Joint Programme on Maternal and Neonatal Health: Phase 2

Transcription

1 Joint Programme on Maternal and Neonatal Health: Phase 2 A Investment Summary table A: Joint Programme on Maternal and Neonatal Health: Phase 2 Start date: <July 2013> End Date: <December 2015> Proposed funding allocation: AUD$ 8,000,000 (i.e. US$ 8,360,000) Investment Concept (IC) approved by: <FADG Name> IC Endorsed by SPC: Yes/No/NA Quality Assurance (QA) Completed: <Enter QA processes completed e.g. peer review> B. Executive Summary Development and end-of-aid outcomes envisaged Development outcomes. Although the Philippines has been a middle income country since 2009, it is unlikely to meet its Millennium Development Goal (MDG) 5 target on maternal and reproductive health unless efforts towards these goals are substantially increased. The 2011 Maternal Mortality Ratio of 221 deaths per 100,000 live births 1 is off track to meet the 2015 MDG target of 5 The under-five child mortality rate (UFMR) as of 2011 is at 30/1,000 live birth (LB). The annual rate of reduction of child deaths to attain the MDG 4 target of 26 child deaths/1,000 LB is on-track. However, the Philippines needs to urgently focus on neonatal mortality to stay on track. This is because newborn deaths account for approximately 50% of under-five year old deaths. 34,000 Filipino neonates die each year from preventable causes. Majority of maternal and newborn deaths occur during the first 2 days of life. Inequities in outcomes and coverage of necessary health services exist. The poorest women in both rural and urban areas carry the greatest burden of maternal and neonatal deaths. The Joint Programme on Maternal and Neonatal Health (JPMNH) represents the collective effort of 3 United Nations (UN) agencies in support to the Philippine government, towards attaining its commitment (to the international community) in achieving MDGs 4 and 5. This Program harnesses the technical expertise and organizational capacities of the 3 agencies (i.e. United Nations Population Fund {UNFPA}, United Nations Children s Fund {UNICEF} and World Health Organization {WHO}) to establish a functional and effective service delivery network (SDN) in the selected vulnerable sites that will be worthy of adoption by the Department of Health as a model for replication in similar localities at the sub-national level, which exhibit parallel geographical contexts and suffer the same MNCHN issues. The SDN is a package of maternal and newborn health services available from the lowest level of health facility to the highest level that includes a functional referral system and delivery of service in partnership with the public sector and the private sector. End of aid outcomes. The Program s desired impact is the reduction of maternal and newborn deaths in the JPMNH sites. It aims to achieve the impact through the main outcome of demonstrating the functionality of the SDN in line with the Philippine Department of Health s Universal Health Care objective of ensuring that all Filipinos, especially those belonging to the lowest two income quintiles, have equitable access to quality health care, and with the Maternal, Newborn and Child Health and Nutrition (MNCHN) strategy of a systemwide approach towards rapid reduction of maternal and newborn deaths 2.The JPMNH will be focused on improving the quality, access and utilization of (a) intrapartum, (b) postpartum, and (c) family planning services in the JPMNH areas Family Health Survey 2 DOH Administrative Order No , Implementing Health Reforms for Rapid Reduction of Maternal and Neonatal Mortality 3 DOH Administrative Order No , The Aquino Health Agenda: Achieving Universal Health Care for all Filipinos 1. 1

2 At the time of proposal development, baseline data for key outcome indicators (e.g. skilled birth attendance {SBA}, facility based delivery {FBD}, family planning {FP} utilization) are available from secondary sources down to the provincial level only. (Please see Table 8: Logical Framework) While it is ideal for firm targets to be stated at this point, the JPMNH will utilize a participative and consultative process with the local government units, including municipalities, in setting the final targets. The target-setting process will use as benchmark the results of the AusAID-funded 'Investment Case for Scaling up Equitable Progress Towards MDGs 4&5 in the Philippines', where, applying certain modelled strategies or packages of assistance, neonatal mortality (NMR) is reduced by 18%, under 5 mortality (U5MR) by 16% and maternal mortality (MMR) by 45% in a rural setting. For an urban setting, the expected impact includes a 6% reduction in NMR, 8% for U5MR and 14% for MMR. To this end, baseline data and annual milestones/target shall be completed within four months from the start of the JPMNH. During this period, the JP will conduct an evaluability assessment, a detailed situational analysis/baseline study, and strategic planning workshops with the Department of Health (DOH) and field implementing partners (LGUs) to discuss and commit to SMART (Specific, Measurable, Attainable, Realistic, Time-bound) targets. The JPMNH Phase 2 design will build on previous investment and gains made in the Transition Phase. To maximized impact of interventions from the Transition Phase, the Phase 2 design will be focused on interventions in the intrapartum and postpartum periods, since approximately half of maternal deaths as well as newborn deaths occur in the narrow time span during labor, delivery or the first 24 hours post-partum, and for which effective interventions are already known. Post-partum family planning is included in the thematic convergence of interventions, cognizant of the evidence that at least 44% of maternal deaths could be averted if women have access to modern FP methods. A geographic convergence of interventions will also be implemented in this design, to synergize efforts of the three agencies. The SDN to be developed have considered the following local contexts: (i) an urban poor setting with a high density of conditional cash transfer (CCT) beneficiaries; (ii) rural settings with geographically isolated and disadvantaged areas; and (iii) highland and coastal municipalities. Hence, the JPMNH sites include: Rural: Region 12: o o o Municipalities of Lebak and Kalamansig in Sultan Kudarat Province (40,475 CCT households); Malungon municipality in Saranggani Province (30,000 CCT households); Municipalities of Aleosan, Midsayap, Arakan and President Roxas in North Cotabato Province (77,605 CCT households) Urban: Quezon City in National Capital region (NCR): o The poorest district of the highly urbanized Quezon City, District 2 (i.e. with 9,555 CCT population base). The JPMNH Phase 2 is envisioned to complement national government s Conditional Cash Transfer (CCT) program by concentrating its efforts in increasing the quality of care where the CCT interventions bring the families to the service providers. In the course of establishing the SDN of the sites mentioned above, the JPMNH envisions that non-cct households using the same service delivery networks will also benefit from the interventions. These are likely to be poor households for they are the primary users of public health services. The program will widen its reach within Region 12 as it provides selected interventions to facilities and LGUs -- impacting on the lives of at least a CCT population base of 241,575 people. Timeframe for engagement and resource commitments The JPMNH will run from July 2013 to December The starting date is perfectly timed with the administration of the new set of local chief executives who would have sworn in after the local elections come May The envisioned end date aligns with the governance schedule of the current Aquino administration. Requested funding from AusAID is eight million (8,000,000) Apart from the funding of the donor, the agencies are committing its respective field personnel already stationed in the JPMNH sites, as deployed by its country programs/cooperation plan with the Philippines, specifically its commitment of support to the Department of Health and selected local government units (i.e. provinces, cities and municipalities). Furthermore, the 3 UN agencies involved makes available the wealth of technical expertise and knowledge base on health sector reform -- especially the development and strengthening of the service delivery network targeting the underserved and very poor populations. 1. 2

3 The JPMNH will focus on supporting intrapartum and postpartum, and family planning interventions, creating demand for services to increase utilization, and improve the health systems underpinning the delivery of the core package of services and the service delivery network. In particular, it will: Improve the quality of facility based intrapartum (IP) and post-partum (PP) care (Sub-outcome 1): Generate demand for IP and PP services (Sub-outcome 2): Improve the availability of quality family planning (FP) services (Sub-outcome 3): Strengthen the health systems of JPMNH areas in support of IP, PP and FP (Sub-outcome 4): and Institutionalize the joint working approach to program management and implementation (Sub-outcome 5). In order to achieve a population-based impact within a two-year duration, two types of intervention packages will be provided: 1. Full Support for the Service Delivery Network (Full SDN Package): this would focus on the targeted rural and urban poor communities and the health service delivery system that supports the community. Among the elements of the full package are: Maternal Death Review and Vital Registration System Strengthening Health information systems operationalized in local health facilities Improved LGU and Center for Health and Development (CHD) capacity on public-private partnership (PPP) management for IP/PP elements of MNCHN Improved local health governance for IP, PP and FP elements of MNCHN Increased capacity of CHD in providing technical assistance (TA) to LGUs on IP/PP elements of MNCHN Increased PhilHealth accreditation for facilities covered in the JPMNH sites; and Integration of minimum initial service package on reproductive health (MISP-RH-RH) in local disaster risk reduction and management (DRRM) plans. Targeted Support to Facilities (strategic intervention package): this will be applied to the wider areas of region 12 and NCR. Depending on the capacity gaps of facilities and the funds available to the JPMNH, support would include: Quality-of-Care through the Essential Intrapartum Newborn Care Practices (EINC-Package): targeted for lying in clinics, Basic Emergency Obstetric and Newborn Care Facilities (BEMONC) and Comprehensive Emergency Obstetric and Newborn Care Facilities (CEMONC). Family Planning Support to primary facilities (FP-Package): To avert maternal deaths due to pregnancies of high risk women, commodity provisions will be provided in primary facilities; covering the commodity needs of the CCT families it covers. Recommended delivery approach and key partnerships The JPMNH works within existing country systems in line with Paris Declaration of Aid Effectiveness The JPMNH interventions take into account that the provision of health services is devolved to the local government level. Interventions will be tailored to three levels: regional, provincial and city or municipal. The program aligns its activities with the local planning cycle, while utilizing existing local health systems (e.g., inter local health zones {ILHZ s}). The JPMNH taps AusAID s aid modality of support to partner government programs. The JPMNH interventions are aligned with the Department of Health s MNCHN developmental thrusts for the next 3-5 years, focusing on the identified JPMNH areas. As such, it will address the Department s Universal Health Care thrust related to MDGs 4 and 5, as it also seeks to make its contribution in the alleviation of poverty, with an equity focus on the identified CCT areas of the JPMNH sites. Overall implementation through partnerships with private or non-government providers such as local professional organizations (e.g., the Family Planning consortium, Philippine Obstetrics and Gynaecologists Society, Midwifery and Nursing societies and civil society (grassroots) organizations in JPMNH sites) will be a key implementation modality. Lastly, the JPMNH seeks to strengthen ownership by LGUs and their local chief executives by building up health system elements for the sustainability of changes in the locale. 1. 3

4 Any critical challenges to success, and how these will be addressed. The JPMNH seeks to fully engage the ownership of local chief executives and health managers for sustainability and strengthening of health reforms. To this end, political support is needed. The forthcoming elections with changes in the political landscape and potential shifting of LGU priorities must be considered a risk. Evidence-based advocacy, tapping national and local civil society organizations (CSOs) to claim right to health, and timing of engagement for bottom-up planning and budgeting are planned to manage or mitigate the risks. Furthermore, increasing capacity of local chief executives in a local health leadership programme is seen as pivotal in harnessing support, through policies and resources, in the provision of IP, PP and FP services for MNCHN. Reproductive health remains a challenging policy issue in the Philippines. At the time of the revision of this proposal (December 2012), the controversial Reproductive Health (RH) Bill, was passed into law. Organized opposition through avenues outside the legislature, such as the Supreme Court, popularization and localization of the law in cities and towns are now the challenges to the implementation of this young law. Attitudinal issues towards FP remains a very sensitive matter both for Filipino service providers and users. Addressing concerns such as fear of side effects and inadequate information about effects need to be addressed to bridge the efforts of making FP available and the recognized need. Therefore, popularization of the RH Law, evidence-based advocacies and demand generation activities are included in the JPMNH. The RH Law offers opportunities that can enhance planned JPMNH interventions. Notably, provisions on the accessibility and standards of emergency obstetric and newborn care further strengthen the DOH administrative orders to the IP, PP and FP packages to be scaled up in the JPMNH areas, specifically addressing the issue of the giving of oxytocin by midwives, perceived by some groups as in conflict with the Midwifery Law. The new law is also a strong policy support for the postpartum family planning interventions planned. Another challenge refers to the potential inadequacy of human resource complement in the JPMNH sites, especially those under the employ of the LGUs. This concern will be addressed through the strengthening of public-private partnerships, whereby these private partners could provide the human resource complement to bridge gap or institute changes to increase the efficiency of the current complement. Institutionalised joint working approach to program management and implementation among the UN agencies is new and UN agencies may not be able to sustain delivering as one principle. The presence of United Nations Coordination Office (UNCO) oversight on joint work arrangements will be strengthened. 1. 4

5 Acronyms 4Ps AHA ANC AO AOP ARMM ASRH AusAID BEmONC BHIC BHS BHWs BUB BTL C4D CBGs CCT CEmONC CHD CHIT CHO CHT CPR CSOs CSR DHS DOH DSWD EINC EMONC EO EPI F1 FBD FHSIS FIC FP FPAS GAD GIDAs HACT HEART HSP HSRA IEC IMR JAPI JPMNH KP LB LBW LCE LGU M and E MBFHI MCP MD MDG MDR Pantawid Pamilyang Pilipino Program Aquino Health Agenda Ante-Natal Care Administrative Order Annual Operations Plan Autonomous Region for Muslim Mindanao Adolescent Sexual and Reproductive Health Australian Agency for International Development Basic Emergency Obstetric and Newborn Care Bureau for Health International Cooperation Barangay Health Station Barangay Health Workers Bottom Up Budgeting Bilateral Tubal Ligation Communication for Development Community-Based Groups Conditional Cash Transfer Comprehensive Emergency Obstetric and Newborn Care Center for Health and Development Community Health Information System City Health Office Community Health Team Contraceptive Prevalence Rate Civil Society Organizations Contraceptive Prevalence Rate Demographic Health Survey Department of Health Department of Social Welfare and Development Essential Intra-partum-Newborn Care Emergency Obstetric Newborn Care Executive Order Expanded Programme on Immunization Fourmula One Facility-Based Deliveries Field Health Service Information System Fully Immunized Children Family Planning Family Planning Action Session Gender and Development Geographically Isolated Depressed Areas Harmonized Approach to Cash Transfer Health Equity Assessment and Response Tool Health Service Provider Health Sector Reform Agenda Information, Education and Communication Infant Mortality Ratio Joint Assessment and Planning Initiative Joint Programme on Maternal-Newborn Health Kalusugan Pangkalahatan Live Births Low Birth Weight Local Chief Executive Local Government Unit Monitoring and Evaluation Mother-Baby Friendly Hospital Initiative Maternity Care Package Doctor of Medicine Millennium Development Goal Maternal Death Review 1. 5

6 MISP-RH MMR MNCHN MOP MPTF MWRA NCDPC NCHP NCP NCR NDHS NDR NGO NHTS NMR NOH NOSIRS NSO NSV P/CPH PDP PhilHealth PHO POPCOM PPP PPPP(4Ps) PWD QC RA RAMOS RH RHU RUP SDN SHPs SOCCSKSARGEN TBAs UFMR UHMIS UN UNCO UNDAF UNDP UNFPA UNICEF UP WHO Minimum Initial Service Package on Reproductive Health Maternal Mortality Ratio Maternal-Newborn-Child-Health and Nutrition Manual of Operations Multi-Partner Trust Fund Office Married Women of Reproductive Age National Center for Disease Prevention and Control National Center for Health Promotion Newborn Care Package National Capital Region National Demographic Health Survey Neonatal Death Review Non-Government Organization National Household Targeting System Neonatal Mortality Ratio National Objectives for Health National Online Stock Inventory Recording System National Statistics Office No-scalpel Vasectomy Provincial/City Investment Plan Philippine Development Plan Philippine Health Insurance Provincial Health Office Population Commission Public-Private Partnership Pantawid Pamilyang Pilipino Program Person with Disability Quezon City Republic Act Reproductive Age Mortality Studies Reproductive Health Rural Health Unit Reaching the Urban Poor Program Service Delivery Network Skilled Health Professionals South Cotabato, North Cotabato, Sultan Kudarat, Sarangani, General Santos City Traditional Birth Attendants Underfive Mortality Ratio Unified Health Management Information System United Nations United Nations Coordinating Office United Nations Development Assistance Framework United Nations Development Program United Nations Population Fund United Nations Children Fund University of the Philippines World Health Organization 1. 6

7 C. Analysis and Strategic Context C.1 Country/Regional and Sector Issues Although the Philippines has been a middle income country since 2009, it is unlikely to meet its MDG targets on maternal, neonatal and reproductive health unless efforts towards these goals are substantially increased. The 2011 Maternal Mortality Ratio of 221 deaths per 100,000 live births 4 is off track to meet the 2015 MDG target of 5 Family planning is estimated to reduce at least 44% of maternal deaths, but national contraceptive prevalence rate (CPR) stands at 49% 5 against a target of 80%. The under-five child mortality rate (UFMR) as of 2011 is at 30/1,000 LB. The annual rate of reduction of child deaths to attain the MDG 4 target of two-thirds reduction of UFMR of 26 child deaths/1,000 LB by 2015 is on-track. Although the country s overall UFMR is reducing on track (i.e. at 3/1,000 LB in ), the rate of newborn deaths remains almost unchanged. This will require close attention to newborn deaths which account for more than 50% of under five year old deaths. 34,000Filipino neonates die each year from preventable causes and most of these deaths occur during the first 2 days of life. The poorest women carry the greatest burden of maternal and neonatal deaths. To respond to these health gaps, the Department of Health (DOH) launched the Health Sector Reform Agenda (HSRA) in 2004 and again in 2006 as the Fourmula One strategy. Aimed at strengthening the local devolved health system, the DOH policy recommends the establishment of health care Service Delivery Network (SDN) covering a province or the inter-local health zones (ILHZs) with private health sector participation. One major focus of Fourmula One is the rapid reduction of maternal and newborn deaths in the country in support to the country s commitment to the achievement of the MDGs by As a result, the DOH in 2008 issued Administrative Order No , the Maternal, Newborn and Child Health & Nutrition (MNCHN) Policy as the national strategy for the rapid reduction of maternal and newborn deaths. This was supported with the development of a manual of operations (MOP) as guide in its operationalization. The strategy states that health system reforms be in pursuit of the following intermediate results that can lower the risk of dying related to pregnancy and childbirth: 1) every pregnancy is wanted, planned and supported, 2) every pregnancy is adequately managed throughout its course, 3) every delivery is facility-based and managed by skilled birth attendants, and 4) every mother-newborn pair secures proper postpartum and postnatal care with smooth transitions to the women s health care package for the mother and the child survival package for the newborn. Under the current administration s Aquino Health Agenda (AHA), the HSRA Framework takes on universal health care (UHC) as its centrepiece. Dubbed as Kalusugang Pangkalahatan (KP), the DOH issued AO No. 0036, s.2010, The Aquino Health Agenda: Achieve Universal Health Care for All Filipinos. KP has three strategic thrusts: (i) increased risk protection especially among poor households in Quintiles 1 and 2 through premium subsidy in the PhilHealth social health insurance program, greater availment of benefits, and increased support value, (ii) provision of greater investments in the hospital system by rationalizing the Service Delivery Networks and public/private partnerships (PPP); and (iii) strengthening the public health system for the achievement of the health MDGs, mainly through invigorated Community Health Teams (CHT) and refurbishing of rural health units (RHUs) and other public health infrastructure. To date, varying degrees of compliance have been achieved by the different LGUs nationwide to organize, train, and deploy CHTs in their respective barangays. The 4Ps or Pantawid Pamilyang Pilipino Program is a conditional cash transfer (CCT) program which provides cash to beneficiary households, subject to compliance with program conditionalities. Together with KP, the administration s strategic focus on poverty reduction is operationalized. A total of 5.2 million households have been identified under the National Household Targeting System for Poverty Reduction (NHTS-PR) as the poorest of the poor (quintile 1) and are eligible for the 4Ps program, currently administered by the Department of Social Welfare and Development (DSWD). The 4Ps is targeted at chronic poor households with children aged 0-14 years who are located in poor areas. The cash grants range from P500 (US$11) to P1, 400 (US$32) per household per month, depending on the number of eligible children. To qualify for the grants, beneficiary households must undertake certain activities that are meant to improve Family Health Survey 5 Ibid. 6 Ibid. 1. 7

8 children s health and education such as visiting health centers regularly, sending children to school, and undertaking preventive check-ups for pregnant women. Like most CCT programs, the 4Ps aims to alleviate current poverty by supplementing the income of the poor to address their immediate consumption needs, while the conditionalities can help improve human capital and thus break the intergenerational cycle of poverty. In recent years, several countries have adopted the CCT program as a new approach to providing social assistance to the poor. Many countries in Latin America have such a program, and large-scale CCT programs are also being undertaken in Asian countries such as Bangladesh and Indonesia. The 4Ps started as a pilot program of the Department of Social Welfare and Development (DSWD) in 2007 when the agency was embarking on social sector reform. Today, the program is seen more broadly as a vehicle for enhancing coordination within the government in assisting the poor and for increasing the effectiveness of social protection programs, including health. It does this by complementing supply-side interventions of other line agencies such as the Department of Education (DepEd) and Department of Health (DOH) in addressing lagging human development outcomes. Additional priority segments to receive intensified government assistance have been identified. These include 5.6 million households classified as near-poor (quintile 2). The DOH also identified 12 MDG breakthrough provinces, including the National Capital Region (NCR) to receive full support to improve performance against MDG-targets. Additionally, 609 municipalities have also been identified by the National Anti-Poverty Commission (NAPC) as priority areas for poverty reduction due to markedly higher incidences of inequity. An essential complement to these efforts was the issuance of PhilHealth Circular No on New PhilHealth Case Rates for Selected Medical Cases and Surgical Procedures and the No Balance Billing Policy (NBB) covering the enrolled members to the PhilHealth Sponsored Program, including their dependents and the other member in accessing services from MCP accredited (non-hospital) providers. One of the provisions supports the country s commitment to reduce maternal and infant mortality rates and improve maternal and newborn care enunciated in the MDG. Family planning (FP) remains a challenging policy issue in the Philippines. At the time of the revision of this proposal (December 2012), the controversial RH Bill, was passed into law. Strong opposition through avenues outside the legislature and localization of the law in cities and towns are now the challenges to the implementation of this young law. Attitudinal issues towards FP remains a very delicate matter for Filipino service providers, men and women also remain, aggravating the problem of poor FP service delivery and compliance as evidenced by the low CPR. C.2 Development Problem/Issue Analysis 1. Child health indicators have been improving in the Philippines; however the rate of decline in neonatal (or newborn ) mortality rates (NMR 7 ) has either remained stagnant or slowed. At current rates, the Philippines needs urgent focus on neonatal mortality to keep on track to reach MDG4. Reductions in the maternal mortality ratio (MMR 8 ) have been dismal. The national MMR during the periods was 209, and by 2007 had only improved to 16 At the current rates, the Philippines is off track to meet its MDG5 target of an MMR of 5 Inequity is also a concern, with gaps both in health outcomes and MNCH intervention coverage, between key segments of the population: rural versus urban, across wealth quintiles, and a combination of both characteristics. Gaps in the health service delivery and provision are seen as the main causes of the slow decline in both maternal and child mortality. There remain large disparities in health outcomes between the rich and the poor resulting from economic and geographic barriers to accessing and utilizing health services. For instance, there is skilled attendance at 95% of births among the highest income quintile, compared with 25% in the poorest quintile. Only 13% of all births in the lowest quintile occur at a health facility, compared with 84% in the highest quintile. One of ten poorest women (Quintile 1 and 2) receive no postnatal care in contrast to 7 Newborn deaths per 1,000 live births. 8 Maternal deaths per 100,000 live births. 1. 8

9 only one in twenty of the highest wealth quintile women. The following table from the NDHS 2008 demonstrates this disparity by wealth quintile. 3. Table 1: MNCH Statistics by Wealth Quintile Wealth Quintile Facility Based Delivery (%) Skilled Birth Attendance (%) No postnatal care (%) Q Q Q Q Q Source: NDHS 2008 A Philippine study on the inequities in health outcomes and coverage was conducted in Funded by AusAID, the Investment Case research findings conducted in Pasay City and the provinces of Northern and Eastern Samar 9 identified key some demand/supply constraints seen in the local setting: Supply side challenges Lack of standardization / poor quality care; Government s limited regulation of practice in both private and public sectors result in low practice rates of efficacious and cost-effective interventions, despite the presence of policy issuances. Guidelines (e.g. for evidence-based newborn care protocol), need to be systematically and rapidly scaled up. Health workers are inadequate both in quantity and quality in terms of up-to-date training. Inadequate supplies at health facilities; Procurement of relevant commodities has been delegated to the LGUs, which have yet to have adequate allocation thereto in local budgets. As a consequence, the poor are forced to buy supplies on their own. Demand side challenges Insufficient access (physical and financial) to quality facility-based delivery at required levels of care; In urban settings, remaining home births take place among the urban poor communities, in spite of a high coverage of facility-based deliveries, such as in the case of Pasay City. In rural settings, there are limited BEmONC and CEmONC facilities in the locality, aggravated by an even smaller number of facilities that are PhilHealth accredited. Financial access barriers include low PhilHealth enrolment and availment among urban and rural poor. Lack of community knowledge regarding care during pregnancy and delivery, and infant feeding Knowledge on practice of healthy behaviors as well as demand generation for service delivery and quality of care were inadequate. Demand-side challenges specific to FP such as lack of knowledge are consistent with findings in the 2011 Family Health Survey on key reasons cited by respondents for not using any family planning method (aside from wanting to have more children): About 40% of women cited method-related reasons for non-use; Fear of side effects and other health concerns (32%); Opposition to use (4%) either because the husband or partner is opposed or because the couple itself is opposed to family planning or is prohibited by their religion; and Hard to get method (0.5%) 9 Developing an Investment Case for Financing Equitable Progress towards MDGs 4 and 5 in the Asia Pacific Region (Scale Up Report). December 2011; pages

10 Dependence on fate for their health, pregnancy and delivery also contribute to non-access of FP services- many Filipinos still believe that the number of children they have is according to God s/allah s will, and children are blessings from the deity. 3. The Philippines is like other countries with problematic maternal and child mortality rates, in that the majority of maternal deaths directly result from pregnancy complications occurring during labor and delivery (intrapartum), and the immediate post-partum period. These complications include hypertension, post-partum hemorrhage, severe infections, and other medical problems arising from poor birth spacing, maternal malnutrition, unsafe abortions and presence of concurrent infections like TB, malaria and sexually transmitted infections as well as lifestyle diseases like diabetes and hypertension. 10 Many of these complications are potentially manageable such that death could be averted. The fact that the efficacious interventions that could avert these deaths are inadequately practiced is a result of the supply side factors cited in the Investment case studies. The majority of neonatal deaths occur within the first week of life, with the highest risk of dying within the same crucial period as mothers (24-48 hours after delivery). These conditions are often due to asphyxia, prematurity, severe infections, congenital anomalies, newborn tetanus, and other causes. 11 Again many of these are manageable, and death could be averted. In the Investment Case studies, the problem was worse in the rural areas and projected that the proportion of newborn deaths to under-five deaths will only get higher if not addressed. If the Philippines is to achieve its MDG4 Goal, it should concentrate on addressing neonatal deaths The high rates of deaths in this critical narrow period occur partly because of the quality of care at the point of delivery, but also because of delays in receiving appropriate care leading up to delivery, opening the door for unnecessary complications to occur. Global experts have characterised three delays as major contributors to maternal and neonatal death rates: These are (i) delay in identification of complications; (ii) delay in referral; and (iii) delay in management of complications. Although the Government of the Philippines has generally created an increasingly favourable policy environment for addressing maternal and neonatal health, as described above, these delays are still present for poor women and their newborns. There are a number of contributory factors: (1) There are high rates of mistimed, unplanned, unwanted and unsupported pregnancies Furthermore, 22 percent of currently married women aged 15 to 49 have unmet need for family planning, which is more than a one-third increase from its previous level in 2003 (NDHS 2008). Ten percent of adolescents aged 15 to 19 has also already begun childbearing (NDHS 2008); in the Philippines, adolescents are prohibited to use any form of contraceptive. In the RH law of 2012, they can only do so with parental consent. 10 The MNCHN Manual of Operations, 2 nd Edition. Department of Health; March 2011; page Ibid; page Developing an Investment Case for Financing Equitable Progress towards MDGs 4 and 5 in the Asia Pacific Region (Scale Up Report). December 2011; pages

11 (2) Women do not access adequate care during the course of pregnancy; (3) Women deliver without being attended by skilled health professionals, and lack access to good quality emergency obstetric and newborn services (4) Women do not secure proper postpartum and newborn care for herself or her newborn. 13 (5) There is documentation that intrapartum and immediate post-partum practices in the Philippines poorly comply with evidence-based standards (Sobel et al, 2011) and anecdotal reports of negative attitudes and prejudicial treatment of poor women seeking delivery care. C.3 Evidence-base/Lessons Learned C3.1 Introduction The Transition phase of the JPMNH has generated useful lessons that are relevant to Phase II, specifically in the areas of improving quality in intrapartum and post-partum care, increasing access to services, and increasing the provision of family planning services. Lessons have also been learned from programme implementation arrangements. There are also several lessons from the government experience of implementing the MNCH strategy and other donor funded projects in similar areas. C3.2 Lessons on improving quality in intrapartum and postpartum periods 14 The Essential Intrapartum and Newborn Care (EINC) intervention which was piloted in 11 hospitals in the transition phase has yielded favourable practice changes, and is ready for scaling up. The evidence-based guidelines of EINC have been incorporated in the BEmONC training curriculum. In one of the pilot hospitals, skin-to-skin contact was associated with lower mortality (OR % CI ), lower risk of sepsis (OR % CI ), and lower risk of severe disease (OR % CI ). Non-separation of mother and newborn led to successful initiation of breastfeeding and manifested in high exclusive breastfeeding rates: 90 to 100% upon discharge, 85% at day 7, 69% at day 28. Because of the EINC initiative, safer maternal care practices were adopted by the participating hospitals including soaring rates of practice of the Active Management of Third Stage of Labor (baseline 28% to 100% mobility and position of choice in labor (from 0% to 100% in most sites), partograph use (0% to 100% in one hospital), and antenatal steroid administration in preterm labor (from 0 to 100% in most of the pilot hospitals). Initial results from the systematic EINC implementation in 11 hospitals have documented positive outcomes, with admissions to the neonatal intensive care units dropping by 50% to 75% in some hospital sites. Neonatal sepsis rates were reduced by as much as 70%. There was a reduction in term newborn deaths by as much as 50% in many of the sites. These good results were used in initital efforts to leverage national policy to ensure scale-up beyond the initial sites. The quality standards of EINC were successfully lobbied for inclusion in the Philhealth benefits packages for newborn and maternity care. Congruence between social health insurance guidelines and DOH regulatory documents need to be ensured. Documentation of the EINC results and experience in JPMNH Phase II will be part of the knowledge products that would be made available to the audience as deemed appropriate: health professionals, local health managers, and general public. Phase 2 activities will also build on the gains made in the Transition Phase in which updates such as EINC were incorporated in the curricula of doctors, nurses and midwives schools. C3.3 Lessons on increasing access 15 Community mobilization and participation contributed to the increased utilization and access to MNCHN services among the GIDA/ urban poor population in JPMNH areas. The Reaching the Urban Poor (RUP) initiative had individual sites that were able to demonstrate progress in increasing access to and better utilisation of primary health services, e.g. Navotas. 13 The MNCHN Manual of Operations, 2 nd Edition. Department of Health; March This is cognizant of the findings of the IPR mission per the Independent Progress Review of the UN Joint Program on Maternal and Neonatal Mortality Reductions Philippines; Section 3.1, page 12 and Section 7.2, pages Ibid

12 Table 2: Navotas RUP end of project results against baseline Baseline End-of-Project Number of deliveries with at least 4 ANC visits 934 2, 321 beginning in 1 st trimester Number of facility based deliveries 870 2, 276 Number of newborn breastfed within first hour In Tacloban results were as follows: Table 3: Tacloban City RUP end of project results against baseline Baseline End-of-Project Number of pregnant women with at least 4 ANC Visits Number of facility-based deliveries Number of newborn breastfed within first hour Efforts to improve health seeking behaviour especially among the marginalized segments of the population need to be supported and scaled up in the next Phase. There is a need to harmonize the community mobilization and participation processes used in JPMNH project sites to align with government strategies under the Universal Health Care strategy targeted at the 4Ps /CCT program beneficiaries in urban poor communities and in GIDA municipalities. In some JPMNH areas, partnerships between the LGUs and civil society organizations in implementing interventions for their urban poor population have shown good results in terms of increasing access and utilization to MNH services. However, there is a need to build the capacity of the LGUs to manage and sustain partnerships with the private sector. 16 C3.4 Lessons on strengthening Family Planning 17 The Transition Phase underscored the importance of leveraging government efforts to provide access for long-acting and permanent FP services to the poor through public-private partnerships as well as provision of commodities. In areas where availability of trained FP providers are limited, the private providers through the FP Consortium has substantially covered a significant number of unmet need for bilateral tubal ligation, non-scalpel vasectomy and IUD provision in close collaboration with CHOs, PHOs CHDs. The introduction of Implants in selected areas in Manila have also resulted to a positive response from the Department of Health to include it as part of the method mix in selected DOH-retained facilities and provinces to address unmet needs for safe and effective FP methods. C3.5 Lessons on addressing health system constraints 18 The Transition Phase also demonstrated that, the participation and involvement of key DOH officials at the national and regional levels and at the LGUs needs further strengthening in the next phase. At the same time, local ownership of the JPMNH interventions in the JPMNH sites must be assured by participative assessment of the local situation, a process to identify what it takes to improve their maternal and newborn health status, and determine how the JPMNH assistance could be leveraged in responding to their priorities and needs. The Department of Health has called on development partners to support government efforts to implement MDG breakthrough strategies and the localization of the MNCHN strategy. One of the interventions that the next phase of the JPMNH should support is the establishment of the Service Delivery Network or SDN. In the transition phase, the program has had some successes in implementing and establishing models of some of the SDN components such as improvement of the quality of services at the tertiary level (e.g. EINC), establishment of community volunteer groups or CHTs, PhilHealth accreditation of health facilities and provision of equipment for upgrading of primary health facilities for BEmONC accreditation. Implementation 16 Ibid; Section 3.3 (bullet #3), page Ibid; Section 1.3, page 7; Section 3.1, page Ibid; Section 1.2, pages

13 during the transition phase also clearly showed that to effectively establish the network, there is a need for a mapping of all the health facilities at the community and city or municipality levels. There is also a need to establish partnerships with private health care providers particularly in urban areas where many of these types of facilities are significant service providers. C3.6 Lessons from organisational and management arrangements in the Transition Phase The Transition Phase has revealed the challenges of having a joint programme amongst agencies of different mandates, programme and geographic focus. Despite the effective technical interventions, without complementation of interventions or focus on common geographic areas, overall impact of the JPMNH was diluted. The JPMNH implementation phase will benefit from the UN Development Assistance Framework and the evolving role of the UN Coordination Office in facilitating the coordination and collaboration across agencies and clearer geographic and technical convergence. UNCO s roles include coordination among agencies, with AusAID and national DOH; situating JPMNH within the UNDAF, and contributing towards building more trust, collegiality, collaboration and communication among all three agencies. UNCO will ensure greater emphasis and consistency with delivering as one in which the Philippines UN Office has invested. It was acknowledged in the transition phase that mechanisms for jointness need to be clarified and agreed upon by the agencies for collaboration and cooperation to happen in the JPMNH sites. The management and monitoring & evaluation systems also have to be harmonized between agencies. Coordination mechanisms such as joint planning, joint monitoring (e.g. field visits, reporting, program implementation reviews) and communication flows must all be agreed-upon at the design and conceptualization stage and strictly observed as the implementation progresses. C3.7 Lessons from working with other donors Health system strengthening towards maternal and newborn death reduction requires substantial resources and mix of technical expertise and ground-level experience. There are a number of development partners and civil society organizations engaged in the same efforts, and just like the UN agencies, have their own mandates. It has been seen and is highly probable that in some areas, programs and interventions will be duplicated. It is therefore important to have a programmatic framework where different partners can identify their niche to support the MNCHN strategy. Alignment with national policies and standards is a crucial component of such framework. Existing coordination mechanisms such as DOH Bureau of International Health Cooperation (BIHC) and venues like the Health Partners Meeting should be maximized to avoid duplication and competition. From the Transition phase experience, it is therefore, not only important to mobilize and advocate for more resources but also to equip the DOH and LGUs on how to effectively plan, absorb and utilize these resources to meet the large unmet of FP/MNH in their localities. The coordinating mechanisms for donor agencies should be strengthened not just at national level but also at the regional and local levels in order to harmonize and maximize the support of donor agencies and CSOs. C.4 Strategic Setting and Rationale for Australian/AusAID engagement C4.1 Strategic setting for AusAID engagement AusAID s country cooperation strategy for aligns with the Philippine Development Plan for One of the AUsAID s strategy s aims, based on the Comprehensive Aid Policy Framework (CAPF), is to provide equitable access to basic health care for all, while reducing maternal and child mortality, and morbidity -- all of which are directly supported by the JPMNH. 19 The JPMNH began from the AusAID country cooperation strategy of It was aligned with Australia s development strategy towards the achievement of MDGs 4 and 5. The current cooperation strategy however no longer includes development aid in the health sector. Notwithstanding, the JPMNH is 19 Ibid; Section 1.1, pages AusAID, Australia-Philippines Development Assistance Strategy ,

14 strongly aligned with the current AusAID CAPF 21, as it addresses local government service delivery, emphasizing on local government capacity building, creating political support for essential health services and evidence-based policy making. Moreover, the JPMNH is closely aligned with the cross-cutting themes of the CAPF such as good governance, gender equity and inclusive development. (For further details, please refer to Sections E7.2 and E7.3). The JPMNH is consistent with AusAID s Family Planning Guidelines (2009) The Philippines high population growth has increased demands on basic services with subsequent delays in achievement of the MDGs. Population control is important to curb the high population growth in the Philippines and achieve MDG 5. 22,23,24 One of the JPMNH s strengths is the support for family planning through capacity building for training, procurement of contraceptives, and demand creation. Health (saving lives) is one of the five strategic goals for AusAID in the CAPF. 25 This is where the JPMNH is most relevant to the broader Australian Government s global aid policy. The program has also established its relevance on the strategic areas of (a) effective governance, through fostering increased collaboration between LGUs and CSOs (as in the case of RUP initiatives); and (b) sustainable economic development as overall interventions target CCT families in the selected sites. AusAID has invested in the CCT program aiming to reduce poverty and improve essential service utilisation of the poorest households in the Philippines. This program addresses supply side issues for services to these households, and addresses other problems of access to services such as poor referral networks and lack of transport in emergency deliveries. Within the UN family the JPMNH has been developed within the strategic context of the UNDAF, which like AusAID s Australia-Philippines Aid Program Strategy ( , supports the Philippines Development Plan. The UNDAF is expected to help realize the capacity development requirements of the Philippine Development Plan (PDP) including the country s commitment to the 2015 MDGs. Its theme of supporting inclusive, sustainable and resilient development, specified several outcome areas that need focused attention and assistance from the UN agencies. Outcome Area No. 1 is universal access to quality social services with focus on the MDGs. where reproductive health, maternal and newborn health care are one of the key elements. JPMNH fits within that Outcome Area. Development outcomes to be achieved through this programme are: Reduced maternal and neonatal mortality Improved governance of health services at both local and national levels Improved delivery of essential health services Poverty reduction by improving the economic prospects of children through increased rates of survival and reduced morbidity C4.2 Rationale for AusAID s investment AusAID approved the JPMNH under its previous country strategy when health was still a focal sector for the agency in the Philippines. The JPMNH has demonstrated results in key areas (see section C3: lessons learned). Previous AusAID investment and gains is made at risk if investment is discontinued. The JPMNH has restrategized in this concluding phase to refine its geographic and technical focus to ensure consolidation of gains and maximisation of impact; as well as clarified its exit strategy and sustainability mechanisms. There is therefore a good rationale for continuing funding to the end of the program period, as 21 AusAID, Australia-Philippines Aid Program Strategy ( ), 2012a 22,AusAID, Australia-Philippines Aid Program Strategy ( ), 2012a. 23 DOH, Administrative Order No : National Strategy Towards Reducing Unmet Need for Modern Family Planning as a means to Achieving MDGs on Maternal Health WHO, 2011, Op. Cit. 25 AusAID, 2012c, Op. Cit

15 originally intended. Although the IPR identified a number of issues with implementation in the midpoint of the Transition Phase the UN team has started to address several of these in the last year (2012). C4.3 Donor Mapping In February 2012, as an input to its MNCHN strategic planning, the DOH National Center for Disease Prevention and Control conducted a partners meeting on MNCHN and EINC. An initial output of the mapping meeting indicates that there are many activities related to MNCHN, building up some supply or demand side components or support to the Service Delivery Network. (See Table 3: MNCHN Partners Mapping.) The mapping is useful in identifying geographic overlap of similar projects/programs so these can be avoided in the future and to synergize current efforts. Donors coordinate with government through existing mechanisms mainly through the DOH s Bureau of International Health Cooperation (BIHC) that conducts a quarterly Health Partners meeting among representatives from the donor community active in the (health) sector. The Department makes use of this platform to inform every one about everyone else s initiatives and how these fit in with the respective thrusts of the agency. JPMNH representation in that meeting is maintained to ensure aid harmonization by identifying collaborative efforts and subsequent donor engagements as well as by staying abreast of developments and concerns identified by the Department that can impact on JPMNH efforts. Juxtaposed against current efforts, the JPMNH Phase II with its approach to establishing SDNs in identified areas of high CCT burden from municipal or city to provincial and regional is unique among the initiatives mapped. Even in areas of overlap, target segments for interventions differ. PRISM, for example, deals with private practicing midwives, while the JPMNH will work with the public health sector in capacity building. In areas where previous efforts have ended (e.g., HEALTHGOV), JPMNH planned interventions may assist in bringing the gains achieved to come full circle, i.e., in a functional service delivery network. Mothers and newborns needing appropriate care cannot be expected to stick to geopolitical boundaries at the time of need during the delivery period. If the SDN is functionalized, contiguous areas will also potentially benefit. Table 3: MNCHN Partners Mapping Partner MNH Initiatives Notes/ Opportunities for Cooperation PRISM II (USAID funded) HEALTHGOV (USAID funded) JICA Population Services Pilipinas Incorporated (World Bank funded) improving health system through policy, stewardship and CHD buy-in Mapping of LGUs practicing Active Management of Third stage of Labor and EINC; Installation of Service Delivery Excellence in Health (SDExH), a client focused standards based quality improvement approach for FP-MNCHN services at the health facility; health promotion activities Health system strengthening for Maternal and Child Health Family Planning services provision and PhilHealth accreditation of providers of maternal care - Overlapping areas in NCR and Region 12; also in Regions 1,2,7 and 8 - Program ends in Output contributory to JPMNH planning and implementation; with some overlapping provinces such as Saranggani and Sultan Kudarat, however program ends in USAID, through HealthPRO, is currently engaged in several IEC campaigns with DOH, promoting both natural and modern methods of family planning. - In terms of policy formulation, USAID can look at LGUs with no RH ordinances and GAD codes - No overlap with JPMNH proposed areas (Region 8 and CAR) - Initial roll out in Region 8 in late 2012; potential for collaboration if they will expand to contiguous or overlapping provinces 1. 15

16 MSD foundation a. UNCLASSIFIED Partner MNH Initiatives Notes/ Opportunities for Cooperation EU funded NGO partners Good governance for MCH in District 3 of Quezon City, Increase the utilization of the maternal health services by organizing and training barangay health leaders health promotion and communication RH rights and services, policy support for RH and MCH in various provinces - Potential partner in QC District 2 site. Currently in District 3. - Covers ARMM, which is contiguous to JPMNH sites. Also with presence in Quezon City D. Investment Description D.1 Logic and Expected Outcomes D1.1 Program Impact: The ultimate goal of the program is to reduce maternal and newborn mortality in the JPMNH sites. D1.2 End of aid outcome: To improve quality, access and utilization to intrapartum, postpartum, and family planning services in JPMNH areas by improving the functionality of service delivery networks, in line with the Philippine Department of Health s MNCHN strategy. At the time of proposal development, baseline data for key outcome indicators (e.g.,sba, FBD, FP utilization) are available from secondary sources down to the provincial level only. (Please see Table 8: Logical Framework) While it is ideal for firm targets to be stated at this point, the JPMNH will utilize a participative and consultative process with the local government units, including municipalities, in setting the final targets. The target-setting process will use as benchmark the results of the AusAID-funded 'Investment Case for Scaling up Equitable Progress Towards MDGs 4&5 in the Philippines', where, applying certain modeled strategies or packages of assistance, neonatal mortality (NMR) is reduced by 18%, under 5 mortality (U5MR) by 16% and maternal mortality (MMR) by 45% in a rural setting. For an urban setting, the expected impact includes a 6% reduction in NMR, 8% for U5MR and 14% for MMR. To this end, baseline data and annual milestones/target shall be completed within four months from the start of the JPMNH. During this period, the JP will conduct an evaluability assessment, a detailed situational analysis/baseline study, and strategic planning workshops with the DOH and field implementing partners (LGUs) to discuss and commit to SMART (Specific, Measurable, Attainable, Realistic, Time-bound) targets. D1.3 Rationale for programme focus The intrapartum and postpartum periods are the focus of this JPMNH phase since most maternal deaths occur during labor, delivery or the first 24 hours post-partum and most complications cannot be predicted or prevented. Neonates account for approximately half of all under five deaths, and among neonates, 50% of deaths occur in the 48 hours surrounding labor deliver and the immediate postpartum, with an additional 25% of deaths occur in the remaining days of the first week of life. Philippine studies have also documented that the evidence-based practices to prevent deaths in these crucial periods are inadequately practiced in a 2009 landmark observational study of 481 births in 51 hospitals. (Sobel et al 2011). (See also section C2) Family planning is included in the JPMNH because it is a low cost effective intervention to reduce maternal and neonatal mortality. It is estimated that at least 20% of maternal deaths could be averted if women avail and comply with FP services, with any modern method of their choice. D1.4 Programme beneficiaries The JPMNH will be targeted so that it complements CCT program efforts by increasing the quality of intrapartum, postpartum and family planning services while the RUP and CCT/4Ps interventions bring the families to the service providers. SDNs are to be developed in an urban poor setting with a high density of CCT beneficiaries and in rural settings with geographically isolated and disadvantaged areas: highland and coastal municipalities. The 1. 16

17 JPMNH will focus on the service delivery networks that are or should be accessed by CCT households in the following areas: Rural: Region 12: Municipalities of Lebak and Kalamansig in Sultan Kudarat Province (40,475 CCT households); Malungon municipality in Saranggani Province (30,000 CCT housesholds); Municipalities of Aleosan, Midsayap, Arakan and President Roxas in North Cotabato Province (77,605 CCT households) Urban: Quezon City (NCR): The poorest district of the highly urbanized Quezon City, District 2 (with 9,555 CCT population). Other households using the same service delivery networks will also benefit from improvements. These are likely to be poor households because they are the primary users of public health services. The JPMNH will become more inclusive within region 12 by providing selected interventions to facilities and LGUs. The total population that may benefit from the JPMNH in region 12 is 241,575 CCT population. All three UN agencies are present in these areas and as a team are able to operate across the service delivery networks. D1.5 Theory of Change The impact that the JPMNH hopes to achieve is the reduction of maternal and newborn deaths and contribute towards the achievement MDG 4 and 5 in the Philippines. To bring about this goal, the building blocks that must be in place comprise the service delivery network. If the service delivery network is fully functional, mothers and new-borns can access skilled birth attendance in a facility, receiving quality care in the critical periods that are highest risk for mortality: the intrapartum and postpartum period or family planning services as appropriate. The key components leading to improved quality, access, and utilization of intrapartum, postpartum and family planning in JPMNH areas are community mobilisation efforts, referral system, supply side elements of quality IP, PP and FP services, and strengthened health system building blocks (governance, information systems, vital registration and death reviews, health financing, and publicprivate partnerships). (See also Annex 7). The UN experience in implementing the JPMNH through a joint effort with DOH and local government and private-public partnerships (PPP) to achieve synergies through a combination of the agencies comparative advantage is a relatively novel approach. The experience of SDN building as well as joint programming will also be gathered and disseminated to government and development partners. D1.6 The MNCHN Service Delivery Network (SDN) The MNCHN Service Delivery Network envisioned by the DOH refers to a network of facilities and providers (both public and private) within a province-wide or city-wide health system offering the MNCHN core package of services in an integrated and coordinated manner. It includes the communication and transportation system supporting this network, and community level providers, Basic Emergency Obstetrics and Newborn Care (BEmONC)-capable network of facilities and providers, and Comprehensive Emergency Obstetrics and Newborn Care CEmONC-capable facilities or network of facilities to address access and quality issues in maternal and newborn care. Post-partum care, including comprehensive family planning services, is provided by the BEMONCs and CEMONCs. The JPMNH will seek to operationalise the MNCHN SDN. a. Community level providers give primary health care services. These may include outpatient clinics such as Rural Health Units (RHUs), Barangay Health Stations (BHS), and private clinics as well as their health staff (i.e., doctor, nurse and midwife) and volunteer health workers (i.e., barangay health workers, traditional birth attendants). At this level of care, the emphasis is on birth preparedness and complication readiness. Women and families will be provided with antenatal education and support to develop individual Birth Plans, to ensure women, families, and their community understand the processes to take during obstetric emergencies. It is also at this level of care that pregnant women are encouraged and assisted to enrol in Philhealth in preparation for delivery

18 b. Basic Emergency Obstetric and Newborn Care (BEmONC)-capable facilities can be hospitals, RHUs, BHS, lying-in clinics or birthing homes. If the BEmONC is hospital based, blood transfusion services which may or may not include blood collection and screening will be provided. These facilities operate on a 24-hour basis with full staff complement of skilled health professionals such as doctors, nurses, midwives and medical technologists. BEmONC facilities need access to emergency transport and communication facilities. The provision of blood transfusion services in non-hospital BEmONCs is dependent on the presence of qualified personnel and required equipment and supplies. c. Comprehensive Emergency Obstetric and Newborn Care (CEmONC)-capable facilities are endreferral facilities capable of managing complicated deliveries and neonatal emergencies. The facility should be able to perform the six signal obstetric functions 26, as well as provide caesarean delivery services, blood banking and transfusion services, and other highly specialized obstetric interventions. The facility should also be capable of providing neonatal emergency interventions, which include, at the minimum, the following: (a) newborn resuscitation; (b) treatment of neonatal sepsis/infection; (c) oxygen support for neonates; (d) management of low birth weight or premature newborn; and (e) other specialized neonatal services. D1.7 Programme interventions In order for the JPMNH to achieve its impact and outcome, it is firmly aligned with the MNCHN strategy that defines a core package of services to be delivered by providers that comprise the service delivery network. The MNCHN Core Package of Services consists of interventions that will be delivered for each life stage: pre-pregnancy, pregnancy, delivery, and the post-partum and neonatal periods. The JPMNH will focus on supporting intrapartum and postpartum, and family planning interventions, creating demand for services to increase utilisation, and improve the health systems underpinning the delivery of the core package of services and the service delivery network. JPMNH interventions are summarised in the Program logframe in Annex 2: JPMNH activities are described below, listed according to the contributory sub-outcomes: Improve the quality of facility based intrapartum and post-partum care (Sub-outcome 1): To improve quality of care in health facilities designated as BEMONCS, facilities shall be supported to achieve full capacity to carry out the six signal functions. Support includes training for health staff, provision of equipment and supplies, and provision of operational standards. The same support shall be provided for the designated referral centers or CEMONCS. Essential intrapartum and newborn care (EINC) is a key intervention that improves clinical outcome as well as quality of care, as documented in the first phase of the JPMNH implementation (see lessons learned). Management of labour using partograph and active management of the third stage is one of the central elements of quality intrapartum care. Institutionalization of EINC in the facility shall be done using a quality improvement approach, i.e., facilities will be supported not just through training, but by programmed supportive supervisions, quality tools and standards, computer-based self-instructional programs, as well as the establishment of a working committee based in the facility. EINC institutionalization will be standardized across JPMNH sites. Adoption of EINC also includes capacitating facilities in client s rights-based and culturally-sensitive intrapartum care, such as allowing women to deliver in their position of choice. Based on first year experience, the process of local facility EINC adoption takes between 3 to 6 months. As in the Transition phase, the JPMNH will support the BEMONC training of health staff, contract local NGOs to provide technical assistance to facilities and local government health offices in institutionalizing operational standards, and provide supplies to a limited extent, and preferably as leverage for local procurement. Equipping facilities shall be highly selective based on high degree of need. The JPMNH will not support the building of facilities. Generate demand for IP and PP services (Sub-outcome 2): 26 The six signal functions of BEMONC are (1) parenteral administration of oxytocin in the third stage of labor; (2) parenteral administration of loading dose of anti-convulsants; (3) parenteral administration of initial dose of antibiotics; (4) performance of assisted deliveries in imminent breech; (5) removal of retained placental products; and (6) manual removal of retained placenta. Implementing health reforms towards rapid reduction in maternal and neonatal mortality. Manual of Operations. DOH

19 Community health teams (CHTs) or existing community-based maternal and newborn support groups shall be organized, mobilized and capacitated in JPMNH areas. Enhancing the mandated function of CHTs to increase utilization of Philhealth enrolment especially of CCT families belonging to socioeconomic quintile 1 (sponsored by the national government) and quintile 2 (sponsored by the local government unit), CHTs will also be trained in health promotion and education, including educating families on appropriate care-seeking for postpartum complications. In urban areas, the Reaching the Urban Poor approach shall be replicated. Demand generation components will be tailored for targeted groups such as adolescents and indigenous peoples. To the maximum extent possible, existing Communication for Development and behaviour change communication packages of DOH will be utilized. The JPMNH will support the training of LGU health staff, including health promotions officers, in communication for development using knowledge products already developed by the DOH. As in the transition phase, the approach used in Reaching Urban Poor initiative to contract local NGOs to implement community based interventions will be utilized. Improve the availability of quality FP services (Sub-outcome 3): Regional Training Centers of Excellence and the local chapters of the Family Planning Society will be tapped to provide competency-based training and quality assurance support to service providers and facilities in the provision of short, long-acting and permanent FP methods in JPMNH sites. To address stock-outs and enhance reproductive health commodity security, the JPMNH will strengthen logistics information systems and provides support to local governments in undertaking local forecasting and monitoring stock levels. JPMNH will advocate for LGU budget allocation for the procurement of FP commodities through the adoption of the Contraceptive-Self Reliance Policy at the city, municipal and provincial levels. To meet the sexual and reproductive health needs of young people (i.e. to address the high incidence of teen pregnancy and HIV/STI infections among the youth), the JPMNH will engage CHDs to provide technical support and supervision to health providers in the use of Job-Aid Manual in the provision of ASRH information and services. Public- private partnerships will be strengthened in the provision of quality contraceptive information and services to enable young mothers practice effective birth spacing. Community health teams and organizations will be engaged to create increased demand for modern FP methods as well as address gender issues that obstruct women to access and use family planning. The JPMNH will support capacity building for providers and managers of family planning services through partnerships or contracting of family planning professional organizations and NGOs to provide technical assistance to LGUs. Direct support to local government units for the limited procurement of commodities for JPMNH sites will also be employed. Strengthen the health systems of JP areas in support of IP, PP and FP (Sub-outcome 4): Intrapartum and postpartum care, as well as family planning services should be supported by health system instruments to sustain quality implementation.. The health system building blocks to be strengthened essentially addresses the bottlenecks identified in the investment case analysis: critical inputs, accessibility to human resource, physical accessibility, demand side interventions, continuity of care, and quality of services. If these are improved for intrapartum, postpartum and family planning services, other primary health care programs administered by the same health facilities and workers will conceivably also benefit as a result of increased efficiencies (e.g. of health staff), easier access and more resources (e.g., availability of Philhealth capitation funds). Capacity of CHDs on providing technical assistance to LGUs on IP/PP care and Family Planning elements of MNCHN shall be provided, including the use of the MNCHN monitoring tool. Other CHD technical assistance to be strengthened includes the conduct of regular maternal death review (MDR) and the addition of neonatal death review to the MDR process, with mechanisms and processes to disseminate and refer maternal and neonatal death review findings to the appropriate health policy-making bodies. Health information systems in the JPMNH sites shall be improved by installing interoperable systems such as the Community Health Information System or CHITS. (Please see Annex 2, Sub-Outcome 4.8). Monitoring and supervision of facility staff will be implemented; to improve quality of data management. Data generated shall be advocated for use in planning. Support will be offered to strengthen vital registration systems through barangay level 1. 19

20 efforts to capture births, deaths and vital events by the local civil registrar by interventions piloted in the transition phase (the Move It project of the National Statistics Office). Support to set up the referral system through necessary transportation and communication channels for intrapartum and postpartum care shall be provided. For example, in the transition phase, boats were provided for an island municipality. Technical assistance for appropriate up-referrals i.e., from a BEMONC to a CEMONC as well as down-referrals to decongest crowded hospitals, and appropriate systems to track patients and receive feedback shall be provided. Where the LGU is a member of a defined Interlocal health Zone (ILHZ), such functionality of the ILHZ shall be supported. Local government units and Centers for Health Development are encouraged by the Department of Health to engage in public-private partnerships for health care delivery. The capacity to manage PPP s may not exist in these offices and shall be included in health system strengthening inputs by the JPMNH. Support for local chief executives on capacity for local governance for IP/PP care and Family Planning shall be offered, including health leadership training, localization of relevant health policies and laws, use of evidence and community participation in health planning, and allocation of resources for IP, PP and family planning. Technical assistance to LGUs for Philhealth accreditation of facilities will be provided. To ensure that the RH needs of internally displaced people during emergencies are met, JPMNH will assist local government partners in the provision of the Minimum Initial Service Package on Reproductive Health (MISP-RH) that includes distribution of RH kits. The JPMNH will support the technical assistance to be provided by professional groups and relevant NGOs for capacity building and/or institutionalization of interventions such as maternal and neonatal death reviews, MNCHN monitoring tool, referral systems, and PPP management. Specialized providers of health system elements such as health information systems, barangay vital registration system, will be procured for the JPMNH program sites. Direct support for local health managers in leadership and planning will be provided. The interventions are inputs to health programs that are mandated by national policy, planned, or currently implemented but of suboptimal quality. The exit strategy of this investment will include incorporation in local health plans, allocation of budgets, and advocacy strategies with local chief executives and health boards, so as to ensure that local government takes over the running and maintenance of these inputs. Public information and demand generation for the services and/or the quality standard are also seen as drivers for the adoption by LGUs for sustainability. Institutionalise the joint working approach to program management and implementation (Suboutcome 5) To maximize the individual UN agencies organizational strengths and mandates, and synergize their contributions towards a common goal, mechanisms and structures are set forth in Phase II of the JPMNH to operationalize joint working, as detailed in Section E (Implementation Arrangements). Implementation processes and structure will also facilitate a stronger role of the Department of Health in the JPMNH. The three agencies will work and deliver support on the same provincial, city or municipal service delivery network (SDN) within a specified geographic area. Knowledge generated from the experience of making the service delivery network operational shall be documented via operations research and M&E and shared with DOH, AusAID, other Donors, and UN Agencies. The UN agencies will assure Joint planning, management, implementation, monitoring, evaluation and reporting (see also Annex 5). D1.8 Geographical scope of Interventions: In order to have a population-based impact within a two-year implementation phase, two types of scope of intervention ( packages ) will be provided for the identified areas: 1. Full Support for the Service Delivery Network (Full SDN Package): this would focus on the targeted rural and urban poor communities and the health service delivery system that supports this community. Among the elements of the full package are: Community, BEMONC and CEMONC level providers capacitated to provide quality care Functional Community Health Teams increase demand and utilization of IP, PP and FP services 1. 20

21 Supportive local health policies, plans and budgets (e.g. CSR plans, localization of MNCHN policies/strategies, RH ordinances, support to bottom up budgeting process) Maternal and Neonatal Death Review conducted quarterly with Vital Registration System Strengthened PhilHealth accreditation of facilities Referral system and transportation network for two-way referrals Health information system installed Targeted Support to Facilities (strategic intervention package): This will be applied to the wider areas of region 12 and NCR. Depending on the capacity gaps of facilities and the funds available to the JPMNH, support would include: Quality-of-Care through the Essential Intrapartum Newborn Care Practices (EINC-Package): targeted for lying in clinics, Basic Emergency Obstetric and Newborn Care Facilities (BEMONC) and Comprehensive Emergency Obstetric and Newborn Care Facilities (CEMONC). EINC was seen to show results in decreasing newborn infections and deaths in the facilities while improving quality of maternal care during delivery. Family Planning Support to primary facilities (FP-Package): To avert maternal deaths due to pregnancies of high risk women, commodity provisions will be provided in primary facilities; covering the commodity needs of the CCT families in JPMNH areas. Minimum Initial Service Package for reproductive health (i.e. RH and rape kits): to ensure that JPMNH sites RH needs are met, especially during emergencies and disasters. D1.9 JPMNH Areas The JPMNH team selected convergence areas to enable all three agencies to work together. The starting point was the municipal level as the bottom of the service delivery triangle (i.e. see diagrams on immediately below) as this was the smallest geographical area where UNICEF, UNFPA or WHO worked with communities. Once defined, overlapping higher levels with UN agency presence were mapped. This process enabled the following considerations to be taken into account: LGU with potential for SDN delivery at 3 levels: LGU, provincial, CHD Building on gains in Transition phase- common areas where some components of SDN in place: EINC in CEMONC, RUP activities, family planning commodities and systems Convergence of three UN agencies activities / common country program sites The process built on the list of UNICEF Investment Convergence Municipalities and Cities that were selected based on highest poverty criteria and in common with identified NAPC priority municipalities and cities for poverty reduction (NAPC Memorandum circular : Priority Municipalities for Poverty Reduction ) and readiness for the government s bottom-up budgeting process and ability to independently submit their own local anti-poverty plans, also determined by NAPC. In addition to the equity and vulnerability-focused criteria used by UNICEF in selection of initial municipalities. The selected municipalities are 4th and 5th class municipalities with either a high proportion or absolute numbers of CCT beneficiaries, or with geographically isolated and disadvantaged areas. Additionally, the selected municipalities belong to vulnerable provinces (Saranggani, Sultan Kudarat, and North Cotabato) with SBA coverage of less than 50%. Table 4: List of JPMNH Sites List of convergence LGUs Examples of JPMNH transition phase work to build on Agency Focal Municipal and City Level Malungon in Saranggani province Lebak & Kalamansig in Sultan Kudarat Aleosan, Arakan, Midsayap and President Roxas in North Cotabato Quezon City, District II BEMONC training, PHilhealth accreditation in Saranggani, UNICEF 1. 21

22 a. UNCLASSIFIED List of convergence LGUs Provincial Level Saranggani and Sultan Kudarat provincial level engagement; North Cotabato and Quezon City through PPPs (e.g.,family Planning Society) Regional Level CHD strengthening of Region 12 and National Capital Region Examples of JPMNH transition phase work to build on Agency Focal FP Commodities, system strengthening for Contraceptive selfreliance UNFPA RUP in General Santos and Quezon Cities, EINC model hospitals in 1) General Santos and Cotabato Cities (referral centers for facilities in Saranggani, Sultan Kudarat and North Cotabato) and 2) Quezon City (East Avenue Medical and Quirino Memorial Medical Centers WHO 1. Rural JPMNH Site: Region 12 The rural poor communities targeted are among the government identified poorest municipalities in the country. Interventions will need to consider geographic, cultural and financial constraints in seeking and utilizing quality maternal-newborn care services. a. Full SDN Package will be provided to Midsayap, President Quirino, Aleosan, Arakan, Kalamansig, Lebak and Malungon, the poorest municipalities of North Cotabato, Saranggani and Sultan Kudarat, its primary facilities and its referral facilities; with the end referral facilities of General Santos City Hospital (GSCH) and Cotabato Regional Medical Hospital (CRMC). b. Targeted Support to Facilities: EINC-Package will be provided to all MCP accredited facilities (including lying in and BEMONC facilities) under Region 12 FP-Package will be provided to primary facilities and lying-in facilities under Region 12 to cover the FP needs of CCT families. Urban JPMNH Site: Quezon City The urban poor, mostly informal settlers in the area, live in the largest city of Metro Manila; facing financial and social barriers. a. Full SDN Package will be provided to the CCT families of District 2, the primary facilities 1. 22