies for maternal and child health/family planning or communicable disease control or environmental sanitation could be centrally designed and their efficient implementation could be centrally planned and controlled by establishing disease reduction targets in a specific period of time. Under this system, adjustments are allowed for differences in morbidity pa tterns in a given area and for population size and demographic structures. current methods and practices of supervision are perceived by a number of midwives and nurses in the area to gauge the performance of the health workers and their knowledge and application of procedures for implementing centrally designed programmes such as maternal and child health, environmental health, communicable diseases, etc. and adherence to service delivery targets such as the number of home visits, the number of immunizations, etc., for the population served; and, the existing information and reporting system is designed primarily to collect and maintain data on programme implementation targets and on disease reduction targets. 3. The management of the project 3.1 Background
By 1977, several projects in health services research had been successfullY completed by the Ministry of Health with the support of the UP and WHO. This project, however, differed in three vital aspects. First, it had fundamentally different assumptions about health development and approaches to effective health care delivery. Second, its objectives were to develop methods and procedures which would opera tionalize these assumptions. And third, the design, development and application of these new methods and procedures could not be done without the full participation of the communities and the health services staff in the project area. Given these differences, it followed that conventional methods of research previously used in the health services were not appropriate. Having no previous experience in participative developmental research,
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the Ministry of Health, the UPCMl and WHO had to improvise approaches for managing the project. The management of the project, therefore, became in itself, an experiment. 3.2 Findings
With such basic differences in assumptions about health and lack of experience in developmental research, there was ample room for conflict and confusion not only among those directly participating in the project but also between the proponents of the project and the staff of the PHOs and the RHOs in the region. There were two principal causes underlying the problems of management of the project. First was the absence of a conceptual framework or a model of how the health services and the communities function together to achieve a common objective. Second was the absence of an explicit research design2, although it was understood that participative problem-solving was to be used as the main approach. The absence of these two elemental factors made it difficult for the project management to: achieve consensus on problem definition; enable partiCipants to clarify their roles and functions and potential contributions; design and classify project documentation; maintain continuity of the support staff; achieve consensus on interpretation and significance of findings; and, maintain continuity of the developmental processes and directions towards the principal objectives of the project. For these reasons, the project experienced: high turnover in project support staff; periods of low morale not only among the staff but also among the participants in the health services and in the communities;
1The management of the project was later assumed by the UP-Health ScienCes Centre. 2The design presented in Chapter II, pages 7 and 8, gradually evolved towards the end of the project's life cycle.
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various experiments wi th project organizational structure (please refer to Chapter III for description) which varied in the degrees of control and direction exercised by national, regional, and field or operational levels; and low level of efficiency in the implementation of findings and expansion of the project into other communities during the first two and a half years of the project.
While the problems of managing the project varied in intensity and duration, periods of high productivity appeared when the participants in the research, namely, the health staff and the BN members in the pilot communities had agreed upon a clear course of action supported by the project's support staff. It was during these periods that: methods and procedures were developed; problem-solving skills and creative potentials of health officers were further imprOVed; frequent informal meetings were held among the heal th officers to share experiences and seek mutual support; there was greater awareness of national resources involved in similar studies; and a strong espri t de corps evolved. In the end, the problem-solving approach and the basic shared commitment to improve the health of the people in Carigara were the principal forces which enabled the research participants to develop further their technical and managerial skills and produce developmental products. Perhaps, the most important results of the experience in managing the research were: (a) The awareness of the effectiveness and validity of action research as an approach to designing solutions which are implementable and acceptable at a level where they are to be applied. (b) The awareness of the broad range of managerial and non-formal educational skills needed to manage the research process. (c) The need for close technIcal collaboration and support with other research and operational groups addressing similar or related problems.
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(d) The need to reorient both administrators and researchers to the concepts and practices related to this research approach as a means of "facilitating" their support and optimizing contributions. (e) The development of a supportive research mechanism designed to provide support at the regional level to action research activi ties undertaken by the health services.
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CHAPTER VII CONTRIBUTIONS TO HEALTH SYSTEMS DEVELOPMENT
The contributions of this project should be viewed in the light of its impact on approaches used to improve the effectiveness of the health services and the skills of the health workers. These contributions can be seen at several levels. I. The communi ties in Carigara The communities in Carigara involved in the project learned how they could take an active role and contribute to the improvement of their own health situation. Their successes and their enthusiasm created a demand in the surrounding communities for a chance to be involved and i ncl uded in the Study. Through their participation in the Study, the communities also experienced an interdependent relationship with the government health services and developed skills in managing that relationship. But most importantly, they developed a sense of purpose and self-confidence by having control over the affairs affecting their communal lives. Another important realization was that group action in the community was a fast and effective means to achieve results in meeting health care needs. 1.1 The health services in Carigara The Study gave the staff of the CEH and the RHUs in the CCA an opportunity to evolve methods of work which optimized their individual and collective skills and resources for the purpose of delivering health services. More specifically, the health workers in the CCA began to view and depend on each other as an interrelated system with clearly defined interdependent roles. Beyond providing primary health care, the RHUs became support centres for the health development programmes of the communities and a vi tal monitoring link between the community and the hl"alth system. For its part, the hospital became the primary referral centre for the RH Us as well as the principal centre for ciinical diagnOSis and public health investigations. It also served as a technical problem-solving and training centre for all CCA staff and a medical supply centre for all the RHUs in the CCA.
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These represented significant shifts in roles when compared with current institutional practices in the health services. Several important steps were taken to ensure that these new roles could be maintained and further developed. These steps were: First, resources, hospital facilities and equipment, e.g. laboratory, paedia tric surgical services and pharmacy were upgraded. Second, the administrative procedures both in the hospitals and in the RHUs, e.g. patient record and filing systems, systems of claims and re imbursements were streamlined. Third, a two-way referral system was designed. Fourth, procurement, control and distribution of medical supplies and equipment in the hospital were centralized. Fifth, an information system reflecting changes in the health status in the CCA was developed. Sixth, joint planning and problem-solving team approach of health workers (the RHU and the hospital) for technical or programme delivery matters was developed. Seventh, the training of health workers as part of the supervisory activities of the more senior staff in the CCA was undertaken on a continuous basis. In this manner, it was prossible for the health services in the CCA to initiate functional integration. Further development and application of the "epidemiological approach" in all RHUs and in the hospital would have resulted in completing a functional integration of hospital and public health service. 2. t'rovincial health system The centre for planning and coordinating the expansion of the CCA Study was the P HO of the province of Leyte. Health development tools and strategies developed in the CCl\ were immediately converted into operational policies and implementing guidelines and merged with the existing supervisory scheme, technical programmes and the design of various other programmes of the PHO.
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The provincial health officer of Leyte adopted the following tools and strategies in the implementation of these various programmes: the CCA Model for developing a barangay health programme; the integrated hospital and public health services scheme; in relation to the above scheme, a concept for the training of catchment area-based trainers responsible for the training of health personnel; and the "epidemiological approach" as a framework for problem-solving and planning. Using a combination of the above-mentioned tools and strategies, the PHO had, as of early 1982, initiated the "partnership approach" to health care delivery in almost 50% of the province's 1327 barangays, exceeding its own planned target of 39.33% of all barangays by 1985. As to the integration of hospital and public health services, the PHO began implementing a nationally coordinated scheme for administrative integration. 3. The regional health system By 1979, the Ministry of Health had adopted health for all by the y... ar 2000 through primary health care as the principal health policy of the country. This policy embodied concepts and practices of health which was similar, if not identical, to those being applied in the CCA. Given an opportunity to implement new national policies through the expansion of poliCies developed in the CC A, health officials in Region VIII prep<1red jointly with all the health officials in the region a regional strategyl. The principal characteristics of this strategy were: (a) To reorient health staff and develop managerial and technical skills at all levels in the region through a series of problem-solving and planning workshops called the manage ment series and the technical series; To improve the regional training centre as an educational support system for regional and provincial supervision;
(b)
I Region VIII, An Organization Strategy and Plan of Action for Health For All Filipinos By the Year 2000, ;'v\inistry of Health Region VIII, March 1980.
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(c)
To develop a monitoring and information syste;n in ~upport of primary health care and intersectoral strategies for health development; and To encourage the initiation of action research activities at all levels to ensure continuation of developmental process begun in the CCA.
(d)
During the last quarter of 1980, the RHO developed a separate plan to accelerate the process of integrating hospital and public health services in the region. It. The Ministry of Health
In 1977, the Ministry of Health had prepared its second Five-year National Health Plan covering the period 1978-1982. At that time, both policymakers and planners in the Ministry oegan to turn their attention to the problems of effective implementation of planned health programmes throughout the country. The oasic question was how to improve the management system particularly in the hospitals and in the RHUs including the BHSs. In early 1978, the Ministry of Health convened an intersectoral group composed of the UP-Institute of Public Health (UP-IPH), the Development Academy of the Philippines (DAP), the National Economic Development Authority (NEDA) and WHO to develop a strategy for improving the implementation of health program;nes of tne Ministry. Coincidentally, in September 1978, the Member Governments of WHO adopted primary health care as the principal approach for the delivery of health care particularly among the under served. The group convened by the Ministry proposed that the Ministry adopt a partnership approach to achieving the goal of health for all Filipinos by the year 2000. The Carigara Study was the only practical example where such an approach to health development was being developed. It was, therefore, based on the experience of this study that the intersectoral group of the Ministry of Health formulated a national strategy for expanding and further developing the experiences which had already begun in Carigara. This became known as "An Organizational Strategy and Plan of Action for Achieving Health for All Filipinos By the Year 2000, A Private, Community and Government Partnership through PrimarY Health Care". The concept of partnership and its strategy for implementation became part of the national health policy in October 1979. In May 1980, the strategy was presented to the World Health Assembly of WHO as the
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Philippine Government's contribution to approaches for achieving health for all by the year 2000. The strategy supported a decentralized and ''OOttom-up'' approach to the development and improvement of the health system. It, therefore, delegated the development work to each RHO throughout the country and established a framework for each region to learn from the experience of another (please refer to page 12, Part II of the document entitled" An Organizational Strategy and Plan of Action For Achieving Health For All Filipinos by the Year 2000 - Partnership Through Primary Health Care" for a description of Region VUI's strategy). Its philosophy embodied the basic principles of health for all by the year 2000 - primary health care policies and adopted assumptions about health and health work which were similar if not identical to those which formed the basis of the Carigara Study. The main features of the strategy are. the adoption of a human resource development programme at national and regional levels; the development of monitoring and evaluation systems at all levels; the improvement of the health planning system and procedures at all levels; the development of a health information system designed to support the planning and assessment of effect ive health programmes; the improvement in the policy formulation process; the development of intersectoral planning and assessment systems; and the promotion and support of health systE'ms rE'search at all level s. 5. At the international level The Carigara Study became a fiE'ld study centre for international groups wishing to observe new methods and approaches in health manpower development and organization and implementation of primary health care. For this reason, Region VIII was a host to four international workshops which addressed important issues. These workshops were: (a) (b) The WHO Interregional Workshop on the Development of Health Teams in Rural Health Work held from 22 to 27 October 1979; The IntE'rnational Primary Health Care Workshop sponsored by the South-East Asian Medical Information Centre (SEAMIC) in February 1981;
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(c)
(d)
An interregional Workshop on Primary Health Care sponsored by WH0 from 21 to 25 April 1'J81; and A WH0 Interregional Workshop on the Development of Health Statistics System at Family, Community and Primary Health Care Levels.
In addition to these workshops, Region VIlI and the study area became a centre for technical exchanges of foreign public health officials visiting the Philippines and of heads of international institutions or programmes concerned with health. From an international perspective, the study area had contributed to the development of a process of technical collaboration among deve loping countries.
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CHAPTER YIlI CONCLUSIONS
I. General The Carigara project was not concerned with designing and testing health care programmes for the rural areas. Rather, it was a study to develop the means by which the communities, the health services and other sectors could design, implement and evaluate jointly community health development programmes. These means included the development of methods and procedures for: reorienting health staff; social preparation and community organization and development; lay reporting; and planning and evaluating the utilization of health resources at the community level. When used together over time, these methods and procedures can SE'rve not only to initiate and sustain a partnership between the health system and the community but also to constitute a monitoring system reflecting changes in the following: (a) (b) (c)
(d) (e) (f)
(g) (h) (i)
(j) (k)
health problems of the community; socioeconomic factors contributing to health problems; health status of vulnerable groups in the community; effectiveness of health technologies and health care stra tegies; contributions and effectiveness of health-related sectors; contributions and effectiveness of various community organizations; support requirements from the higher levels of the health system role and function of health workers at the community level; level of problem-solving and technical skills of health workers at the community level; targets and indicators used to moni tor implementation and the impact of health programmes; and assumptions about the design of health programmes.
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This information could then form a basis for the UP-lHS and other health manpower and training institutions to plan the curricula and develop training/teaching methods compatible with the needs of the rural population; for the Ministry of Health to design and implement rural health programmes relevant to the changing needs of the population; and for the community to assess its progress in health development • .l\t this stage, conclusions cannot be made on the performance, findings and usefulness of the monitoring system to its users. The project's main achievement during its five-year period of implementation
was the design and testing of the various components of the monitoring system in a given area. Conclusions can, therefore, only be drawn from this experience. These results are presented here as they relate to five major areas of concern. 2. The community Each community in the project area demonstrated the unique relationship between socioeconomic factors and the health of its p<'pulation. The balance in this relationship had been and continue to be influenced by the rapidly changing environment. Two conclusions could be drawn about the relationship between the community and its environment. First, families and communities have different capacities and skills to manage a given environment contributing in various ways to their own health development. Some of the areas where differences in the capacities of the communities were noted included: (a) (b) (c)
(d)
skills for planning and problem-solving; knowledge of, and access to, information about resources and opportunities to solve problems from sources outside the community; creativity in conceptualizing new solutions to old problems; and skills in communication (oral and written) particularly with organizatIOns or agencies outside the community.
Second, the BN is an effective system not only in providing health care to the individuals in the community but also in communicating information and initiating community action for social and e~'onomic development.
-'
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uther factors related to the community's capacity to respond to its environment were: (a) (b) (c) (d) (e) the nature of the material and physical resources in the community; the prevailing pattern of problem-solving and decision-making procedures in relation to the social and political structure of the community; the methods and practices used for allocating resources and opportunities to community members; the self-image and prevailing values and traditions which guide community actions on socioeconomic and health services; and the number, composition, functions, and capacities of the existing formal or informal, temporary or permanent, organization in the community.
3. The health system Several conclusions can be reached aixlut the relationship between the health services and the community and about the capacity of the health services to respond to the health problems in each comlnunity. First, the health services today tend to emphasize the provision of medical care to the community. This approach often precludes opportunities for developing community self-reliance in health and for influencing intersectoral support for health development. Second, current decision-making procedures, particularly those for planning and implementing health programmes at the primary level of the health services, do not take into account the changing socioeconomic factors related to specific health problems in each community. Consequently, the effective use of health knowledge and resources cannot be realized. Third, without information about changes in socioeconomic and health factors in the community, effective community health programmes cannot be designed or implemented. Fourth, various organizational systems in the health services such as planning, training, supervision, information and referral are inappropriate to support community health development programmes planned at the primary level.
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4. Health manpower The Study showed that from the health worker's point of view, the planning and implementation of health programmes jointly undertaken with the community required reorientation, clarification of roles and functions and development of new skills for all health workers. The principal conclusions were: First, the reorientation of the health staff could be more effectively achieved through a process of individual and team assessment of programme and service impact. Second, the use of the "epidemiological approach" as a planning method and the procedure for primary health care required skills in the following areas: planning and problem-solving; applied epidemiology; public speai<ing; organizational assessment of the communities and other agencIes; analysis and synthesis of health development plans and activities; facilitation of groupproolem-solving and decision making; clinical assessment and management, particularly related to common diseases and conditions; and physiological effects of selected drugs, pharmaceuticals and traditiondl medicine. Third, the use of new methods and procedures for planning community health programmes indicates that the nurse and midwife would play a greater role in problem-solving and facilitating health action at the community level whereas the municipal health officer would play an increasingly technical and collaborative role in addressing the heal th problems of the communi ty. 5. Management of R&D Action research has proven to be an effective approach for developing new methods and procedures and strategies for health development in the context of the situation they are to be applied. It has the following advantages: (a) It unites all those affected by a problem to participate actively in designing and implementing its solution. (b) It provides a framework for continuous non-formal education (learning by doi ng).
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(cl It provides a basis for combining theory and practice. (dl It allows and encourages development of creative solutions. (el It provides a basis to test solutions in the context of real situations. (fl It permits and encourages active participation and contribution of "outside" expertise and knowledge. Some of the disadvantages arel (al It requires discipline and commitment to achieve objectives. (b) It assumes a consensus about objectives among all participants. (c) It requires mutual trust and openness to learning on the part of all the participants. (dl It requires the support of a decentralized management system. the
Some principal concl us ions on the management of this research are: First, it should be managed at the level where the research is tC'king place. Second, those who manage the research should be knowledgeable in the subject matter as weJJ as in the method used. They should also have the following skills: (al (b) (c)
(d) (el (f)
(gl
facili tation; problem-solving, planning and monitoring; ability to communicate clearly (oral and written); content analysis; knowledge of sources of external resources; conflict management; and synthesis of findings.
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Third, that a research team (including all participants) requires extensive preparation to ensure the development of a common understanding and a consensus on problems to be solved and types of solutions to be developed, including identification of the roles and responsibilites or the expected contribution of the participant. Fourth, that strong central level support is required for: (a) (b) (c)
(d)
inter- and intrasectoral arrangements; access to external sources of knowledge and expertise; development of conceptual framework; and broader use of research findings.
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CHAPTER IX RECOMMEND AnONS
During the five years of its implementation, the project succeeded in designing and testing the components of a monitoring system for both the health services of the Ministry of Health in Region VIII and the UP-IHS. Based on the findings and conclusions of the Study, three major courses of action are recommended. First, the products of this study should be implemented initially in the BHSs, the RHUs, and the outpatient departments of the district hospitals. This action will provide the means needed for the UP-IHS needs to monitor health development continuously and for the Ministry of Health in designing their respective programmes. Additionally, implementing the products of the research will be an important step in institutionalizing primary health care in the rural areas and in initiating the functional integration of the RHUs and the district hospitals in a contiguous catchment area. Second, developmental activi ties at the community level should be continued. Specifically, these activities include: the development of methods and procedures which can be used by the families and the communities to manage their health development activities; the development of training methods and materials aimed at developing problem-solving, decision making and communication skills in the families and in the communities; and the development of improved methods or instruments for collection and analysis of family and community health information. Third, developmental activities in the catchment areas of a hospi tal and its satellite RH U should be continued. Specifically, these activi ties might include: the development of planning and decision-making methods and procedures at the RHU and hospital levels which are designed to support health programmes planned and impiemen,,,,d with the community;
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redesigning of methods and practices of supervision at the RHU and district hospital levels to support the development and implementation of community health development programmes; and redesigning of the health information and reporting system to support the planning, implementation and evaluation of health development programmes in the communities. Fourth, developmental support activities at the provincial and regional levels of the Ministry of Health should be continued. Specificaly, these activi ties might include: the development of simulation training programmes for health workers to improve planning, problem-solving and decision-making skills. The planning framework of the "epidemiological approach" could be used as an analytical framework for this purpose; the revision of logistic support systems to support community health programmes at the primary level; the development of training methods intersectoral planning for health; and and materials the for
the development of institutionalized support for health systems or research activities in the region (see proposal in Annex 13). Fifth, the internal research and development capabilities in the IHS should be promoted for the purpose of developing the cur riculum and designing training materials and teaching methods using information generated by the monitoring system.
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REFERENCES
Aleta, Isabel R. "A Case Study on Community Health Development Through Strengthening of the Health Care Delivery System and Research and Development," WPR/PHC/79.2. Sanzon, Amparo. 2 October 1978. "A Partnership Approach to Health Care."
Bonifacio, Armando F. "The Institute of Health Sciences: A Strategy for Health Manpower Development," in Development of Health Manpower for the Rural Areas. Quezon Ci tYI UnladJahi Foundation, 1979. pp.43-54. "The Institute of Health Sciences Research and Development Programme, A Retrospective Report," ICP/PHC/OOI, da ted 7 April 1980. Cruz, Juanito C. de la. Emmanuel 'VI. Solis, Rolando O. Borrinaga and George L. Dorros. "Health Programme Analysis: An "Epidemiological Approach", October 1981. _".---:_ and the Chiefs of Hospitals. Province of Leyte. "A Position Paper of the Provincial Health Office and the Hospitals of the Province of Leyte on the Ministry of Health Health Services Integration", September 1981. Damian, Augustus Jr. C. "The Institute of Health Sciences and the Future," in Development of Heal th Manpower for the Rural Areas. Quezon Ci ty: Unladlahi Foundation, 1979. pp. 95-109. de Veyra, Federico Jr. and San Miguel RHU staff. communications.
Personal
Domingo, E.O., E.D. Tiu, P.A. Peters, K.S. Warren, A.A.F. Mahmoud and H.B. Houser. 1980. "Morbidity in Schistosomiasis japonica in relation to intensity of infection: Study of a community in Leyte, Philippines." Am. J. Trop. Med. Hyg., 29(5): 858-867. • "Note for the Record, Preparation of Protocol R de D IHS, --""Ta-c-I'o"';'"b-'an," ICP/HSD/003, 9 January 1979. Dorros, Sybilla (;. "Initiating Popular Participation at the Barangay Level: A Case Study of the Community Health Development Project at Carigara", September 1978. 16 pp.
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Enrile-Santiago, Carmen. "The Preparation of a Community towards the Development of a Holistic-PartnershIp Approach to Health Care System", 1979. Estrada, Horacio Co "The Realities of Philippine Medical Education," m Development of Health .'vlanpower for the Rural Areas. (Proceedings of the Scientific Session, 32nd World Medical Assembly (1978, Manila). Quezon City: Unladlahi Foundation, 1979. pp. 17-21+. Fevidal, Prudencio Jr. and Jaro RHU staff. Personal communications.
Johnston, M. and S. Suprehatan. "Report of Indonesian Team on Visit to the Philippines, II April - 10 .'<Iay 1979". Ministry of Health Region VIII. "An Organizational Strategy and Plan of Action for Achieving Health for All Filipinos by the Year 2000 (Partnership Approach to Primary Health Care)". March 1980. Misagal, Arturo and Capoocan RH U staff. Personal communications.
Nugroho, Gunawan. "A Better Life for Leyte," World Health Magazine, February 1980. "Progress Report on the R 6c 0 Project, March 1978".
Pami, Gerardo and Carigara RH U staff. R /I(
Personal communications.
D Documentation Unit. Towards Alternative Approaches to Health Development in Under served Areas (A Retrospective Report on the Research and Development (R 6c Dj Program of the UP-Institute of Health Sciences 1977-1980). Tacloban City: R <Ie D, UP-Institute of Health Sciences, 1980.
R 6c D Project Report. "Experiences in Community Health Research and Development at the University of the Philippines-Institute of Health Sciences (Tadoban)," August 1977 • • "An Interim Report on !\Iternative Approaches to Health ---'De=v":'"e:";I'-o"'prnent in Under served Areas" (A Joint Project of the UP-Institute of Health Sciences and the Department of Health Region VIII Office), November 1977. R 6c D Staff. "Annual Report to the Population Center Foundation", October 1978.
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Redulla, Dometillo and Bernardo de Guzman. "Report of the Carigara Emergency Hospital on the Five-Year R &: D Project" and personal communications with the Carigara Emergency Hospital staff. Romualdez, Alberto Jr. G. "Progress Report (l January 1978 to 30 April 1978)." R &: D report submitted to the Population Center Foundation. _ _.....,.,-..;. "Research and Development as a Component of the Institute of Health Sciences," Lecture delivered during the 32nd World Medical Assembly, Manila, November 1978. Till,
Editha and Barugo RHU staff. "Action Research," Chapter 9 of the book Methodology in Educational Research (?),pp. 174-189. (xerox copy in the R &: D file). Personal communications.
"Progress Report; Research and Development in Primary Health Care", Tacloban, Leyte, Philippines. I January to 31 December 1980.
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ANNEX 1
MAP OF REGION VIII (EASTERN VISA YAS, PHILIPPINES)
.C!::J -,.
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ANNEX 2
THE PHILIPPINE HEALTH SERVICES SYSTEM*
Health facilities under the Ministry of Health The general description of each health facility will identify its service, diagnostic and treatment capabilities. I. Barangay health stations (BHS) These are the satellite health stations of the RHUs manned by a retrained rural health midwife. It is established at a strategic barangay to serve an average population of 5000 (usually the "catchment area" is composed of three or more barangays). The BHS delivers the basic health services, i.e. maternal and child health/family planning-nutrition, health education, environmental sanitation, control of communicable diseases, school health, dental health, simple and ambulatory medical care, normal deliveries and first aid. The diagnostic services in the BHS consist of simple urine examination and collection of specimens - urine, stool, blood smear for rr.alaria and sputum smears which are forwarded to the RHU-main health center (RHU-MHC) for laboratory examinations. 2. Rural health unit-main health center (RHU-MHC) The RHU-MHC, located at the poblacion of the municipality, is manned by a health team composed of the rural health physician (RHP), the public health nurse (PHN), the rural sanitary inspector (RSI) and the rural health midwife (RHM). The composition of the RHU team depends on the population of the municipali ty.
*Presented as one of the documents during the WHO Interregional Workshop on the Development of Health Teams in Rural Work, Tacloban City, Philippines, 22-27 October 1979.
- 86 -
Annex 2
The RHU-MHC also delivers the basic health services mentioned in relation to the BHS. The treatment services are only of the outpatient and ambulatory type. The diagnostic services available in this type of health facility are examinations of urine, stool (for intestinal parasites), sputum microscopy (for tubercle bacilli), blood (haemoglobin, cell blood count (CSC) and parasites). 3. Community hospital and health centre (CHHC) This is a health facility initiated by the Philippine Medical Care Commission (MEDICARE) and established in remote municipalities. Its staff are appointed by the MEDICARE and are based in areas without RHUs. In areas where there is an existing RHU, the CHHC is staffed by the RHU personnel. The CHHC has a bed capacity ranging from 10-15 beds. Its service capability is the same as that of the RHU (basic health services); however, it delivers not only outpatient but also inpatient general care. The diagnostic service capability is the same as that of the RHU, except for blood typing and x-matching. 4. Puericulture centre (PC) This health facility is under the technical supervision of the Ministry of Health. It is administered by a PC board which is composed mainly of members of civic and religious groups. It is staffed by a physician, a nurse and midwives appointed by the PC board. Where a physician is not available, the RHP also serves as its physician. The PC has a bed capacity of ten or more beds, mostly for .'1aternity cases. Its service, diagnostic and treatment capabilities are, however, the same as those of the CHHC. 5. Emergency hospi tal (EH) This is a rural hospital with a 25 to 50-bed capacity. It has a complete staff - chief, emergency hospital; resident physiCians; nC.rses; a pharmacist; a dentist; a medical technologist; X-ray tecnnicians; etc.
- 87 -
Annex 2
The basic health services rendered by this hospital are: maternal ar.d child health/family planning-nutri tion, health education, dental health, medical care (outpatient and inpatient), normal deliveries and first aid. The diagnostic services are more or less complete, i.e. urine, stool, sputum, blood microscopy and chemistry, urea, urine, creative sugar and cholesterol), pathology (anatomic, microscopy of smears from urethra, throat, rectum, etc.); diagnostic radiology (chest, fracture, kidney/ureter/bladder (KUB) and intravenous pyelography (IVP». General surgery and obstetrics and gynaecology are also being done in this hospi tal. 6. The provincial hospital In the provincial capital, you will find the provincial hospital. The provincial hospital usually has 100 beds wi th a fully departmentalized medical department, a surgical department, a pathology and bacteriology department, a radiology department, an outpatient department, etc. It has a complete staffing pattern. The basic health services being rendered are the same as those of the emergency hospital. [n comparison to the basic health services rendered in the RH Us, the provincial hospital does not deliver environmental sanitation, control of communicable diseases and school health. Its diagnostic services capability is more adequate than that of the emergency hospitals. Diagnostic examinations available are b1'.cteriological examinations-cul ture, antibiotic sensitivi ty, electrocardiogram (ECG) and basal metabolic rate (BMR). The treatment capabilities, particularly inpatient medical care, include general and specialized care in medical and surgical cases and physical medicine. 7. The regional hospital The next health facility higher than the provinCial hospital is the regional hospital usually located in the city. It is a 300-bed capacity hospital with complete staffing. Its basic health services capability is almost the same as that of the provincial hospital; however, its diagnostic and patient treatment services are better than those found in the provincial hospi tal.
- 88 -
Annex 2
8. The medical centre On top of these various levels of health facilities mentioned above the medical centre found at the national level in the Metro Manila area. It is a specialty hospital and centre with at least 1+50 beds. It makes use of sophisticated medical technology requiring highly skilled staff and expensive equipment. Diagnostic services and treatment facilities are complete. IS
The medical centre receives patients referred by the lower level facili ties in the rural areas who need specialized diagnostic and treatment facilities not available either in the provincial or in the regional hospi tal.
ORGIIN I ZA T I ON CHART HEALTH REGION NO. V III
r I Administrative Division
Regional Health Di rector
'---------1 I Budget and Finance Division
Special Health Services
1 I
I Technical Division
I Regional Training
I Regional Laboratory
Regional Hea It h Training
Hospital
Center
8
\D
CD
r Provincial
Health Offices
IH L{
I City Health Offices
Provincial Hospi tal
I
~General Hospital Erner gency
Hospital
~
I\)
-91/92-
Annex 2
ORGANIZATION CHART PROVINCIAL HEALTH OFFICE
Provincial Heal th Officer
Assistant Provincial Health Officer
I Administrative Section
L Technical Section
Field Health Services (Rural Health Units)
- 93(9 4 -
Annex 2
ORGANIZATION CHAR T MUNICIPAL HEALTH OFFICE
I r Public Health Nurse
Municipal Health Officer
I
I Rural Sanitary Inspector
I r Rural Health Midwife
I Rural Health Midwife
-
95/~
ANNEX 2
Fui1LUOIU and actlvltie$
Qh
~.I'JHjCI~1 Health Officer (MHO)
Public Health Nurse ,PHN) (I)
RY"al II)
s.nltarlllU~ctor (RSI~
Rural Health Midwife (RHM) (I)
III
Determines the health needs of the commlllity
oetermine$ the health rweds of the commoolty Orsar'lizes the beranit&)'
DetermInes the environmental health needs of the oomml.Rty Orpnius the barangay I\e.lth centre
Asses,.. the ht'alth
need, of the community (2)
," 'II
OrgiUUitet the heallh centre
barenuy
(2)
(2)
Organizes the baranRay
health centre OJ
health centre (3) Plana, Implementl and
sef\'IC~
Prepares the health programme fQr
Prepares the proaramrne lor the nursing and midwifery healv.
(3)
Prepares the environmental sanitation services programme
tht"
community (')
evaluates the health services in the commW!.lty (.)
servlou ,:.)
Performs aPPropria1e JctlvlOeS to meet the health needs of the cQmmUl'lity Vlltlilte~
Performs appropriate activi ties to meet the health needs of
(.)
Performs appropriate activi ties to meet the health needs of the commmil)' E'oIL\ua\~ health sC!'vh:::u in the commW\lty
Trains and supervl!es
the community
,,' 16,
e'ola\l..Iat\.on ot
."'Iealth
services the RHU llaJf In
m (6)
EvL\\Mtes ~e health services in the communit)' 0r,anl~s.
(l)
(')
Records and rc.poc'b the health serviceJ in the commuruty
I\~Slsts
UKlducIS
(6)
t1l1!ir work with hilot VOltJl1CHfJ and other I"~m~! of the community
and nalw.les training of~
Super\ti:tO. sanitation service! In the commlWlity SU<;h as prblise coUectloo, water diunfectlot\, etc.
(1)
~'Jpervhe! the HI
RHU staff
(7)
their work (I)
And1:s the RHM In tralnt", and KUldlng voh..,teers !luper vises midwives and keeps hit
(7)
Assbts in recruiting and guiding volunteers Maintains adequate methods of recording ."d reporting of environmental san!. tatlon servl~s
,81
CQQrdlnalOili th. CQmmunlty health ,ervlces
(S)
i'ldlndua! records 19' Eruurel that All required recOfds and reports we ac:cumpllshed and sd.mUted propeorJy I
(0)
MAIntain. acIequI.te
methods of record inS and repartin& of nl.l',ln& octl\tltl~
I'~
Keeps the personal record. of nat! '!.ces 1<0 U that 1upplles land equipment :1eeded by the umt are properly requisitioned, I,r,I!"H_maintain~ and ke;>! 3CCOunte<! lor
(10)
Monltors the status of supplies and equipment ensurlns their adequacy Checks elfe<:1lft utlllu,Uon
,]1)
(II)
of 1UppI'-es and equIpment
,-
- 97 -
ANNEX 3
THE UNIVERSITY OF THE PHILIPPINES-INSTITUTE OF HEALTH SCIENCES: AN INNOVATIVE STRATEGY FOR HEALTH MANPOWER DEVELOPMENT AND DlSTRIBUTION*
The University of the Philippines Institute of Health Sciences (UP-IHS) was established in Tacloban City, Leyte in 1976 as an experimental medical school with a curriculum which aimed at developing community-oriented health workers. The Institute seeks to contribute to the development of various levels of health manpower which can be functional in the rural communities. Its objectives ar~ (a) to produce a broad range of health manpower to serve the depressed and underserved communities in Region VIII comprising of the islands of Leyte and Samar; and (b) to design and test programme models for health manpower development that would be applicable in other parts of the country, and hopefully, in other countries similar to the Philippines. The UP-IHS is an outcome of an increasingly resonant expression that the delivery of health care in developing societies needs a large pool of primary health care workers. This expression arises from the understanding of the broader concept of health, which is, that health includes not only the condi tion of the body but also of the environment. This broader concept focuses on the reality that the delivery of effective health care requires a "team" of health workers supporting each other with different levels of expertise and interest. Included in this team is the community itself which must play an active role in the promotion and maintenance of its health. The students at the Institute are recruited primarily from target communities which are badly in need of health workers. These students are nominated by their barangays; the selection of nominees is, in fact, made in an open barangay meeting. Upon nomination, the student, with
*From "Towards Alternative Approaches to Health Development in Underserved Areas," a retrospective report of the Ministry of Health-IHS Research and Development (R &. D) programme 1980.
i
- 98 -
Annex 3
the consent of his parents, pledges to return to the community to render service as a health worker. This pledge operates as a type of social contract entered into by the student and his barangay. The barangay, in turn, pledges to provide a measure of support to the student while at the Institute. This support includes transportation subsidy, provision of medical kits and community participation in the health programme that the student will set up upon his return to the barangay. In a larger sense, therefore, the beneficiary of the Institute is not the student alone but the entire barangay. This relationship builds upon the principle of "active partnership" between the Institute and the rural communities. In fact, major decisions in the nomination as well as the recommendation for a student to go on to the higher training modules offered by the Institute are made solely by the barangays. The curriculum of the UP-IHS is unique. In one complete programme, it can produce an entire range of health workers with vary ing levels of expertise and interest, from barangay health workers to midw ives, nurses and full-fledged medical doctors. The Insti tute has an evolving "ladder type" currirulum structure with various points of exit and entry (See Figure I). Students admitted to the programme initially go through what is commonly known as paramedic training or formally, the barangay health worker (BHW) programme. This programme consists of II weeks of training covering such subjects as paediatrics, obstetrics, nutrition, comlounity hygiene, sanitation, primary health care, emergency care and rural SOCiology. After one quarter, or II weeks of training, a student receives a certificate as a BHW, qualifying him to be a practising paramedic. If his barangay recommends him for further studies, the student can study for an additional five quarters to qualify as a community health worker (CH W). Completion of this programme entitles the student to the university-awarded Certificate in Community Health. This certificate was originally termed Certificate in Midwifery. The change 111 title
•
- 99/100 -
Annex 3
was necessitated by the fact that the male students did not like to be called "midwives". Moreover, the CH W programme is broader than the standard midwifery programme, because it includes a variety of health and related subjects such as English, mathematics, ethics, community development, fundamentals of anatomy, physiology, microbiology and public health. The courses prescribed for this programme are only partly determined by government regulations pertaining to the midwifery curriculum. A total of two-and-a-half years of studies would allow the UP-IHS scholar to receive a certificate as a community health nurse (CHN). This programme includes instruction in basic chemistry, chronic and communicable diseases, nursing, pharmacology, folk medicine, anatomy, physiology and community organization. After becoming a CHN, the student may proceed and study for a Bachelor of Science in Community Health (BSCH) degree after two more quarters, or become a medical doctor (MD) after an additional twelve quarters of studies. After completion of each training level, students go on a three-month service leave during which time they practise what they have learned. The UP-IHS curriculum is innovative in the sense that the social context of its courses is a real Philippine rural community, and the student body is solicited from that community. The IHS programmes have been designed with particular attention to community needs arising from sociocultural, economic and political conditions in the rural areas. This system of designing programmes assures that the graduates of the UP-IHS maintain continuity with the communities they are expected to serve. Their competencies are tailoured to fit the context wi thin which they are to be applied. The UP-IHS also believes that as persons, the students have roots in the rural areas supporting the assumption that they would be inclined to go back to serve their home communities.
- 101/102 -
Annex 3
FIGURE I. THE LADDER TYPE CURRICULUM STRUCTURE OF THE UNIVERSITY OF THE PHILIPPINES INSTITUTE OF HEALTH SCIENCES INTERNSHIP ...----DOCTOR OF MEDICINE MEDICAL BOARD
1
!-
DOCTOR OF MEDICINE PROGRAMME ~
(12 quarters with alternating service to the community)
SERVICE LEAVE
•
SERVICE LEAVE
I--------IIJ-
BACHELOR OF SCIENCE IN
COMMUNITY HEALTH PROGRAMME (2 quarters)
SERVICE LEAVE
f------iIJ'--_________-11]r :
COMMUNITY HEALTH NURSING PROGRAMME (4 quarters)
COMMUNITY HEALTH WORKER
PROGRAMME (5 quarters) llARANGAY HEALTH WORKER PROGRAMME (l quarter)
SERVICE LEAVE
--~==========:J ' -_ _ _ _-;-_ _ _ _.J 1 .....
1. HIGH SCHOOL GRADUATES ' - - - - - - - - 1 2 . BARANGAY NOMINEES 3. SCHOLARSHIPS
LEGEND:
Quart(>t Service leave
11 .... eeks
indefinite period of service in the community aft~r every pro~ramme.
- 103 -
ANNEX 4 HEALTH MANAGEMENT QUESTIONNAIRE
I.
Title Health programme; Barangay:
IL
Policies - regulations Describe briefly all the relevant policy statements and regulations/guidelines affecting the problem area. Mention references for each statement.
1Il.
Problem description (J)
Describe how you arrived at defining the problem area. Give an idea of the criteria and selection process undertaken. Describe how the problems affect the community. Describe the problems which you encounter in providing care/services related to the problem area.
(2) (3) IV.
Programme administration (I)
Planning - How did you arrive at a plan for this programme or service you are providing for this particular problem area? Objectives and targets - List, if any, the objectives and targets you have established for your programme related to this particular area. Methods and approaches - Describe the way you provide health services for this particular problem area in terms of: (a) (b) (c) (d) (e) public health measure diagnostic approach curative measure referrals follow-up
(2)
(3)
- IOIf -
Annex If
(If)
Supplies and equipment - Describe the type of supplies and equipment used for the particular problem area in terms of their adequacy, quality, quantity and cost. Major accomplishments and expectations - Describe what you consider to be the most important accomplishments of the service or programme you are conducting and tell why. Describe also what it is you expect to accomplish in the coming year.
(5)
-
V.
Community reactions (I)
Describe the positive community reactions to the service you are providing. Describe the negative community reactions to the service you are providing. Describe the attitude of the community towards the critical health problems you have identified.
(2)
(3)
VI.
Related programmes or services (I)
Describe the activities of other agencies (government or private) which relate to the problerD area. Describe your working relationship with these agencies, if any.
(2)
Vii.
Staff Describe the category and number of staff under your supervision. Mention briefly the activities they are actually performing in relation to this problem area.
VIII.
Budget and costs (I)
Prepare a sample of your annual budget ior one year of operations of your service or programme. Prepare a list of estimated costs for one year of operation of your service or programme.
(2)
- 105/106 -
Annex Ii
IX.
Monitoring and control In relation to the problem area identified: (l)
Describe the way in which you monitor and control the activi ties of the staff. Describe the way in which you monitor the health problems in the community. Describe one or two samples of how your monitoring and control procedures have affected your service or programme activities.
(2) (3)
x.
Evaluation (l)
Describe the criteria you are currently using to evaluate the service or programme you provide. Describe the method of evaluation and the frequency of evaluation of the service or programme you provide. Describe the action you intend to take as a result of recommendations made after an evaluation.
(2) (3) XI.
Opportunities Assuming that you were working in an ideal situation in terms of adequacy of staff, supplies and equipment and facilities, describe the activities you might additionally undertake.
107
ANNEX 5
CUI a< SURVEY FORM ESt e:
Name
Remar ks
I.
2.
3. 4.
5. 6. 7.
8.
9. 10. II.
12. 13. 14.
ANNEX 5
108
· ~
·
• • • • • • • " ~ • • 0 ~
• • • ~ > • • c " 0 0 ~
· ~ ~
0
0 0
~
0
~
~
~
~
~
~
U 0
U
L U
u
•
0
0
~
•
0
"
Z
0
<:
0
z
0
L
C;
-
':>JI~Je
~4~1;)1.1 l4~1;)ff',
"11 Jt.>UJ,;I
J
s,sou~elp/uo~ss~Jdwt
'>l U !tqduKlJ S;)Uoq
ul"s U~ald5 J~'" ~
1
~ ~l.n I
SlH!'Hl
"pu(>,~
J I (>4
109 -
Annex 5
3.
Soc i oeconomi c ------------Means of subsistence; Agriculture; rice cassava corn vegetables Ha. Ha. Ha. Ha.
Type of landholdings: Total landholdings: Total cultivated land:
Cash income: Animal husbandry; cows own!
sharing;
buffaloes goats chickens ducks Fisheries; Trade: Labourer; Others; Family expenditure: rent food clothing Ii gh t water school fees medical expenses social obligations
Cash income: Cash income; Cash income: Cash income: Cash income:
Total annual fami ly income: Total annual expenditure: Savings/deficit: Remarks:
-
I 10 -
Annex 5 -------
If.
Environment ---------Housing: brick hal fbr ick wooden bamboo Waste di sposal: human waste: animal waste: Garden: Place for animals: Water supply: own we II: comnunity well: tapwater: spring:
garbage: sewage:
5.
Culture:
------
(customs/habits/bel iefs)
Pregnancy: Prenatal care: taboos on food: sex:
customs: beliefs:
Delivery: indigenous midwi fe: taboos: Postnatal: Child rearing: breast-feeding habits: feeding habits: taboos on food: If child is sick: taboos: beliefs:
-
II I
Annex 5
The number s are re I a ted No. 4 is Car los Montoya; No. ,\oIon toya.
to 4
page 107, e.g. on on page 108 refers
page 107: to Ca r los yellowish in column
Put a + only for positive sign or symptom, e.g. hair, put + in column hair, a palpable spleen, but + spleen. Ask the complaints. fever diarrhoea cough haematuria thus: No.4, has means that cough. ~ake
respondent about his your own coding, e.g. F D
C H, etc. In column complaints: FOC, he has: fever, diarrhoea and
This is your own impression of the respondent, e.g. sick, or thin or weak, etc. Use your own coding. This is your diagnosis a member 0 f the f ami 1 y. Remarks: ------when you examine
This 1 S to r emi nd you of some important sign or s ymp torn, e. g • i f the ch i J d 1 S pale, weak and you think of anaemi a or tbc, you write: tbc? or anaemi a + etc. and arm circumference are anthropometric
Weight, height informat ion.
Before you do a survey, collect some basic information on health, e.g. infant mortality rate (I~) or disease, etc., to "guide" you for certain direction, e.g. if there IS malaria, look for a + spleen. If schistosomiasis is pre v a J en t, J 00 k for the s e s ymp toms.
-
I 12 -
Annex 5 ------
Sum up the diagnos i s and get an idea of the diseases in the corrrnunity to help confirm the diagnosis. Review the + s~ptoms and get the percentage. Count up the s~ptoms in the complaint, to give you a rough the health s~ple at this time. Count up findings sample. the impress ion regarding the column idea 0 f ~
to suppor t your health of the
The information on children (right side part of the page) gives you the infor:nat ion on I~ and death among older children. Specific inforrnation could be gathered after processing the data, e.g. if you have found many cases wi th H (haernaturia), try to lind out what the underlying cause of the information is, e.g. possibility of schistosomiasis H.
-113/114-
ANNEX 6
BARANGA Y NETWORK
Baranga;r Council (BC)
Purok
--
Purok
Unit
Unit
Unit
Unit
Unit
Unit
Unit
Unit
Unit
Unit
N.B.: Each unit is composed of 10-15 families.
- 115/116 -
ANNEX 7
Fl\MI LY SHEET*
No. 0f
children born a live:
Obstetrical cases
No. of children at present: No. of chi Idren died
Gynaecological cases: Miscarriages
Fami ly Planning
*Family
sheet
is composed of:
A.
deve lopment
sh€_et and
B.
health
sh~et.
- 117/118 -
Annex 7 A. Development Sheet --~-----------------
--------quarter
---------quarter
---------- ---------quarter quarter
ater: ------
---------~----------
1 19 Annex 7
B.
Heal th Sheet
.', ..
" • ..
"
.. , ,. , ~
r. "
,.
~
" ,.
· .' •
..,!'
" ~'
D.
N.
-, ., ..
" ~.
R N. .~
" .\.. ., .. " " '
, "
.... ,!
... "
• ."
c
, ~
'.!
~
..... -
• ".. .. ,- - ... :.- ::
~
- ...
~,
• .,. -
~
- .. f.o ". ,.
, , r. 5.
" I. .. , ,. r.
" •
•
"
0
•. •
.'
D' x'!'
•r •
..
.' < •. "' ,. -, .• ' " ..D' .....
=~ u
• • "'
" ,
1!'
.. •
•
Q
::
~
- .......................
~;-.':
120 -
Annex 7
• " ~ ~
,. ~
.. " • >. • < A ~
"'
"' . • .. r.
"
.. u ~; ~.
~
"~
, Po • :. .e 0
0 y
" ~
~ ~
• •• w.
., X'
,.
.'
".' ",
O~
v' ., 0=
W' · ·
-
-
........ " <: ,
" " "
.', . O•
... w• X~ .~
,.
~
, '" "', .... "":'
- .. ,.. ........
~
~--
- 121/122 -
Annex 7
A.
Explanat ion of the Deve lopment Sheet
The purpose of the development sheet is to know if there is an improvement or deterioration in the community. For example: (I) In the first quarter, the wall of the house was made of bamboo, and in the fourth quarter, they were able to replace the bamboo with bricks. This is improvement.
(2) In the first quarter, the family had 10 acres of cultivated land, and in the fourth quarter they had only 4 acres left. This is, of course, deterioration and could be the explanation for less income. Why the family had to sell the six acres must be examined separately. This information on socioeconomic development can give us a better insight into the health problems of the family/community.
House wall rooms
I st quarter bamboo 3
2nd quarter half bamboo II
3rd quarter bricks 4 none clean pen
4th quarter bricks 4 +
kitchen yard place for animals
none dirty in the house
none dirty separate, in the yard open well wood
well-kept pen improvement development healthy well kerosene
water energy
river
wood
covered well wood
-
- 123 -
Annex 7
B.
Explanation of health sheet
The numbers on the left side of the tables correspond wi th the numbers of the family members (family sheet). How to complete this table: Suppose member No. 6 fell ill on 6 January with the following symptom: fever (F). Probability: The mother gave aspirin, then entered F and so on. January 2, 3 I 2 3 4 5
If
5
6
7
8
9
10 F C D FC Fever Cough Diarrhoea Fever + Cough FD - Fever + Diarrhoea P - Pain
6
F F Il'l 1lF> )(
F - Fever. Self-medication F - Fever. Treated by the RHM
fFl- Fever. ® - Fever.
Treated in the RHU Treated in the hospital
)( - Patient died. If the patients were treated in the RHU or in a ho,pital, the diagnosis/treatment and cost would be entered in the book of the barangay network (BN) (a community organization set up to help the community in implementing the primary health care programme).
- 124 -
Annex 7 Suppose that after a period of time, there is an indication that, say, diarrhoea is increasing, use a separate sheet: a diarrhoea sheet to collect specific information on diarrhoea.
- 125 ANNEX 8
THE GROWTH CHART
- 126 -
Annex 8
c-------------
HH~++rrHH~++rrHH~ m
~
;;I
z
:::
~
• !
f
..•
~
! i
'r "
~
iI
Ii' !l l" • .- l • i ! I I • % ~
~
~
.i
G') ::0
o
I----;;
j ~
• 1" iI p
~
~
::tl o """"9 ::t ~ » ::0 If
-t
~
f
•
-t
~_~_~~
I __ ~ ________ ~ _ _ _._J
- 127 -
ANNEX 9
MANAGEMENT OF THE INFORMA nON SYSTEM FOR THE COMMUNITY HEALTH PROGRAMME
Family sheet WHO collects Family Head Mother
Unit Sheet Unit Leader or Designate
Purok Sheet Zone Leader
Baranga;t Sheet Baranga;t Councilmen for Health Sheet Semi--annual
H~w
Record Sheet As often as necessary To be designed Home
Sheet Quarterly or as often as necessary To be designed Unit leader
Sheet Se mi --annual
collected Frequency of collection Method Update Where stored
To be designed Purok Leader
To be designed Barangaz:: Councilman for Health
- 12& -
Annex 9 R &: D UNIT DEVELOPMENT DEVELOPMENTAL INFORMATION REPORTING REQUIREMENTS R &: D Field Staff to IHS Committe, Manila
Cri teria
Information required
Source IHS R&D staff MHO R&D staff
Frequency
I.
Ability to generate
Submission of proposals
Ad hoc Monthly
R&D 2. Financial Submission of budgets management and financial state ments or inGenerating funding dependence sources
3.
Ability to plan, implement and evaluate R&D programmes
Reports or plans Reviews
R&D staff
Quarterly
4.
Staffing pattern completed
Staff report
R &: 0 staff
Quarterly
5.
Staff traifled to carry out functjons
Staff report
R &: D staft
Quarterly
6.
AbiJity of R &: D staff to link with other agencies
Staff report
R &. Ostaf!
Quarterly
7.
Developing a reporting system Publicity
8.
- 129 -
ANNEX 10
THE "EPIDEMIOLOGICAL APPROACH"
Introductory note A simple planning method was designed with the RHU staff to guide both the community and the midwife at the health centre in the preparation of a community health programme. The contents of this annex describe this system of analysis, the procedures used and contain an actual example of how the analysis was made by one midwife. The illustration has not been modified and is an actual representation of the midwife's level of comprehension at the time the list was accomplished. The planning method was designed to be completed under the supervision of a PHN. Its repeated use would thereby result in progressively more accurate technical statement over" period of time. The contents of this annex were originally prepared as a workshop training material entitled, "The Epidemiological Approach", by Dr Juanito C. de la Cruz, Emmanuel M. Solis, Rolando o. Borinaga and George L. Dorros. I. Description Through a process undertaken, for example, by the Capoocan RHU staff, an epidemiological approach was evolved with the following steps: (Annexes 10 - A to IO - G - Sample Outlines) Describe the policy and procedural base for the programmes as follows:
1.1
Directional outline:
Spell out among other things the following (see Annex 10-A):
the mission, policies and goals of the Ministry of Health; basic directions or instructions addressed by the Mini stry of Health to the PHO, the hospital, the RHU or the BHS; the RHU team's own objectives; special instructions to RH Us, etc.
- 130 -
Annex 10
1.2
Programme strategy outline (see Annex 10 -B) The programme strategy outline contains statements on the basic strategies, technical tasks, descriptions of procedures and processes necessary to im p1ement and realize the missions, policies, goals, etc. contained in the directional outline.
2.
The community Characterize the community through the following;
2.1
Socioeconomic health profile (See Annex 10-C)
The socioeconomic health profile charts the weather pattern, major economic events, major social events and other necessary data about the general way of life of the people of a barangay, municipality or hospi tal catchment area over a period of time, i.e. one year. On top of the chart should be placed an overlay - preferably a plastic acetate sheet - on which the number of cases of health problems over a period of time, i.e. one year (Annex 10 -C, "Data Collated from the Family Health Sheet") is graphed. 2.2
Spot map
(See Annex 10 -D)
The spot map plots the latest information about a barangay, municipality or hospital catchment area that concern the health worker or the health team. Among these are; roads and pathS; major rivers, streams and creeks; houses and public buildings like BHSs, schools, churches, etc.; geographical distribution of the population; sanitary facilities; health problem areas, etc. 3. The population groups Describe the population groups, their corresponding health problems and interventions through the Problem Statement Outline (Annex IO-E).
-131-
Annex 10
3.1
Area of concern - Select the illness/symptom; the health problem.
3.2
Problem statement Levell: Individual Determine population at "risk", age group, location in the communi ty and period of time. Family probable cause/root of illness/symptom Community related health illness/symptom and socioeconomic cause of
Level II: Level Ill:
3.3
Programme review
What did we learn during our implementation of activities and programmes addressing the problem(s) last year? or What can we learn from problem(s) last year? 3.~
our
experience in addressing the
i{evised plan
What are we going to do (approaches and tasks) to solve the problem(s) at the following levels? individual family community 3.5 Support requirements
What support do we need from the RHU, the hospital, the community or other government and private agencies? How are we going to get that support? 3.6 Monitoring
What information do we need to know to implement our solutions to the problem(s)?
-152-
Annex 10
Where and how will we get the infor mation? How often should we get it? 3.7 Research and development/areas for further study
What assumptions are we making about this/these problem(s)? What questions remain in our minds about these assumptions? 4. Formulation of a primary health care programme
Formulate a primary health care programme of a community using the following outline with a description of headings. For samples of primary health care programmes developed using the above method, see Annex lO-F. 4.1 Affected group
This refers to individuals who are health "risks" classified according to age groups such as 0-6 years old, 7-14 years old, 15-55 years old and 60 years old and above. 4.2 Health problems
The narrative under this heading includes actual descriptions of the health problems of the affected age groups and summarizes the problem statement and programme review columns of the Problem Statement Sheet. 4.3 Programme description
This is an outline of a year's health and health-related activities, which takes into consideration the socioeconomic and cultural pattern of the community and intra- and intersectoral efforts and community hvolvement in promoting health and preventing/curing/rehabilitating health prOblems. This outline is based on the Revised Plan Column in the Problem Sta tement Sheet. 4.4 Support requirements
This is a list of specific support reqLi,r"ments needed for Daran6ay health development programmes which are available and can De tapp"d from the health system, from other government and private agencies a,-,d from the community.
- 133 -
Annex 10
4.5
Programme monitoring
This is a list of specific indicators of success/failure for each activity outlined under Programme description. This is based on the Monitoring Column in the Problem Statement Sheet. 4.6 Research activi ties
This is a list of activities which need further study/investigation or new assumptions needing validation given the planned activities, support provided and the specific monitoring indicators. For this approach, the reference materials include the RH U in: (a) (b) (c) (d) (e)
(f) (g) (h) (i)
(j)
(k) (I)
(m) (n)
Individual experience Group or team experience Consolidated data from family and health sheets RHU plans/programmes Family ties Dispensary records Administrative orders Job descriptions/assignments of staff Provincial health plan Minutes of provincial or RHU staff meetings Consolidated reports Administrative accomplishments (New performance appraisal system (NPAS» Organizational chart Vi tal statistics per barangay RHU~
Outside the (a) (b) (c)
Municipal development plan Plans of other agencies Provincial development plan
While intended for the barangay level, this problem-solving and planning guide can be utilized to suit the needs of other levels of the health system, i.e. municipal, provincial and regional.
- 134 -
Annex 10
This approach utilizes simple tools that facilitate the management of health services, mobilization of intersect oral support, as well as the education of community members to health problerns and their determinants. A general model for developing a barangay health programme appears in Annex 10 - c. Competencies of families and communities for health care are then defined both from the health professional and layman's viewpoints. These serve as the basis for step by step upgrading of self-help care by the communities and the support capacity of the health and health-related agencies.
- 135/136 -
Annex 10
FIGURE 2.
RECOMMENDED MANAGEMENT PRIORITIES (PROBLEM AREAS) OF THE DIFFERENT LEVELS OF THE HEALTH SYSTEM
incial Health Systems RHO
Croups
hment Areas P H 0
Groups
!
icipal Systems
- 137 -
ANNEX IO-A
SAMPLE FRAMEWORKS/INSTRUMENTS FOR HEALTH PROGRAMME ANAL YSIS USING THE "EPIDEMIOLOGICAL APPROACH"*
I. Directional outline 1.1 Principal commitments of the Government for health development The mission of the Ministry of Health is to improve the quality and quantity of health care especially to the under served areas at a cost the community and the Government can afford. To give direction to this miSSion, the Ministry of Health has declared that its goal for the next two decades is "heath for all by the year 2000", which is interpreted to mean that all citizens should be able to lead a socially and economically productive life.
1.2
Policies of the Ministry of Heath and the RHO To involve communities in a partnership with other government and private agencies. To go into intersectoral coordination with other government and private agencies. To integrate hospital and public health services. To provide promotive, preventive, curative and rehabilitative services (according to the degree of competence). To implement primary health care that should include at least: education concerning health problems and the methods of identifying, preventing and controlling them;
*Prepared tn collaboration with the Leyte.
RHU staff of Capoocan,
- 138 -
Annex IO-A
promotion of food supply and proper nutritIon, an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; promotion of mental heal tho To promote dental health care. 1.3. Instructions for, and objectives of, the RHU personnel These are: To To To To To improve the health status of the community; render essential health care; utilize the referral system; initiate intersectoral activities at the local level; participate in community development activi ties.
Specific tasks include: Maintaining scheduled travel within the catchment area; Facilitating community meetings on health and related activities; Attending staff conferences; Supervising indigenous health workers; Participating in income-generating projects (in the pilot barangays). 1.4. Personal objectives of health personnel To improve the health of the community; To utilize community community projects; resources for health and related
To encourage mothers engaged activ i ties, etc.
lJl
income-genera ting acti,,; ties;
To encourage the use of proper Isafe garbage/waste dispc>dl
- 139/140 -
ANNEX IO-B
PROGRAMME STRATEGY OUTLINE
National/regional/provincial levels In order to achieve its goals (see directional sheet), the Ministry of Health has outlined the following approaches for improving its services, improved managerial processes for health development focusing on primary health care as the major approach to achieve health for all by the year 2000; health manpower development to include the development of relevant basic and continuing education programmes for all levels of health workers; health system development to include the improvement of effectiveness of existing health services and the formation of needed support mechanisms; and development of appropriate health technology and research.
P~AA\ME
:> nt, TEGY OUTL j NE.:
~
LEVEL
------~----~---
---.~---.-.-----------
..
-------------Task. onCe Histoc-Yj phy,ieai e>l.lInllnatlon, e.I. weight, blood pressure (6P). Abdominal palpiu.tionl tetanus toxoid il1Th.Jnization (Jut tritnl!sterJi ad ... ice on diet, hYlpene lH.d activities History; physical examination; laboratory e~ami~ationl blood and udne; lollow-up of BPI medic'1.tlonl; adviee on diet and ",ctivitie. Aseptic attandance of del ivery; care 01 mother and Int.nt belor. and alter del ivert
Pro'lr<l.lrrTlO'! \!arern .. l .. "J o.lid He_It'! Pre"aCit] : - Nor'TU I:
Str .. tegy
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Horroe d,,\ i V<:'f Y
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r~~j"r~t"Jfl
{Home or cl iniel Home visit - daily for firs' weeki once per week for four week, (Home or e1 iniel - I 'co 6- ye"t,; onee per month
Accomplishmotnt and s\lbmission of bint! certilicues Vital e'I. ePj temperature, abdomin"l palpI(lltion; ",erlne.1 inspection; care of inlant Hi.toc-)'; phy,ical e>l.amination, e.g. ",eight; IrrmoJniz.tion; adVIce on diet Conducts mIItner'. classes once e .... r)' six; months &t clinic; regul .. r mothec-s' "..tlnl Cla.ses OilC. "'ary year with I'I'II)nthly meet in,s Healilt educulon. dewvrmlnu IlI1n.Il'li~ation;
PO$lnao.l:
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periodic weighing
Supplement ... , (eedin,; promotion of Green Revolution
Family PI,l"nins
PremaritAl counsell in, trltersectoral activities with PClPCCM MotiYation ... ! actlyities. Home ... Islts
T_-d ..., monthly lectures at RHU Clinical "istorH physic ... 1 ..,d laboc-ator), '..:.... in4tlon.; supplies contc-.ceptl ..... to acceptors ... her delivery Oi'cussi~t
..,. ~ ..,. >-' >-' f\)
with couple
HanIe ... i.iu of hmi I)'
O'.custion • .,lth couple Acc"""tistment of referral forms
planninl dropouts Referrals to l.HJ/hospit ... I, cOI'I'IpI iClIt ions and abnomal cue, - Case_finding lind treatment:
Comnun ic:ab I e Oi seases
Clinic con$ultations
History; physical u:aminationj labora.cory .x ....ln.tion; pre.crlption of drugs
HIlme visits ~
E'resenta.uon:
IrnRJniz&lion twice a year FebC'l.l ... ry/M&rch, July/August
8CG; dipntheri./pertuuisfteunus {OPTlj polio; clio leral typha i dl par a typho id/ an t i gen (CTPA) dur i ng rainy se ... ,on, Monthly recordin, and cltaning 01 selected diseases; investIgations of outbreaks Demonstratiol'l on ",ater-sealed toilet cOnstruction and installuionj discu"ion, (Individual oCIroup) on sanitary disposal of wutes; periodic inspection of I!llcreta dispo,al Periodic inspection of .,ater sources Perl~dic
Epidemiol(lgical survei ilance ~virorvnenul
~ o I
>-'
Proper disp(lsal of ellcreta
SAnitation
tD
\/later u.nitation Food hygIene
laboratory examinatiorlS for store owners and classes for stoteowners I per year
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- 157 -
ANNEX lO-F
FORMULATION OF A PRIMARY HEALTH CARE PROGRAMME
I.
Affected group 0-6 years old
2.
Health problems Most common conditions by order of frequency~
upper respiratory tract infections (UR TI) (40 %) diarrhoea (25 %) malnutrition in children (l0 %) bronchi tis (5 %) parasitism (5%) 2.1 UR Tl and bronchi tis common in Zones 2, 3 and 4, where known tuberculosis cases reside frequent during the rainy months (from October to January) diagnosed bronchitis cases consult at a late stage of disease after self-medication by parents 2.2 Diarrhoea distributed in Zones I, 3 and 5 swampy area with stagnant water due to obstruction by nipa groves least number of functional water-sealed toilets improper water collection and storage frequent during the dry season (March and April), which is favourable for drying and preserving fish and shrimps; sun-<lrying technique attracts lots of flies provision of Oresol to ail cases; 100% recovery rate ob3erved
- 158 -
Annex lO-r
2.3
Malnutrition in children distributed in Zones 3, 5 and 6, where 50 % of preschoolers are affected common during the planting and weeding months of July and August (also an off-fishing season); known as lean months when families generally have no income.
2.~
Parasitism sporadically distributed in barangays common during the fish and shrimp season (January to July)
3.
Family profile of affected children large family size (8-10 members) come from monthly income group of Pesos 300 and below absentee parents (out of the house earning a livelihood) hence improper food preparation and storage, improper water collection and storage poor environmental sanitation~ improper waste collection and disposal; non-functional water-sealed toilets or no toilet at all
4.
Community factors coastal barangay sources of income~ fishing and agriculture fiesta in August (a lean month) yet expenses for social obligations incurred BN~ linked wi th the health staff unit leaders given training in Oresol preparation and distribution to families
5.
Programme description January Organization of mothers in Zones 2, 3 '-'ild 4- for the purpose of demonstrating how .. 0 prepare tamarind-luya-calamansi (TLC) solu don to :-elieve cough and cold using their own availaole resources
- is? -
Annex IO-F
February
First round for the immunization (EPI)
expanded
programme three
on
Immunization of children aged months with BCG, polio, OPT
to eight
Training of unit leaders for Oresol preparation and distribution March ; Organization of mother's class in Zones I, 3 and 5 for discussion am (a) (b) (c)
(d) (e) (f)
(g)
common herbal preparation for common diseases the need for steam inhalation with a return demonstration the three basic food groups, proper techniques of food preparation and storage proper techniques of water collection and storage proper method of waste disposal and collection, particularly the importance of the demonstration of construction of water-sealed toilets family planning methods
Home visits to Zones 1. 3 and 5 by the RHM and the RSI for follow-up Supplementary feeding in Zones 3, 5 and 6 by the BNSs and the Catholic Relief Services (CRS) April ; Operation Timbang (OPT) with unit leaders Meeting of mothers in Zones 5 and 6 for discussion om (a) (b) {d the three basic food groups food preparation and storage importance of water-sealed toilets
- 160 -
Annex 10-
r
(d) (e) (f) May
waste disposal and COllection water collection and storage Family planning method
· ·
Second booster dose for polio Home visits to Zones 2 and 4 by the RHM to give health teachings on herbal preparation and use, demonstrations on steam inhalation and cheap sources of Vitamin C in the locality
June
:
campaign for backyard and communal gardens management Coordination with the farm technician (FMT) on demonstrations of gardening techniques and provision of seedlings Mid-year collation information sheets of community health
July August
Second round for EPI, DPT' and BCG to school entrants
· ·
Third booster dose for polio Supplementary feeding in Zones 2 and 4 by the Home Management Technologist (HMT)
September
Organization of a community assembly by the BN and the community for the purpose of planning/establishing income-generating activities (piggery and citrus planting); reviews of BN organization and problems and health programme plans and activi ties : Organization of Fishermen's Association (ten members per association) in coordination with the Bureau of Fisheries and Aquatic Resources (BFAR);
October
-
161 -
Annex 10- F
Enough supply of medicine for cough, fever and colds to be procured for the coming three months November Home visits by the RHM to children with UR TI and bronchi tis in Zones 2, 3 and It; this month is the peak level of the disease; attributed to absentee parents working during the harvest season Collection of information data for the purpose of analysing them and redesigning strategies or programmes for the coming year
December
6.
Support requirements RHU Technical support of MHO, PHN and RSI Logistics Visual aids handouts, posters, flip charts, contraceptives Antipyretics cough expectorants and decongestants, antihelmintics supplements Oresol No. 50 packets Weighi ng scale - 10 Hospital Vaccines 8 ampoules of BCG 8 vials of DPT 10 vials of polio 12 ampoules of BCG 8 vials of DPT 5 vials of polio Ministry of Agriculture Technical support; logistics -FMT - HMT - Seedlings, fertilizers
-
162
-
Annex IO-F
Municipal government BNS Parish Priest - CRS BFAR Technical support (spawns) MLGCD - 10% barangay development fund to finance income-generating projects in the barangay. MECS - Campaign for construction and utilization of water-sealed toilets Green revolution and community beautifica tion BC Passing of barangay ordinances on environmental sanitation campaign BN Unit leaders, purok and Zone leaders 7.
Programme monitoring: (a) (b) (c)
(d) (e) (f) (g)
(h) (i)
(j) (k)
Decrease of 50 % in morbidity cases, i.e. U R TI, bronchi tis, diarrhoea, malnutrition and parasi tism Elimination of second and third degree malnutri tion in children Acceptance by families of water-sealed toilets resulting in increased construction and utilization Immunization of children aged three to eight months initiated by parents; unit leaders assist in case-finding Acceptance by families of Oresol through their respective unit leaders Community beautification and sanitation; no stray animals and flies around Implementation of supplementary feeding by the BNS, HMT and CRS Utilization by families of backyard and communal gardens including herbal medicine I ike the TLC solution Practice by families of proper food preparation and storage, water collection and storage and waste collection and disposal Active participation of the community in the implementation of specific programmes Augmentation of food supply and income during rhellonths of July and August through income-generating activities like piggery and citrus planting
-
163/164 -
Annex lO-F
8.
Research activities (a) (b) (c) Ability of the family to sustain continuing feeding activities after agencies withdraw their services to malnourished children Ability of the community to sustain support of health development programmes in the community Effective management of income-generating projects
- 165/166 -
fu'l}iIDC 10 - F &ranny 8a.iue Plan 01 Action for Primary Heal1h Care
ImpLementation Programme
T i rn e
Table June
Objecti..-e
Proll"arnme COntent
Activity
Target sroup ,
MethodoJol)'
Persons involved
R~c. ConnT~nn Requiremenu
Expected Res.ults Jan Feb
----Aug
Mar
Apo-
May
July
Sept
Oct
Nov
De<:
Communlr.r:-
FOIilill progam!11'
based
.. improve. ment of
.. maternal and
.. AP consul-
-pregnant
hea11h itldud\Ac the qua-
dlild heallh
tation and homevishs
women
- casefinding
.. MW', PHN, SN, CHI(
.. ManPOwer
- ino-cased case-finding thereby meeting targets
- ldentlfication of
lity of life In 1h.ecommt.nity
hJ&IWIsk mother.
.. a.ttendance at deUvery caUl
- expecW1t
-DOS
.. MW, PHN, CHW
mothers
:- improved heaJth status of women in labour; ellmination of c.ampllcations during labour .. decreased post-partum complica.tioN!
.. post-partum folJow~
.. mother who has just delivered .. newborns
-nome visits
.. M:W, PHN, CHW
I
.. we11-baby
.. consultation/
suponIslon
under I year of age
.. MW, PHN, mo1hen
.. lood bealth to newborns and infants
treatment -home visits
.. wcll-child suptfvisicn
.. 1.4 years
of ale
- COIl$uI-
.. MW, PHN,
.. good health to presd'looJers
"tion/ -home vlIIt>
mothers
treatment
- hilot
lOiiO..-up
- ...&!ned and untrained
- foUow",,",p ofQIeI
-~ MW,PHN
auended by~
bile
-poor cooperation of ~
- deaease in, or eliminAtion
of tetanus neonatorum and puepet""aJ sepsis cases
- regular
meetings - family
planning
- recruitment of new acccptOI"S
- MCRA
- home
- ,\4W, PHN, FTOW,
vlsJ" - casetind.lnB
BN
_ manpower - necativc attitude of
_ increase in me nu~~ of family p1ann.ing acceptors
couples
- follo .... ...yp of
~ MCR~
- hotTie vi~t.s
•
~'I'.
PHN, FTO"',
family planning acceptors
BN
_ deae.ue in the number o! defaulters in family pbnning
- ca.se· Un:Lnc
- 167/168 -
ANNEX 10-F
Implementa.tion Programme ~jective
T i rn e Resource
Tab I e
Programme content
Activity
Taraet ,roup - .ppllcants for marriage
Methodology
Persons involved
Requirements Constl" n
ai ts
Expected Results
Jan ... increased awareness by new
Feb
Mar
Apr
May
J..,.
July
Aug
Sept
Oct
No,
De<:
Commun1!t:based
... premarl tal counselling
p;:oifamme ... nutrition ... dewormlnl
""011"
-lecture. dlscuss~.do-
.. RHU and other
.. vibll aids, manpower
... unavallabi .. lily of
participating
_leo
.'-1 alds
couples of f.l.mily planning thereby applying it durIng
I
mortstr.tions ... 1-6 years old
marriage ... deaease in the incidence of parasltism in the cOmmmunity
- case-
.. 8N, MY. PHN,
finding
eH'II
... antihelmantics, manpower
-lade of supply of ... lhelmintia - lack of
-home visits
-OPT
-0-6 old
)'eM'
-w.~nl of dren quarterly
- BN, M'II.. CH'II
- wei&hlng scofe.
manpower - ME ... food productlon ... 8N, MW. PHN.
supply 01 welahing ocaIe
... identU1catlon 01 malnourished children In tho locality ... improved l\ealth status of 2nd and 3rd degree malnourished children _ deaease in the 1ncldence
- reIIablUtalion of maI-
... lOS of 2nd and
.....Ished children
m_ .. CH'II
... m.npower, ... unavaUablJity of ma.. seeds.
Jrd
dearee
maJ_
vacdnes, visual. ald.
terlab and
resource
person.
nourished chUdren • toilow-up of malnourlslled children
- ~eaI'"
protection .. eN, MW. PHN,
of malnutrition in chIldren in the community
.. 'OS of 2nd and lrd
·ho'!ahh protection
mothers, CH'W
maI-
de&ree
- N1E - food production
nourlslled children
-!!PI
.. lmmunizat.Lon 01 children
-BeG
"'''''
- 8N, MW. PHN, CH"
... manpower, vaccina
-lack of vaccines
2-U months school
.. provide hard immunity in the communi tYf likewise give protectlon to d1e sensitive group
entrants - OPTI and OPTZ .. pallo
- 3-&
months - 3-14 months .. pregnant women
.. tetanus toxoid
- CTPII .. health programme
.. sensitive
areas .. sputum Jection col~
.. suspects,
contacts
.. C.uefinding _home visits
.. 8N, MW, PUN,
.. reagents. s!ides
- unavailabllityof materials needed
_ increase in case-finding
MHO
cases
on pulmonary
tuberculosis
- 169/170 ANNEX 10-'
Implementation
Proarwnme Coml1Uli9:~
Objective
Programme cantttnt
Activity
Taraet group - referrals to X .....y cen ....
---
Resource
Methodology
Persons involved
Requiremer)ts Constraints
Expected R....lts
-------------_._--Time May Table Jan Feb Mar
---Dec
Apt
June
July
Au,
Sept·
()ct
Nc·..
-ref.. ral
- active resLs-
- X-ray machlnes
bali<! lleailll
X....y .......1-
tar
rant <:aleS caws
- improved follow-up of cases and referrals to institu-tionaJized treatment
~e
na'lons - treatment of new and old
"""" -fOUD""~ot
- all 1"'1_ monacy tub<rcutosis cases - defaulters - undet , and abo••
- noguJar,
- drugs
- Jo..verlng of lncidence of pulmonary tubetculasIs
mon!hlyl
weekly raloatlon
old",!, - home visits - a:ssessme1t 0/ oues
cases - diMr"-I disease control
- family folders
- re-1rUfment of detaulten - deaea.se in, or elimination of, the incidence of diarrhoea in me locality
- early treat-
cues, both simple and complicated
ment of diarrhoea
- M", PHN, aSl, MHO
- manpower - una.vallabl- Cresoi lity of Oresol
- givin& 0.-1'" patients willi proper
instrUCtions
- reterraJ. to higher levels
to.
6;&-""",
management
THE C .... R1G .... R"'- C.o\TCHM[NT AR£A iCC,,) MODEL FOR OEVElOPL"IG .... &ARA;§.o\Y HEALTH PROGRAMME
Ph..un of Acti'll.tie
Purpc>se
Suattolies
.....,... """'" 4
OIMk;iMtlt.al coSt Penoru ",v~lve-d
Time fnme
r:~ He.aI1h C~~t,}
I. I.
1& c;otnmI.Wty of leadfnNp
Orllaniutlon of - to est:&blish ol ",.,uir
:=:-=~Oh
- tnt' comrru.\ity 11:1 be
{)evcloplTlent of aN and tdection of It'old~ship
structtre ...t..eby people can actiwety p&rtIc.iJll1e in "the p1-.~cation ¥ld ev;Lluation of prasn-mmes projKts .-w:j
di ...idM:I lnto zones of
fIoWCher !P..1bdiride<l into uniu of 10 to i 1 tamiUes udl
2' familial _ch,
.. _by
- roIe5 and functians of leaden M'II!:ddiMat..:J
"'"--
aN C\&irman, %OM" ..... \rit lMdIrs
- RHUuaU ~i •• 6ri1.~
HeUth
m.mben
-community
- zona and IJJU Is
1Jt-
directly ~vi_ by aN c:Mirman
- zone leaders proYlde direct supervision and ludenNp hi indl"lcbs..I '-milles ~ RHU
- laden .-e (Dmmitlad..,SIW_ ... taPPCrt CDmtlU'lity
--l l-'
I-'
acti"''''
~ --l I\)
st.ff and I!t!!:!I!l Captain tadli tate pr-e<edinl str&teales
2.
Comm\#1ity' asse:m)ly
- tD
pC"esef'/t 1:he IMden to 'Ihe tomml¥Uty
- leaders
&1"". en-
- wmation ol B:.;
O)~. .ed to t&lk ill the aaembly
- RHU staU. K:A_ eft.... Heal1tI
1 day
hto. jO..oO
- to aommit Ita IMd~ to participate and
- open !ot\Im • RHU naU faClit.ate strateaies tnaltiDned
-
5UppOrt tomrnu'\i ty
activities IL
-
.............
...."''-Ien
Brlpde members,,,,,,,"
J>
\PrOjeCtS •
~mnwS~ieets
Implemented in ,_to community needs) I.
~ I-'
!!!!!!:!I!L mee-mp
- 1;;» be
ab&e to priG--
- chain,*, of orpnl-
- 1armuIaI:iI:In of lDr~t..lt
rime prvparnrnes and pi., out .ctivi ties
ution. &1IlSWd bJ RHU/ltadJo,,,. Health Bripd., fad.1itates
............
- RHU st&1f
- muimwn time-table
-ornc.n of theorpniutian in the community
""~ attcI-..Itation pro)ec1s lilt at
- PesOs 100.00
fplusl_-
, ___ re.ourcel
0 I 0
,..... In
meetln& of lea~ twice. month - unit leadl!!rs. astilted by zone leaden. fadlltate: lrit meetings once:A
two~th.5iother
project! {income-
FMRtinc actiYities and a-Ith ~)require mu:laum time to
other agencies
-n::preentat .... 01 p -
prlnteqer...
.........,.... des in ...
..........
~
.....
men..
coml"lll.rlity
......,.,.., iIn'!
comple.te; prajecb
entuated
- 17)/174ANNEX 10-G
~
... g .(
o
.(
z
'" ~
"
E :> E r
~
8 '"
" lin it m .S
i
2 ...:
- 175/176 -
ANNEX 11
COMMUNITY PROFILES
Note:
The data found in the community profiles of the R&D pilot barangays were collated in 1977 from the quick survey conducted by the participating health officers and their staff and from the hospita1/RHU records.
The outline of a community profile contained herein is as follows: 1. Description of the municipality Barangay description Area description Population Socioeconomic profile Occupation Organization Resources Natural resources Human resources Facilities Customs and beliefs Health Environment Statistics
2. 2.1 2.2 3. 3.1 3.2 3.3 3.3.1 3.3.2 3.3.3
4. 5. 5.1 5.2
- 17'i-
ANNEX ll-A
COMMUNITY PROFILE OF BARANGA Y ST A. ROSA
Municipality: &rangay: Municipal Health Officer: I. Description of the municipality
Barugo Sta. Rosa Editha D. Tiu, M.D.
The name &rugo was inspired by a vine that grew in the vicinity c£.lled Balugo. It is said that a Spanish friar finding "Balugo" hard to pronounce changed it to &rugo. Barugo was founded in 1833 by Kasanduk who hailed from Guindapunan, presently a nearby barrio. From a small settlement, it expanded by the influx of more settlers from Guindapunan. Three waves of missionaries came to Barugo, the first of which were the Augustinians, followed by the Franciscans in 1845 and by the Jesui ts in 1852. Barugo is chiefly an agriaJltural town. The Carigara Bay offers an abundant source of marine products. There are two rivers: Himanglos River and Canomantog River. It boasts of its tourist attraction - the Damogdog Beach. It has three elementary schools and one secondary school. It has a Roman Catholic Church and two chapels: Iglesia ni Cristo and Jehovah's Witness. Land and water transportation are available. Barugo is 51+ kilometres away from Tac1oban. It has an area of 53 square kilometres, bounded on the north by the Carigara Bay, on the east by San Miguel, on the south by Tunga and on the west by Carigara. There are eight health practitioners in the municipality: one phYSician, one public health nurse, two midwives and three midwives of the International Bank for Reconstruction and Development (IBRD), all members of the RHU. There are no private practitioners due to outmigration to urban areas and to other countries. However, there are six indigenous healers and 18 hilots.
- IH!-
Annex ll-A
Barugo has a population of 24 5&2 (3759 in the pobladon and 20 823 in the 27 barangays). Its annual income as of 1977 is Pesos 228 946.86. It is considered a fifth class municipality. 2. Barangay description 2.1 Area description Sta. Rosa, named after St. Rose of Lima, is in the eastern portion of Barugo with a river on the south. It has two sitios~ Sucsucon on the east and Dalikyat on the west. It is 8 km. from Barugo along the national highway and is accessible by land transportation. Its origin dates back to the Spanish era when four men from San Miguel built houses in the locality. In 1899, it became a barrio. In 1900, the first school was erected with students mostly adults. 2.2 Population The present population is 10&4 (509 males and 575 females). Dependency level is 61 %. 2.2.1 Sex-age distribution
Age Level Below 1 1-5 6-10 11-15 16-20 21-30 31-40 41-50 51-60 61-70 71 and above TOTAL
Female 8 34 103 145 &4 75 54 49 19 4 0 575
Male 6 31 32 95 105 115 49 45 22
Total 14 65 135 240 189 190 103 94 IL
7 2 509
11
2 1 084
-179-
AnnexlI-A
2.2.2 Educational attainment
Level No education
No. 271 444 282
%
Elementary Secondary College TOTAL
25 41 26 8 100%
87 I 084
There are two schools at present in Sta. Rosa, an elementary and high school; the literacy rate is, therefore, rather high. About 75 per cent. of the population can read and write in their own dialect. 3. Socioeconomic profile
3.1 Occupation Chief source of income;
Farming ~
Other sources:
gathering/copra selling
Distribution of working force (main occupations): farmers teachers fish vendors storekeeper s others Seasonal patterru Planting seasons Lax periods Harvest seasons : 50% 34%
11% 2% 3%
July January February -April August-September November-December May-June
-180Annex l~A
Products: rice cassava corn vegetables coconut sweet potatoes
Sharing of products: 1/3 to the tenant and 2/3 to the owner
2/5 to the tenant and 31S to the owner If the first method of sharing is used, the owner helps the farmer through food provisions and other miscellaneous expenses.
Marketing: Copra is sold to middlemen who in turn sell their product in Tadoban.
3.2 Organizations The existing organizations are. Be
KB PTA Farmers Associations Rural Improvement Club 3.3 Resources Naturab Human: Others; Two creeks serve as sources of drinking water and are used for laundering. The barangay a!so boasts of a river. Potential manpower among the rna)orl ty population belongs to the younger age bracket. of the
An elementary and a secondary school are found in Sta. Rosa. Agency workers of the following agencies also extend services to the barangaYl BAExt MLGCD MECS POPCOM
Health resources found in the area are: BHS with eight barangay satellites, manned by an IBRD midwi1e, one trained hilot and one untrained hilot.
- 181-
Annex 11-A
1+. Customs and beliefs
(a)
Prayer offerings to the souls after harvest time is a custom.
(b) Bananas are planted after lunch so that frw ts grow bigger because the planter has just eaten. (c) Before harvesting the rice, ''tikos'' is practised wherein a small portion is harvested, threshed with the use of the hands, sun-dried, pounded, cooked and eaten. After this, the people can harvest the rest of the rice.
(d) New rice is eaten with sugar cake or "kalamay" as viand so that the subsequent produce will be sweet. (e) The annual fiesta in honor of St. Rose of Lima is celebrated on 30 August. 5. Health 5.1 Environment
Sanitation in the barrio is improving. There are few stray animals roaming in the streets. Ony a few families have blind drainage. Garbage disposal is usually done by burning. There is an on-going campaign to build water-sealed toilets. There is need to look for more sources of water supply in addition to the man-made wells and the two creeks. Most houses are made of nipa and a few of cement and wood. 5.2 Statistics Leading causes of morbidity and mortality are: gastroenteri tis parasitism schistosomiasis tuberculosis Source: Quick Survey, 1977
- 182-
Annex Il-A
Leading causes of infant morbidity and mortality are: pneumonia measles influenza chicken pox Source: RHU Nutri tional status: 1st degree malnourished: 2nd degree malnourished: 3rd degree malnourished: 60 % 30 % 10%
-183-
ANNEX 11-B
COMMUNITY PROFILE OF BARANGA Y BALUD
Municipality: Barangay: Municipal Health Officer: I. Description of the municipality
Capoocan Balud Arturo Misagal, M.D.
Capoocan is 59 kilometres from Tacloban. It is bounded on the east by the Nauguisan River; on the west by the municipalities of Kanaoga and Leyte, Leyte; on the south by the mountains of Minoro; and on the north by Carigara Bay. It is located along the Carigara Bay. The main sources of income are fishing and agriculture with rice and coconut as major products. Within the government set-up, it is dassified as a fifth dass munici pali ty • A number of residents are government and private corporation employees. Others are engaged in fishing, farming, vending, carpentry.
The town boasts of rivers, forests and a bay. It has one secondary school in the town proper and elementary schools throughout the barangays. Land and water transportation are available. There are no private practitioners and dentists. Health manpower resources consist of one nurse and one midwife in addition to one MHO, one nurse, two midwives and two IBRD midwives in the RHU health team stationed in the barangay health centres. Capoocan has a population of 2 I 335 as of 1977. Of this number, 3000 are in the town proper and the rest are scattered in the 19 barangays. The total number of households in the poblacion is 370.
- 184 -
Annex ll-B
2. Barangay description 2.1
Area description
The existence of Balud dates back to the Spanish times. It became a barangay in 1918, and its original settlers came from the Tagalog region, particularly from Cavite. They were fishermen with family names like Grapani, Nicanor, Fernandez, Escobar, Vallar, de los Santos and Madriaga. Balud is the first barangay of Capoocan with a common boundary wi th Carigara. It is bounded on the east by the Nauguisan River, on the south by barangay Balucanad, on the north by Carigara Bay and on the west by Maini t River. It has a land area of 64.96 square hectares or almost one kilometre in length. It has no sitio. The barangay proper is located in one area, and houses are close to each other. It is one-half kilometre away from the town proper. It is located along the national road and is accessible to all forms of transportation. The literacy rate is 80%. This high percentage is attributed to the presence of an elementary school in the community and its accessibility to Carigara and Capoocan which offer secondary and college education. Source: Quick Survey, 1977 2.2 Population The present population is 2691 (1130 males and 1561 females). Number of households Number of families Dependency level : : 310 350 75%
-185-
Annex 11-B
2.2.1 Sex-age distribution
Age Range Below 1 1-5
Female
Male
Total
6-10 11-15
16-20 21-30 31-40 41-50 51-60 61-70 71 and above TOTAL
41 62 198 391 176 281 185 160 30 21 16 I 561
21 107 206 159 157 162 118 131 25 24 16 I 130
62 169 404 550 333 443 303 291 55 45 36 2691
2.2.2 Educational attainment
Level No education Elementary Secondary College TOTAL
No.
%
538 996 834 323 2 691
20 37 31 12 100%
3. Socioeconomic profile Income is derived mainly from fishing.
- 186-
Annex 11-B
Distribution: fisher men farmers employees (government and private) fish vendors and preservers others" Seasonal patterru The livelihood of fishermen is intermittent. A majority of them are in '~asnigan" (fishing boa ts), and they go out fishing during moonless nights and when the weather is favourable. For those who have trawls, they can go out fishing anytime during the month. The methods of sharing of the catch vary~
50 % 10%
50 %
5%
Basnigan: Of the net profit, one-half goes to the owner of the boat; one-half to the employees; five shares to eight shares to the "Maestro'~ 3, 2, 1 share to the "second maestro'~ and different shares to the other employees, according to their type of work. Trawl: Of the net profit, one-half goes to the owner and one-half to the employees (usually one or two only). Marketing: Fish is sold in Carigara, Kananga, Orrnoc, Jaro, Tacloban and in the neighbouring barangays. A small quantity is sold in Balud and the poblacion for local consumption. 3.J
Organizations Barrio Council KB Anak-Bukid Wisernen Club
"Carpentry, nipa-shingle making, tuba gatherers, store owners.
- 187-
Annexll-B
Women's Club PTA Catholic and Aglipay 3.2 Resources Natural: Carigara Bay and Nauguisan River are good fishing grounds. River swamps are sources of nipa. Bamboo and rattan are abundant. About 50% of the population are young and can be tapped for training. Hence, the Management Technician of BAExt is active in the community. Four hilots, three herbolarios and 20 trained first alders A barangay health centre and one elementary school
Manpower:
Health resources: Facilities:
'+.
Customs and beliefs (a) People believe that disease is caused by: (i)
evil spirits in the farm and in the sea;
(il) non-remembrance of prayer offerings for the beloved departed;
(iii)
"gaba" or retribution due to disrespect of elders and wrong doing towards others.
(b)
Other beliefs: (i) Economic activi ty and progress is controlled and determined by God.
- 188 -
Annex 11·B
(ii) Having children is wealth, especially to those who do not even own real properties.
(ill) "Engkantadas" witches) exist. (c)
(fairies)
and
"aswangs"
(ghosts,
Customs (i) Fishermen hold yearly offerings to spirits in the sea who are believed to own the sea resources. A pig is butchered in the boat, its head and innards offered to the spirits and the rest of the meat cooked and eaten without salt.
(ii) Annual fiesta celebration is 16 August, in honor of St. Roque.
(d)
Legend; (i) Most of the residents sometimes attribute some of their misfortunes and ill-health to Umbeng's anger. Umbeng, who was once an ordinary member of the community long time ago, suddenly disappeared. According to some residents, he was taken by spirits living in the big tree found near the Nauguisan River.
Sometimes Umbeng would appear in the form of a big monkey, cat or dog. (ii) It is not advisable to go out of the house during moonlit nights because "engkantadas and aswangs" are searching for victims.
5. 5.1
Health Environment Stray animals are rampant. About 30 % of the families do not have toilets.
- 189/190 -
Annex Il-B
5.2 are:
Statistics Leading causes of morbidity as of 1977 based on the quick survey cough pulmonary tuberculosis colds malnu tri tion fever asthma hypertension toothache
Leading causes of mortality as of 1976, based on the statistics compiled by the Municipal Treasurer's Office, are: pulmonary tuberculosis a vi ta minosi s chicken pox cirrhosis of liver malnutr i tion congeni tal debility cardio-respiratory failure bronchopneumonia acute bronchitis cerebrovascular accident (CV A) hypertension stab wounds influenza
-191-
ANNEXll-C
COMMUNITY PROFILE OF BARANGA Y BARUGAHA Y NORTE
Municipality; Barangay; Municipal Health Officer; I. Description of the municipal ity
Carigara Barugahay Norte Dometilo Redulla, M.D.
The municipality of Carigara is located strategically in the northern part of Leyte. It is the biggest and probably the oldest rr..micipality in the region consisting of 48 barangays. It has an estimated area of II 380 hectares bounded on the north by Carigara Bay, on the south by Amandiwing Mountains, on the east by the municipality of Tunga and on the west by Barangay Balud of Capoocan. Various forms of transportation facilities like jeepneys and buses bound for Tacloban, Ormoc, Leyte-Leyte and other neighbouring towns and barangays pass through the municipality. Its distance from Tacloban is 54 kilometres. The municipality has an abundance of marine and aquatic resources, forests and rivers. There is also a generous supply of nipa, bamboo and rattan. It has three secondary schools in the town proper and two vocational schools. Health manpower resources consist of 7 private practitioners; 4 doctors and 3 dentists; 36 untrained hiJots; 20 herbolarios; and a rural health team composed of one MHO, a nurse, one midwife in the RHU and four IBRD midwives in the barangay health centres and one sanitary inspector. The present population of the municipality is approximately 40 000. Squatters (slum dwellers) are increasing in number in this town. Carigara is categorized as a fifth class municipality. 2. Barangay description 2.1 Area description Barugohay Norte is two kilometres from the town of Carigara. It is named after the Barugohay River which traverses the area from north to south. On the north, it is bounded by Carigara Bay, on the south
- 192-
Annex 11-C
by Barangay Barugohay central, on the east by Barangay Can-omantag, on the south-east by Barangay Parena and on the west by Barangay Gu indapunan. The barangay is reached through a dirt road. Motorized tricycles ply the route from the poblacion to the barangay and vice-versa for a fare of 50 centavos. The original settlers came from the poblacion and bear such family names as Oriel, Oledan, Insigne, Florendo, Digman, Cuevas, Dacoycoy and Macabenta. Migrant families are the Pascuals who were fishermen from Cavite and the Cabillos from Cebu. The settlement was made into a barrio in 1937. The establishment of the Carigara School of Fisheries (1961) and the CEH (1964) created an influx of people into the area. 2.2
Population
The total population of the barangay is 829 (456 males and 373 females). The birth rate is 1.8%, which is low given the national trend of 3.3%. Dependency level is 60%. 2.2.1 5ex-age distribution
Age Level Below 1 1-5 6-10 11-15 16-20 21-30 31-40 41-50 51-60 61-70 71 and above TOTAL
Female 15 30 40 60 35 58 39 48 27 15 6 373
Male 12 46 58 57 63 70 41 39 31 26 12 456
Total 27 76 98 117 98 128 80 87 58 41 18 829
- 193-
I\nnex ll-C
2.2.2 Educational attainment
Level No education Elementary Secondary College TOTAL
No. 332 252 168
%
77 829
40 30 20 10 100%
An average of 60 per cent. of the total population are literate, i.e. they can read and write in the dialect. A number of people attending schools are in the primary grades and in high school. Only 77 people from Barugohay Norte have attended college education. 3. Socioeconomic profile Unemployment is a problem. The School of Fisheries 'lnd the emergency hospital offer employment to about 20 % of the population. Others seek employment in other areas. As such, outmigra tion from the communi ty to the urban areas especially to Metro Manila is high. Distribution of working groups (main fishermen fish vendors employees farmers tuba-ga therers others 30% 10% 20% 15% 5% 20% occupations)~
- 194 -
Annex ll-C
Seasonal pa ttern: "Karayapan" Land preparation: Maintenance and lax period: Harvest: May August-September October "A rnihan" November December-January April
The farmers are mostly tenants, and the land they till are owned by people in nearby towns. Since no landowners have rice or corn farms exceeding seven hectares, the farmers are not entitled to certificates of land transfer as provided for by the Land Reform Programme. Harvest from the sea is divided thus: one-half to the canap, or fishing net, to serve as capital and for maintenance of the fishing boat al.d one-half to the fisherman. Before the harvest is divided, the owner takes his share. When it comes to fishing, employment is sporadic. There is a fishpond in the area covering more than 24 hectares owned by the Movidos. At present, it does not offer employment to the community. Harvest from the sea and farms are sold directly to the middlemen in Carigara; others to Tacloban and to neighbouring towns. Rice is sold by the kilo or by the sack, while harvest from the sea is sold by "kahas" (boxes). -3.1 Organization The BC, Samahang Nayon, the KB, the 4-H Club, and the Legion of :vlary are the prominent organizations. However, only the KB is active; it holds a benefit dance once a week. Funds earned from this activity are used to set-up decorative posts along the road. The BC is interested in finishing a road project once funds are available from the local government.
- 195 -
Annex ll-C
3.2
Resources Natural: Part of the barangay is along the Carigara Bay which is the main source of fish products. The Barugohay River is another source. There is also an abundance of nipa and bamboo in the community. Thirty-two per cent. of the population belonging to the age group 10-19 years old is a potential work force given the proper training. CEH School of Fisheries Rural Youth Development Officer, BAExt IBRD midwife (\1inistry of Health) BNSs, National Nutrition Council of Philippines (NNCP)
Manpower:
Facilities: Agency workers:
the
4. Customs and beliefs 4.1 Beliefs: If a person is destined to lead a hand-to-mouth existence, he (a) will never prosper no matter how hard he works.
(b) (c)
Good harvests from the sea and farms are due to luck.
Savings will make children sick, so it is better not to hoard money.
4.2 Customs: (a) After the harvest season, prayers are offered to departed relatives as a form of thanksgiving. (b) When there is poor produce, farmers invite an herbolario to recite some prayers in the fields.
- 196 -
Annex II-C
(c) Before a new boat is used, prayers are recited in order to drive away bad spiri ts. (d) Celebration of the annual fiesta is held on 16 December in honour of the Mother of Immaculate Concepcion. 5. Health 5.1 Environment Ninety per cent of those who have animals keep them in a pen or tie them. Stray animals are, therefore, not a problem. As per RHU records, 85 % of the population have water-sealed toilets, and 15% have blind drainage. 5.2 Statistics (a) Leading causes of morbidity are: Adult (I)
Infant (I) (2) (3)
(2) (3) (4) (5) (6) (7)
(8) (9) (10)
gastroenteritis wounds asthmatic bronchi tis influenza gastri tis bronchopneumonia parasitism acute tonsilitis acute dyspepsia tonsillopharyngi ti s Hospi tal Records, 1977
gastroenteritis trachea-bronchitis measles
Source~
-197/198-
Annex ll-C
(bJ
Leading causes of mortality are: Adult (1)
Infant (l) (2)
(2) OJ (4)
pulmonary tuberculosis rheumatoid arthritis still birth CVA Hypertension
gastroenteritis bronchi ties
Source: Municipal Treasurers' office, 1977 (e) Degree of malnutri tion I st degree 2nd degree 3rd degree Source: Quick Survey, 1977 138 55 10
- 199 -
ANNEX 11:-D
COMMUNITY PROFILE OF BARANGA Y JUGABAN
Municipality , Barangay; Municipal Health Officer; 1. Description of the municipality
Carigara Jugaban Gerardo Pami, M.D.
Please see page 187 for a brief description of the municipality. 2. Barangay description Jugaban is located in the eastern part of the town. The name was derived from the word "jubag" which means "bulging". It is bounded on the west by Jugaban River, on the north by the Carigara Bay, on the east by San Mateo District and Barangay Barugohay Central and on the south by Barangay Balilit. The original settlers came from Cebu and Bohol. Some of the families are surnamed de la Cerna, Tabada, and lnabangan, to mention a few. They are blacksmiths. 2.1 Population The present population is 1473 (774 males and 703 females). No. of families; Dependency rate;
260 60%
-200AMex 11-D
2.2.1 Sex-age distribution
Age Level Below 1 1-5 6-10 11-15 16-20 21-30 31-40 41-50 51-60 61 -70 71 and above TOTAL
Female 10 32 65 &0 72 75 79 45 20 21 15 514
Male 1& ~5
Total 2& 77 252 177 186 220 277 117 87 37 15 I 473
187 97 114 145 198 72
67 16 0 959
2.2.2 Educational attainment
Level No education Elementary Secondary College TOTAL 1
No. 74 722 589 88 ~7J
% 5 49 40 6 100%
•
The literacy rate of Jugaban is qui te high; 95 per cent. of the total population are able to read and write in the dialect. Majority are studying in the elementary grades and in high school. Only a few of the residents have acquired a coHege education. Source: Quick Survey, 1977.
-201 -
Annex ll-D
3. Socioeconomic profile 3.1 Occupation Low income, unstable jobs and lack of capital are the expressed problems. Distribution of main occupations: farmer fishermen blacksmiths government employees fish vendors others Seasonal pattern: Planting: Lax period: Harvest season: January February March-May July August Septe mber ··October 30%
30 % 3% 3% 14% 20%
The total annual income of the people is Pesos 886 884.05. While two of its residents have an annual income of Pesos 40 000, most of the families earn Pesos 3000; lowest earners have Pesos 600 as annual income. Animal husbandry provides another source of following data are taken from the Quick Survey, 1977: Animals ducks chickens pigs carabaos turkeys goats income. The
No. owned within the community 165 153 123 11 1
1
- 202-
Annexll-D
3.2 Organization The BC is characterized by poor leadership, political conflict and se If-interests. Other organizations:
.,.
KB PTA Neophytes Club Summer Gay Club 3.3 Res0urces
Natural:
The Carigara Bay serves as a natural resource for fishermen. Its shores are a source of sand for hollow-blocks making. Extension workers of the following agencies render services in the community: MSSD Welfare Aid Bureau of Animal Industry (BAl) Municipal livestock inspector MLGCD MECS POPCOM
Agencies:
Heal th resources;
One IBRD midwife of the RHU, one private dentist and a nurse working in the CEH who are residents of ]ugaban • .'\ complete elementary school is located in the community. There is an on-going non-formal education for out-of-·school youth.
,Jthers;
- 203-
Annex 11-D
4. Customs and beliefs (a) Evil spirits are believed to cause sickness. A ritual with the use of "tawas" or cyrstallized alum is done by an herbolario in order to cure the patient.
(b) (c)
Eating fish is believed to cause parasitism. mother is
To avoid cyanosis in newborn children, the prohibited from eating eggplant during her pregnancy.
(d) All closed items in the household such as doors, cabinets, aparadors, jewelry boxes, etc., are opened when a mother gives birth. This is believed to bring normal delivery. (e) When a mother is having difficulty during labour while giving birth, the cause is believed to be "gaba" or retribution. Cocks and fishing nets are taken out of the house while a rnother is giving birth. This is believed to avoid bad luck or bad catch. (f)
\..-oms are placed inside holes of the posts to be erected when building a house. This is done to make the posts strong and to drive away bad spirits. After the house is finished, coins are also spread under the stlircase so that the house will be blessed with good fortune. Rice and salt are the first things to be brought inside the newly-constructed house. This is believed to ensure that the occupants will have food at all times.
- 204-
Annexll-D
5. Health The R.HU records show that the leading causes of; morbidity are: put monar y tuberculosis acute bronchitis gastroenteri tis pneumonia bronchopneu monia whooping cough mortality are: bronchopneumonia pulmonary tubercuiosis malnutri !ion pneumonia hypertension dehydration prematurity
eVA congestive heart disease senility septicimia
- 205 -
ANNEX ll-E
CO:'v1MUNITY PROFILE Of BARANGA Y HIAGSAM
,\IIunicipality: Barangay: Municipal Health Officer: J. Description of the municipality
Jaro Hiagsam Prudencio Fevidal, M.D.
Jaro is 37 kilometres from Tac1oban. It is bounded on the north by the municipalities of Tunga and Barugo, on the north-east by San Miguel, on the south by Dagami, on the west by Alang-alang and on the northwest by Carigara. It is located in the interior part of Leyte. The main source of income is agriculture with coconuts as the major produce. Its annual income as of 1977 is Pesos 4-06 081. Within the government set-up, it is classified as a fifth class municipality. A number of residents are government and private corporation employees. Others are engaged in farming, welding, driving, carpentry, vending, bakery work, rice milling. The town boasts of rivers and forests. It has a secondary school in the town proper and elementary schools in most barangays. Land transportation is available. He".1th manpower resources consist of eight private practitioners, one dentist, two nurses and one midwife, in addition to the RHU health team which has one MHO, a nurse, two midwives and four IBRD midwives stationed 10 barangay health centres. The team has also two sanitary inspectors. It has a population of 36 662 as of 1977. Of this number, 8000 are the town proper and the rest are scattered in the 4-2 barangays. The ;:eta! numoer 0f households in the pohlacion is 773.
In
- 206 -
Annex ll-E
2. Barangay description 2.1 Area description
The existence of Hiagsam dates back to the Spanish regime, although nobody in the community could exactly recall when it was founded and who the original settlers were. The name "Hiagsam" was derived from a wild grass, "agsam" which was abundant in the area. It is the last barangay of Jaro lying in the southern periphery of the municipality of Tunga. It is bounded on the south by Barangay Hibucawan, on the east by Barangay Tuba and on the west by Barangay Magaso, all of Jaro. Hiagsam is almost three kilometres in length. It is composed of the barangay proper and three sitios; Mohon, Kamanuhan, and Kabongahan. It is seven and one-llalf kilometres from the town centre. It is located along the national road and is accessible by land transportation. Source: RHU 2.2 po ?ula t ion Hie present population is 100lj. (562 males and No. of households No. of families Dependency level L80 210 81 % lj.lj.2
females).
-
- 20.7-
Annex Il-E.
2.2.1 Sex-age distribution
.
Age Level Below 1 1-5 6-10 11-15 16-20 21-30 31-40 lJ 1-50
Female lJ
Male 7 . 32 lJ7
Total 11 lJ8
'-
51-60 61-70 71 and above TOTAL
16 25 51 87 92 75 65 20 5 2 lJlJ2
65 73 167 87 58 22 lJ
72 116 160 259 162 123 lJ2
0 562
9 2 I OOlJ
2.2.2 Educational attainment
Level No education Elementary Secondary College TOTAL
No. 261 392 281 70 I OOlJ
% 26 39 28 7 100%
- 208 -
:\nnex 11-E
The high literacy rate of Hiagsam, which is 74 per cent., is attributed to the presence of an elementary school in the community and accessioility to Tacloban Ci ty, an educational centre. \1any of the residents have attended or are completing elementary and high school education; only seven per cent. of the population completed college education. 3. ~ocioeconomic
profile
3.1 Occupation
Income is derived mainly from farming. Distribution of main farmers teachers others* Seasonal 35 12 9 pattern~ occupations~
Planting seas om Lax period: Harvesting: ';'gricultural rice corn crops~
July-August September-October November-December
January-February February-April May-June
vegetables root crops
copra frw ts
do'~estjC
While copra is sold if) the export market, the rest are produced for consumption.
*Cc;rpentry, "tore-keeping.
fish
vending,
copra
business,
.!ub~-gatherlng,
- 209 -
Annex ll-E
Marketing: Tuba (coconut wine) is sold either in Jaro or in Tacloban city and in nearby municipalities. A jug of tuba costs Pesos 16.00 (5-1/2 gallons). 3.2 Organizations BC
BN
KB Barrio Nutri tion Commi ttee Pag-asa Youth Movement PTA 3.3 Resources Natural: Springs are sources of drinking water. Hiagsam River offers good swimming and fishing grounds and is a source of buri (a palm used for making mats). It is also a potential souce of gravel. The river divides the community into upper Hiagsam and lower Hiagsam.
Manpower: The youth comprises a great proportion of the population. They are a potential human resource given the proper training. Extension workers of the following agencies render services in the barangay: MECS ~ASSj)
,VlLGCD
BAExt I')ureau of Plant Industry (BPI)
- 210 -
Annex ll-E
Health facilities and resources are: BHS with eight satellite barangays Hilots: 2 trained, I untrained it. Customs and beliefs
Random
5d.rr.plmg~
(a) To have a good harvest, planting root crops is held between the second and the sixth day after the new moon.
(b) Frui t trees and flower plants are planted on the day after the full moon. (c)
When the moon is surrounded good sign for planting root crops.
wit~
numerous stars, it is a
(d)-\ kcdamay (sugar cake) is placed ;)n the first plot to be planted wi th sweet potato in order to make the produce sweeter. (e) In planting rice and other crops, the farmer must not turn his back as he leaves; otherwise the yield will be poor. (f)
/\n annual fiesta in honour of St. Roque is celebrated on
16 June each year. 5. Health
5.1 Environment Stray anirnals are rampant. water-sealed toilets. Majority of the people do not use
-211/212-
Annex 11-E
5.2
Statistics
Leading causes of morbidity and mortality as of 1977, based on the quick survey, are:
\
....
MorbIdity tuberculosis malnu tr i tion scabies parasitism anaemia asthma hypertension eczema
Mortality pulmonary tuberculosis malnutri tion second degree 10 third degree 6 35 cases 16 cases
- 213-
ANNEX ll·F
COMMUNITY PROFILE OF BARANGA Y CANAP
Municipality: Barangay: Municipal Health Officer; 1. Description of the municipality
San Miguel Canap Federico de Veyra, Jr., M.D.
The beginnings of San Miguel can be traced back to the middle part of the thirteenth century when two adjacent settlements were formed. One was along a brook called Libtong and the other was at the mouth of Sapiniton River. The latter was called Sabang meaning "mouth of a river". The fishing industry in Sabang flourished, and the settlements grew bigger until the time when the Moro piracy and depradation reached Sabang. The residents moved inwards reaching Libtong. At the turn of the century, the settlement was transformed into a pueblo (town) named after St. Michael, the Archangel. However, due to poor revenue collections brought about by the Revolution of 1898, the town was made a barrio of Alang-Alang in 1903; in 1920, it was transformed back into a municipality. San Miguel is 48-1/2 kilometres away from Tacloban. It has an area of 12 square kilometres bounded on the north by Carigara Bay, on the south by Alang-alang, on the east by Babatngon and on the west by Barugo. The main source of income is agriCUlture with rice and copra as the principal products. Within the government set-up, it is classifed as a class five municipality with an annual income of Pesos 136 855.09 (1977). The town boasts of waterfalls such as Bente Falls, Taghavele Falls, and rivers, one of which is Sapiniton river. It has one elementary and one secodary school in the town proper. Elementary schools are found in every barangay except in one. Land transportation is available.
- 214 Annex Il-F Health manpower resources consist of two private practitioners. The RHU has a complete staff composed of one health officer, one nurse, one midwife, one sanitary inspector and two IBRD midwives stationed in the barangay health centres. As of 1977, the total population is II 000 with 2794 in the pobladon and 9096 scattered in the 21 barangays.
2. Barangay description 2.1 Area description Barangay Canap was formerly called '~nis" which means "forest". Originally, it was a forest with only five houses. People from neighbouring barrios like Sta. Rosa in Barugo came to Canap to farm, particularly abaca. In 1937, wi th a considerable number of residents, the s~ttlement was transformed into a barrio. Barangay Canap is located on the western side of San Miguel. It is 1.5 kilometres fro m the poblacion and is accessible by land transportation. 2.2 Population There are 473 residents with a ratio of 1;1.3 female to males. Dependency rate is 68 %. 2.2.1 Sex-age distribution Age level Below I 1-5 6-10 Female 4 9 19 21 33 10 26 27 25 18 3 205 Male 7 II 22 19 30 26 48 47 30 15 3 268 Total II 20 41 50 63 36 74 84 55 33 6 473
11-15 16-20 21-30 31-40 41-50 51~0
61-70 71 and above TOTAL
- 215 -
Annexll-F
2.2.2 Educational attainment
Level No education
No. 118 194 147
%
25 Ifl 31 3 100%
Elementary Secondary College TOTAL
llf 1 084
Only three per cent. of the total population have college education. Majority of those schooling are in the elementary grades. Li teracy level is 75% or 75 per cent. of the residents are able to read and write in their own dialect. 3. Socioeconomic profile 3.1 Occupation
Only 14% of the total population is fully working. percentage, the distribution is as follows, farmers labourers tuba-gatherer fish vendor pensioner, dressmaker, tailor 71 % 11 % 8% 4%
Of this
6%
Other sources of income include buy-and-sell of copra, storekeeping and seHing of ''tikog'', a raw material used for weaving mats. The seasonal pattern follows that of the province, i.e.: Planting season: Lax period;
Harvesting:
July August - October November-December
January February-April May-June
- 216 -
Annexll·F
Products are shared in either of two ways; 1/3 to the tenant and 2/3 to the owner 2/5 to the tenant and 3/5 to the owner In ei ther way. all the expenses are paid by the tenan1:
Land prepara tiom Planting; Weeding:
Pesos 12.00 per head per day Pesos 3.50 per head per day Pesos 3.50 per head per day
Rice production is not abundant, thus people plant only for consumption. However. during harvest time, part of their produce serves as payment for cash loaned during planting. Copra is sold to middlemen who transport these to Tacloban. 3.2 Organization Be
KB PTA Rural (mprovement Chb 3.3 Resources Natural: Human: Others: A spring for drinking. washing and bathing Strong working group composed mostly of males One elementary school Extension workers oil MECS MSSD BAExt
- 217 -
Annex ll-F
4. Customs and beliefs (a) Planting any fruit-bearing plant is done at noontime. If it is in the morning, it will take a long time before the plant bears fruits. If it is in the afternoon, the leaves will turn yellow. (b) Before harvesting rice, a table or bench full of food is placed on the farm where prayers are said for the deceased owners of the land. The food is left on the farm so that souls will smell them. This is supposed to be their share of their land's produce. (c) During lax periods, if children play with kites, this indicates bad harvest. On the other hand, if they play with tops, this is believed to bring good harvest.
(d)
If one sweeps at night time, plants will not grow well.
(e) Diseases caused by supernatural beings like elves and fairies can be cured only by quack doctors. Diseases are treated by submerging a piece of paper with La tin prayers written on it in a glass of water and letting the patient drink the water afterwards. (f)
(g) 5. rlealth
The annual barrio fiesta is 16 June in honour of St. Roque.
5.1 Environment Poor environmental sanitation persists but stray animals have already been minimized. Most houses have compost pi ts for their garbage as well as water-sealed toilets.
- 211 -
Annex ll-F
5.2
Statistics Leading causes of mortality and morbidity are: pulmonary tuberculosis schi stosomiasis malnutrition bronchopneu monia bronchitis third degree malnutri tion: 5 Source: RH U Records, 1977
CARl(-ARA CATCHMENT AREA MODEL FOR DEVELOPMENT OF BARAN(-AY HEALTH PROfRA~ME TL\E FRA\£
H-\.\SES CF PCTIVITIES
Plill'05E
STRATEGIES
EXPfCfEI}OJTPVT
PER:>:N:> INVCi.VED
CEYEI.UM:NfAL <IlST PER 'iW>l'KiAY (\{}i CllNlERPAAT
I. SO:lAL FREPARATI~ CF 11-£ a::M.\.NITY I. flleeting with th~ facilltator~
of the programme at the mJoiclpal level narel}':
crientatlon on the FtL prtncJ»ies, co/)cepts and o~jective~
- NUnicipal Health ~ticer - MUnicipal Development ~flcer - t-lrran Settlerents Officer
M.IOicipal leyel ,reet logs in tile poblacion wi th representatives of agenc ies. Sharing sessions open fafllll5
.Acceptance of the Pte concept and philosophy, both at the rrunieipal and bar angay I eve I •
Rural Heaith Uhit staff \l\.JnicipaJ ~velo~nt 0f f ieer of the \\.OJJ
one day
~
88.00
Representatives of other governrrent and private agencies
HuTan Settlen:nts Officer of the MinI stry of H..rren Settlerrents . Representatives of other goycrnTent and private agencies
2. Meeting with key leaders in the baran@aYI -opinion leaders -political leaders -extension workers of governrrent and private agencies in the
Barangay level ~etings
- Barangay Captain
one day
~IOg.OO
wi th key leaders in the
barangay. -sharing sessions -open forlll"f>
Bar angay Counc i I Hi lots/Herbolar 1os RttJ staff
Executive
~!icers
I\)
barangay
of the Br igades Pub I ic School Head Teacher - Extension Wbrkers 01 gov~rnment
and priyate
~ ~
\0
....
agencies in the barangay
11. MSB..II'IO D'lTA GAJltiUi'G IN) f'IlEPlIIIlATl:N CF CCMolNITY Im"ILE 1. Spot rrepping and zonification To be abJe to knO'N
of the Darangay
the number of houses, boundary and topography of
the canruni ty.
Spot rrappi"& to be conducted by the Barangay Captain and the rrrrrbers of the
Spot napping accanpI} shed; houses
- Barangay Captain
three days e
7.00
nln'bered; community boundaries defined~
- IlIU staff - Kadiwa health brigade rT'e1'bers
Kl'DIWA I-£ALTH zonification is to be done by the RHJ staff. IRJ~;
2. Q.Jick Survey
To gather baseline data fran the camuoily which will s~rve as basis for planning carrruni ty progrCl1ll'es and projects.
rbuse-to-hollse interterview using a structured intervieYI schedui e to be conducted by RHJ staff assisted by the rrr:rrbers of the Kadiwa ~alth Brigade.
QJick Survey
re~ul
ts
consolidated and analyzed.
- lID staff. Kadiwa Hea I th Br i gade members, community
three weeks
11150.00
i
I-' fIJ
,'
(
(
A-lASES CF
,..cn VIT I ES
RRfOSE
S1RA11'G1 ES
EXre:::tID
a.mur
P£R';(N; INIn \Hl
TIM' FRi'M'
n:~
CDST PfR B"IVN:'AY (M:'H <rI.NIl'llPAA T i ~
3. Barangay Asserbly
-To present thp community profile to the people. -To evoke camrruniTy
COnsolidated quick survey results is presented to the camunity with the aid of charts and an<! \'Isual aids. TIle
-The camunity
-RfiJ sla1 f
ant> day
50.00
felt needs. -To elicit probJeT6 and their 50lution5. -To set crit~ria for leader selection. 111.CKl\NIVlT ICN CF 11iE ct:M.1..NITY
process to take pJ ace ina ccrnrun i ty
assmbJy to be fact Ilt<1ted by an RHJ sta1 f,
df!:tenTlined its lelt -Kadj~ Heai1h Brjgade 1l6Tt:l~r s needs; problens -Carrnm j t y pinpointed and prioritized. Solut ions to these prob_ len; evoked. -OJlmmity iden1 ified criteria for leader selection.
preferably the MHO.
I. Leader selection and Barangay Structure Forrretion
To organize a viable structure whereby people can actively
participate in the planning, i~lerren_
tat ion, and evalua_ tion of progr8l'11Tl!s and projects.
-The community is to be divided into zone5 ccrrposed of 25 ftmi lies to be further subdiviinto units COTl>Osed of of 10 to J5 fani 1 ies. -The zones and the units are indirectly supervised by the chainnan of the barangay structure. -The zone leaders give direct supervjsion and leadership to the units. -~ unit leaders provide direct supervision and Jeadership to the individual fanilies. -The precedint proce~s~s are to be facilitated by the R!-U stal! and the SDrangay captain. -Encourage the leaders to talk in the ass~ bly. .Q>en fOrlrn
_RH...I staff. Kadiwa -BN Chainman, zone one- day and unit leaders Health Brigade lT1!nbers are elected by the ....r.mmmi ty people. ~oles and functions of leader 5 are deJ ineated. -Leaders cmmi ted to serve and support cammunityactivities.
~50.
Or,
I\) I\)
~ I\) I\)
I-'
2. Oammunity Assembly
-To pre sent the leaders to the commu-
-Berangay structurE' fomrd
..ruu
i I? 50.00
nity. -To Jet the leader& comrrUt to partiCipate and support community activities.
staff, Kadiwa one day Health Brigade ~ers. community leaders. c::amuni ty
I-' I\)
-The processes to take place here are to be Initially facilitated by the R!-U staf f.
(
RiASES CF JlCTI VITI E.5
IUUDSE
S'lRATI:G1 E.5
EXF£CIID cuTlur
m<!'CNS 1N\a.\ff)
T"'~
r£VEl.ffi£NTAl (J)ST I'ER ~Y(M:H
FRAI.£
<ll_NTI'RI'AATl J V. ffiaR!'M.E.5/ ffiQJEC1'5 (Proie-ct~ are to be ifr(>hrr~nted re~ponse to camwunity need~.)
in
1. Ba r angay iVret i ngs
To be ahl~ to prioritize pro~rammcs and and plan out activities.
-~adf'rs
to meet twice
a rronth 10 be fa(" iii ta_
ted by the chainnan of of the organization. to be assisted by the
Plan of ,Act ion for each uni t i!i fOITi"ulated.
-PH! staft -oflicer~
RHU/KBdiwa Health Bf i gade.
of the oq~anlzat ICm -Omn.Ini ty -Representat ive of goverrrrent
and private agencie!t in the cCJlITIJn i ty.
-lh j t meet i ngs once a a rmnth to be fad I ited by the unjt leaders and assistf"c1 by the zone
zone leaders.
E'I'JO.OO tJax irrun (plus indigetil'T'etable for nous sources a project. e.f!;. beaut i f ieat Ion. found in thE> env i romenta I barangay. and resou rees f rO'T1 sani tat ion are other aJ!'enc ies to be finished which shall be in 2 rmnths. tapped. l Other pro jecu such as incarrgenerating activities and health progrcnrres require a rraxirrvn t irrr to accmpl ish, but projects are
I\) I\) \);
~ I\) ~
evaluated every quarter. V. fficx:ruu.E EII'ILlJI\T leN progr~s
1. Short-tenn
(1 to 5 rronth.)
To be able to monitor programme needs for redirect ion ~nd
-Short-terro progr~5 are to be evaJuated after theil rrents. -Long-r8~e 8ccamplis~
-Weaknesses and strengths of thr
-Gmrunity
one day
J? 50.00
..RHJ
2. too&-ral"!.e progr2nTles (6 months to 2 years)
progra"lt1'1es are ident j f ied. attN \IrtIich redirect ion of pr08r~s are rrede.
planning.
progranmes
are to be evaluated every qvarter. scheme 01 evaluating the prognmnes are to be agreed upon by leader s of the concerned zones and un its and the IHJ staff. -The process 01 evaluation is to be faci Ii tated by the uni t leader. to be assisted by the zone -l~
I I\)
....
leader. -The RHU staff provides technical consultancy for this process.
PHASES
cr PCT I VI TI ES
IUlrosE
SlRATEGIES
EXTK:IED OJTRJT
I'ffiSCI'5 INICL VID
TIM:. !'RIMe
L£\IEl.CfM:N'IAi. <DST f'Bl B'lRi'KAy (M]; mNTffiPAAT)
V I. [OlM,NTATIQ\i (This rrBy Car.! in any phase of the- programre.)
To analyze and to interpret the irrpact of
RtU to produce docl.Jl"I!nts and/or
-RHJ, zone and uni t leaders
P 50.0n
the programme in the c(]l'J'JlJnity, the results of which wi II aJlow
guidelines in developi ng heal th progr cr-rrrrs a 1 the
a continuous improverrent of progranne
barangay
j
eve I.
strategies.
I. RHJ level
Rt-lJ I eve J : -The RH.J j 5 to docl.J'T1ent
the process of the fcHONi ng:
a. organizational strUcture b. planni ng c. linkage d. training I\) I\)
e. programme evaluation f. i nforrret ion flow
-;u. ~
\J1
g. support systf'm 2. O:mnmity level - Merrbers of camunity structure
To share the experiences and insights of the participants of the progr.-rn-e to
-Omnmity level: The zone and unit leaders
others who are e~aged j n heal th progrB11l'Es at the barangay level.
are to document the processes of the following: a. organization design b. leadership building c. decision..neking
d.
probl~solving
e. perception of the
progTiImle f. values and attitudes.
-The RHU interprets and analyzes the data collected by the zone and uni1 leaders. <R'N)
i .... I\)
1OTAi.
1?703.00
PROFILE OF CHANGE"
Belo.-e R&D A. (l)
Present situation
RHUldoctor's role
People relled first on self-medication and indigenous healers and only consulted the RHU for advanced cases.
(I)
The BN, through the unit leaden, handles surveillance cases requiring referral to the RHU or to the MHO. With the use of simple indicators, each is kept informed of the hea.lth status of each member and becomes aware whf'!n to consult the unit leader or the RHU. Emphasis Is placed on the promotion of a healthy lite by means of meetio! the basic needs without ~g1Kt;,g ttle o.ratiYe aspects. Emphasis is placed not onJy 00 the p"evention of diseases but aho, on mecting the bask needs of 1he commlD'lity and its efforts to live a healthy life. The cep.tbllity of the community to take care of its own hc:"a.lth problems, including simple medical care, ha, been stren&thenf'!d. ~dou."
(2)
The RHU primarily provided curative services without neglecting the preventrve aspects of health care.
(2) 0) (If)
() (4) (5)
Thl! lostered dependency on the hospital .... vlc. and medical care to solve health problems. The community depended solely on the RHU for external lervlees, tncludln& dlspenslng of drugs. o\lerburd~lng
All cue. were relerred to the MftO 10< help thu. the health service.
(5)
A referral s),stem at the community level up to the BN level has been developed. O'Ily cases are referre-d to MHO giving him mor~ time to Improve' the health services.
I\)
(6)
ConMquently, the role of MHO was limited to that of a clinician.
(6)
role of the MHO hal been broackned to that of a leader. a i.dlltator, a troliner and a comm\J1lty developer ensuring community participation through the deveJopm~nt of the BN. the importanet' of eady diagnosli and continuous treatment, perrorms irnmt'di.te referral fOf the ot'cenary heahh se-rvlcf" and follow-up. The 8N reaches ovt to evPr'l famU,.. expl~nt
~
'i\r I\)
~
(7)
People dropped out from ~ treatment rellmen (e.g. pulmonuy tuberculosis, 3ChhtosorrUUU) dtJe to lack of follow-up and unlamlUar cll ..... te In the RHU Com1nunlty organization 4f1d Information syuem
(7)
CO
B. (J)
There is Aenenll)' no feed-back mechanism. There was lack of sYltematic collt:ctioo of heAlth data, whkh depende'd pdmarlly on reporu of patients who consult~ th~ RHU or th~ health centres.
(i)
The SN has bfoen estabhsMd WI th the unit leaders responsible for a nlJmh~r of
familiet to (2) (2)
~niure
adeqUAte monItofing and communi<'ation.
Fe-ed-bAckl .re sathe-red IYJotemaUcaJly thro'Jgh the 6N using the folrTuly sneets.
<l)
Oata were abundant but ..... er~ irrelevant to comm\J'lity needs. Communi ty participation The eonc~pt of ht!alth dependeod Oil the providers or the ageoncy. Planning WAS
U)
The lIIrnity sheet providri more accurate d.te making the comn\unilY more aware of its health problel'M and mort capable to ~Jye !Mm. Th~ prople have bKome retpOnslble for the'ir own health. The concept ot he.lth/dlse"'" "taken from the client'. vi.wpoint and synth~.lzed; tho community aBr~ upon a few simple indicators wh.lch it C'.'t.sUy understand,.
C. (I)
th~
perception of
(I)
! t;:
(2)
centralized from top to bottom.
(2)
FamUies confer with unlt leaden. who in turn meet ..... ith other BN IfI'aders. h not only Gone from top to bottom bUT &Iso from bottom to top.
1hu~
plannin8
-Meta, LR. (1979). A ca,.e study on community health development through 1trengthening of
th~
health care delivery system and research and development, "·PR/PHC/19.2
(
.
c
!lefor. R &; D
Present situation (3) The RHU dialogues with the comm1jnity to identify its ne-eds, its problems and the solutions to its problems; people are motivated to sustain programrnes they the-mselves evolve-d. Existing leadership pattern is tapped before it actually reaches out to individual families. Through the BN, the whole community is informt'd. The people participate in probJem identification, planning, impleme:1tation and e . . aluati.:.m.
(3)
The RHU set the priCX'ity health problems, planned programmes and expected people 'to partkipote without social preparation.
(to
Former community leaders were mostly the ones involved in orientating the planned programmes. The people's role was primarily to receive the health service.
(4) (5)
(~)
(')
Programmes were imposed by providers usuaUy resulting in unintegrated and sectoral programmes thus confusing the people.
(6)
The community is aware of its problems. When an agency comes in, it is in the best position to coordinate or fit in the programme and tap·1he agency to resolve its problems. Since problems are varied and complex. their solutions have to be intersectoral, thus leading to the formation of an interdisciplinary health team,
N
O. Approaches to health development (t)
Diseases were regarded as monocausal, treatment of which was the domain of the health personnel. The monosectoral approach to the solution of a healt.'! problem Jed to a single-role conventional type of pro1essional manpower development, i.e. doctor, nurse, midwife.
(I) (2)
Acceptance of the concept that a disease is not monocausal, e.g. diarrhoea, therefore, there is a need for the intersectoraJ approach to solve it. The information system leads to the identification of the complexjty of heaJth problems. This leads to the development of a worker with intersectoral orientation who is able to work with the community and the other sectors, e.g. BHWs, CHWs trained by the IH5.
~ 'c:S
\0
N
(2)
I VI
....