Facility Mapping Final Report Complete Version

Technical Assistance to the Health Sector Policy Support Programme
ESTABLISHING THE WOMENS HEALTH AND SAFE MOTHERHOOD FACILITY NETWORK

IN FOURmula ONE for Health Program Provinces
A Report
Submitted by:
Bienvenido P. Alano Jr., PhD

Consultant October 2007
Technical Assistance to the Health Sector Policy Programme in the Philippines An EU funded programme managed by the EC Delegation and the DoH
TABLE OF CONTENTS Executive Summary Acknowledgements Report Objective and Design Rationale The DOH Strategy in Reducing Maternal Deaths in the F1 Context The Facility Mapping Exercise The Facility Maps of F1 LGUs Ifugao Ilocos Norte Nueva Vizcaya Pangasinan Oriental Mindoro Romblon Capiz Negros Oriental Biliran Eastern Samar Southern Leyte Misamis Occidental North Cotabato Agusan del Sur Lessons Learned Next Steps References 3 8 9 11 14 18 20 21 28 34 40 45 53 61 67 75 80 92 97 101 107 117 119 120
EXECUTIVE SUMMARY
This paper reports on the results of an effort to identify in each of the provinces covered by the FOURmula ONE for Health Program (F1), the network of health facilities that could cost-effectively provide an integrated package of womens health and safe motherhood services. This mapping activity represents the initial step in implementing the DOH strategy for addressing the persistently high rate of maternal death in the country. Implementation experience in the F1 provinces is envisioned to guide the rollout effort towards nationwide coverage. An international consensus on the best way to address high maternal mortality rates in developing countries underlies the DOH strategy. It involves a basic paradigm shift in managing pregnancy and child birth. For the past twenty or so years, the strategy of choice emphasized the importance of antenatal care in predicting pregnancy risks and the training of traditional birth attendants to make pregnancy and childbirth at the grassroots level safer. However, recent studies revealed the ineffectiveness of this strategy in reducing maternal mortality in poor countries. The current consensus is that a strategy of encouraging mothers to give birth in adequately-equipped primary level facilities so that they could be attended by a team of skilled providers would be a more effective approach to addressing high mortality rates. The strategy of the Department of Health (DOH) hews to such an approach. It seeks to establish in every province a network of health facilities that could cost-effectively provide basic emergency obstetric care (BEmOC) during childbirth and comprehensive emergency obstetric care (CEmOC) for high-risk and complicated cases. To help ensure that each pregnancy has a favorable outcome and to avoid missed opportunities, the above services are integrated with other interventions that are deemed critical to the mothers reproductive health, e.g., family planning and STI and HIV/AIDS prevention. This integrated package of service is envisioned to be delivered by highly trained teams of skilled health providers in strategically-located health facilities. To ensure that the facility network is tailored to specific needs of the province and adequately addresses local health concerns, important stakeholders are encouraged to conduct a facility mapping exercise. The exercise therefore usually involves the provincial health officer, the provincial health staff, municipal health officers and heads of hospitals. The facility mapping exercises in F1 sites were facilitated by representatives of the DOH central office, with assistance from representatives of the Centers for Health Development (CHDs).
In an effort to ensure that the facilities in the network are accessible, adequately staffed and are well positioned to sustainably deliver the above package of interventions, the process of choosing BEmOC and CEmOC facilities was guided by the following criteria: 1. Population coverage There should be at least 1 BEmOC facility for a population of 125,000 and at least 1 CEmOC facility for a population of 500,000. 2. Travel time A BEmOC facility should be not more than 30 minutes away from each barangay in the catchment and a CEmOC facility should be not more than 1 hour away from a BEmOC in the catchment. 3. Adequacy of human resource A BEmOC Team should have a full staff complement of doctor, nurse and midwife. For BHS BEmOC, a midwife should be assigned to the BHS full time with the municipal health officer or nurse alternately making supervisory visits. (Thus, the number of BHS BEmOCs is constrained by the ability of the doctor or the nurse to supervise them, especially if the BHSs are in remote barangays). On the other hand, a CEmOC Team should be headed by an obsteric-gynecology specialist or a general practitioner trained on CEmOC service provision and at least 1 operating room nurse providing duty time per 8-hour shift. 4. Financial and Operational Sustainability Careful selection of BEmOC and CEmOC facilities should be observed to ensure that catchments do not overlap significantly as to hamper operational and financial sustainability. (This serves as an additional consideration in the application of the travel time criterion. For the catchment areas not to overlap significantly, BEmOCs should be at least 30 minutes away from each other and CEmOCs 1 hour apart). The report shows the resulting map of the womens health and safe motherhood (WHSM) facility network for each of the F1 provinces covered by this engagement. A map indicating the incidence across municipalities of diseases targeted by the Disease-Free Initiative is also shown. Lessons Learned The mapping experience has generated lessons that could guide subsequent mapping efforts in other provinces. Among the most important are: 1. Parochial concerns eventually give way to the greater good of establishing a cost-effective provincial facility network. The initial tendency of most MHO participants is to lobby for the designation of their RHU as a potential BEmOC, as this would result in the RHU being a recipient of grants for upgrading. However, after the intervention model and its objectives have been fully explained to them, such parochial objectives eventually take a backseat to the higher goal of identifying
strategically-located BEmOCs to comprise the provincial facility network. This shift in outlook is facilitated when the PHO exercises leadership during the deliberations and is seen to be adept at handling the touchy task of explaining to the political hierarchy (especially the municipal mayors) the resulting deployment of grant funds across municipalities. 2. Flexibility is key. While a major objective of the exercise is to advocate for the adoption of the DOH strategy for addressing maternal mortality and while the choice of facilities that would receive DOH grants is to be guided by a set of objective criteria, it is crucial not to be too prescriptive in implementation. It is important to keep in mind that the model will only be effective if it responds to the needs of the local population and that its effectiveness rests on a deployment that adapts well to the local situation and melds seamlessly into the local health system. Adopting such an attitude eases acceptance of the model and lays the foundation for eventual ownership over it by those tasked with frontline implementation. Timing is important. Although most workshop participants initially viewed the activity with reluctance, they eventually come around to appreciate the activity as one that offers them an effective tool for objectively allocating their resources and for amicably settling conflicting claims over these resources. However, the universal lament is that why such an activity, which logically should precede an investment planning process, is introduced at such a late stage in the process. Hopefully, this would be remedied in the succeeding roll-out provinces. Consider the political context. The workshop discussions emphasize that nothing much can happen at the local level without involving the local chief executive in the loop. Public health is no exception. There should therefore be efforts to generate political support for the undertaking. Be sensitive to the capability and will of frontline providers. Some MHOs are aggressive in ensuring that their constituents have easy access to BEmOC facilities, while others are reluctant to take on the responsibility of having to supervise these facilities, especially if they are remotely located. An issue of common concern is the legal liability that the MHO assumes whenever the midwife attends to a facility birth. However, do not underestimate their (MHOs) willingness to collaborate and help each other out. The discussions on the issue of supervising remote facilities have revealed a deep sense of camaraderie among frontline health workers in a province. They are usually ready to pitch in to assist an MHO in a neighboring municipality. Many appear willing to contribute their time to help fill in the staff time needed to keep a neighboring RHU BEmOC operational on a 24-hour basis (the model requires a doctor to be always available on call). Enlist the active involvement of the Center for Health Development (CHD). The CHD staff is usually familiar with the territory and the people. This knowledge becomes invaluable during issue-resolution sessions, especially if the regional
3.
4.
5.
6.
7.
representative is someone the participants look up to. Besides, they will inevitably become involved when the time comes to ramp up coverage. One should therefore try to keep them in the loop from the start. Next Steps The objective of incorporating the results of the mapping exercise into the investment plans (PIPH) of the F1 provinces would be realized by undertaking as a next step a Needs Assessment Exercise for those facilities that were designated to be part of the WHSM provincial network. This could expeditiously be accomplished by using the Integrated Needs Assessment Tool which was developed and field tested in WHSMP2 sites. The tool seeks to determine what each facility needs to be upgraded to either BEmOC or CEmOC by first taking stock of current resources and capabilities and then comparing these with the requirements of the service delivery model. The Needs Assessment Exercise is envisioned to generate the following outputs: A strategy for human resource development and training Needed infrastructure improvement A list of equipment and drugs that need to be procured Systems that need to be developed to enhance financial sustainability Recording mechanisms that need to be put in place to allow progress monitoring
From these, one could generate inputs to the PIPH that are focused on enhancing the capability of the provincial service delivery network to address the maternal and neonatal mortality situation of the province.
SUMMARY TABLE OF WHSM FACILITIES Province Ifugao Ilocos Norte Nueva Vizcaya Pangasinan Oriental Mindoro Romblon Capiz Negros Oriental Biliran Eastern Samar Southern Leyte Misamis Occidental North Cotabato Agusan del Sur Number of BEmOC Facilities 27
(4 Hospitals, 5 RHUs, 18 BHSs)
Number of CEmOC Facilities 2 4 3 6 3 5 2 4 1 5 4 3 3 3
21
(3 Hospitals, 18 RHUs,)
11
( 2 Hospitals, 5 RHUs, 4 BHSs)
7
21
9
( 3 Hospitals, 6 RHUs)
20
24
17
(8 RHUs, 9 BHSs)
36
14
7
( RHUs, 1 Puericulture Center)
11
28
(1 Hospital, 5 RHUs, 22 BHSs)
ACKNOWLEDGMENTS Establishing the Womens Health and Safe Motherhood Facility Network in the FOURmula ONE for Health Program Provinces is a great challenge made easy by the cooperation and enthusiasm of the Local Health Officers. The consultant is truly appreciative of the LGU effort and acknowledges the hard work of the Provincial Health Officers, all the Municipal Health Officers, Chief of Hospitals, Local Government Planning Officers and Finance Officers who participated in the workshops as well as the Technical Staff of the Provincial Health Office, the Nurses and Midwives of the Municipal Health Offices and Hospitals of the following Provinces: Ifugao, Ilocos Norte, Pangasinan, Nueva Vizcaya, Oriental Mindoro, Romblon, Capiz, Negros Oriental, Biliran, Eastern Samar, Southern Leyte, Misamis Occidental, North Cotabato, Agusan del Sur. The consultant is likewise grateful to the following offices of the Department of Health for the technical assistance extended: National Center for Disease Prevention and Control, especially Ms Zenaida Dy Recidoro, Chief Health Program Officer and Program Manager of the National Safe Motherhood Program, who expertly and conscientiously performed the task of Technical Coordinator for this undertaking and ably represented her office (NCDPC) and DOH in all the provinces visited, Bureau of International Health Cooperation, Health Policy Development and Planning Bureau, Bureau of Local Health and Development and the Centers for Health Development in CAR, Ilocos, Southern Tagalog (MIMAROPA), Central Visayas, Eastern Visayas, Western Visayas, Northern Mindanao, Central Mindanao and Caraga. Thanks are also due the Staff of the Center for Economic Policy Research, for the invaluable staff work. Lastly, this consultancy will not be possible without the technical and funding support of the Technical Assistance to the Health Sector Policy Programme in the Philippines, a European Union funded program managed by the European Commission Delegation and the Department of Health. It is to all of you that this Project is truly beholden.
B. P. Alano Jr., PhD
REPORT OBJECTIVE AND DESIGN Current trends in maternal mortality in the country call for urgent attention. The challenge is for the Department of Health (DOH), to achieve the Millennium Development Health Goals (Health MDGs) by 2015, a Philippine government commitment to the international community. Among the Health MDGs, meeting the goal on maternal health by 2015 - including the target that seeks to reduce the maternal mortality ratio (MMR) by three-quarters - poses a challenge and has become the focus of investments by the DOH. While the MMR target is ambitious, the goal is attainable. There are inspiring examples of success from countries that experienced remarkable drops in the maternal mortality ratio, an indicator of the safety of pregnancy and childbirth. These examples remind us that with the right policies and conditions in place, dramatic and rapid progress is possible. A new approach to reduce maternal death has been adopted for implementation under the FOURmula ONE for Health Program (F1). The new approach calls for a paradigm shift in maternal and newborn care service delivery that is simple and relatively inexpensive. The new paradigm views all pregnant women to be at risk of complications and should have easy access to both basic and comprehensive emergency obstetric care. Relative to the Philippine governments robust bid to achieve MDG 5 the national advocacy is for all local governments to establish facilities that can provide emergency obstetric care in places nearest to homes and to integrate related basic services into a single service package so that missed opportunities in health particularly those that target women are avoided. The service package seeks to improve public health service in the areas of maternal and newborn care, family planning and STI prevention and HIV control, important elements of reproductive health that are viewed as having the greatest impact on womens health. Establishing these facilities starts with two critical activities: Facility Mapping and Needs Assessment. These activities seek to 1) identify a province-wide network of strategically located health facilities that could cost-effectively pursue the above objective and 2) generate a rational investment plan that would rapidly and effectively upgrade the capability of each facility to address maternal mortality in the province. Activity Objective The main objective of this Report is to present the Facility Maps which are customized to fit the local situation in each of the 14 provinces participating in the F1 for Health Program. The maps identify strategically-located facilities that can effectively deliver the womens health and safe motherhood service package, especially, basic and comprehensive emergency obstetric and newborn care services.
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This Report is presented in 5 parts: I. Rationale gives a brief account of the debate on how best to address the high maternal mortality ratios in the developing world and describes the current consensus and how it was arrived at. To complete the context, the Philippine situation is also briefly described. This section serves as a backdrop for a description of the DOH strategy for achieving MDG 5.
II. The DOH Strategy for Reducing Maternal Deaths in the F1 Context is a discussion of the womens health and safe motherhood integrated intervention model which was designed in the context of the F1 reform pillars. III. The Facility Mapping Process explains how the Facility Maps are tailored to fit local situations through a participative approach. It describes the consensus-building process and the issue-resolution mechanisms used to generate agreement on the facility maps. IV. The Facility Maps is a presentation the Provincial Facility Maps and convey the result of the consultations with LGU stakeholders. It describes specific circumstances that apply to each province, the unique factors considered in each and the dynamics of the discussions with the local health officers. V. Lessons Learned and Next Steps reflects on what could be done to improve the planning process in the roll out sites and the immediate next step.
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RATIONALE The Global view

During the 20 years of international and national advocacy for safe motherhood, an estimated 10 million women have died of maternal causes. For this to happen in a world where we state that we know what works and that 88-98% of maternal deaths are preventable is obscene.
(Campbell OMR, Graham WJ, Lancet 2006).
The above statement expresses the collective frustration of the international community over the persistent failure to address the problem of high maternal mortality ratios in developing countries. This section tries to give a brief account of what works in order to serve as a backdrop for the attempt to apply these strategies to the Philippine situation. But first, it would be useful to review those strategies that have been found to be ineffective and to try to cull lessons learned from their implementation. What Has Not Worked Two basic strategies have underpinned past efforts to address high maternal mortality ratios: applying the risk approach through antenatal clinics and TBA training (traditional birth attendants). (De Brouwere, et al. 1998). The risk approach takes the view that a sufficient number of antenatal visits would allow the attending health provider to identify at-risk pregnancies and anticipate complications. (Tucker J, Florey CdV, Howie P, Mellwaine G and Hall MH. 1994, in De Brouwere, et al. 1998).i Thus the focus during the 1970s and 80s was to promote the development of antenatal clinics and to encourage mothers to make the necessary number of antenatal visits (V. De Brouwere et al. 1998). The risk approach went practically unquestioned until a series of studies were done in the 80s, which revealed the low predictive value of antenatal visits. In a study of antenatal clinics in Aberdeen, Hall et al. (1980) showed that antenatal clinics were not effective in predicting and identifying obstetric problems. This finding was subsequently reinforced by the results of the Kosongo study (Kosongo Project Team 1984) showing women at risk to be only a small proportion (29%) of all women with obstructed labor. Maine et al. (1991), in turn, used this finding to argue that antenatal clinics could not effectively identify most complications that threaten a mothers life (V. De Brouwere et al 1998). The current consensus is that even in developing countries where the prevalence of risk is higher, antenatal screening has low predictive value because of its low sensitivity (30%) and its relatively low specificity (around 90%) (Chang et al. 1980; Hall et al. 1980; Koblinsky et al. 1994;
Walsh et al. 1994; Acharya 1995; Rohde 1995; Yuster 1995; Dujardin et al. 1996; McDonagh 1996) (quote from V. De Brouwere et al. 1998).
TBA training was the other strategic axis. It was justified by the observation that there were not enough professional health providers to attend to mothers in need of maternal care. TBAs, on the other hand, were highly accessible, especially in the rural areas. They
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were also culturally acceptable and were usually able to influence a mothers healthseeking behavior. Training them on modern methods of childbirth was therefore widely seen as a logical solution to the health provider gap. Moreover, community empowerment was at the core of the primary health care strategy in the 70s and training TBAs was fully consistent with this overarching objective. The mid 80s saw the emergence of studies evaluating TBA performance and voicing skepticism about the strategy (Namboze 1985, Ross 1986). This gradually developed into a shared conclusion that the training of TBAs has had little impact on maternal mortality and that the most effective measures were those that which make it possible to reach a well-equipped hospital (Greenwood et al. 1990; Maine et al. 1991;Fauveau
& Chakraborty 1994; Koblinsky et al. 1994; Turmen & AbouZahr 1994) (quote from De Brouwere et al. 1998).
De Brouwere attributes the failure of the TBA training strategy to a number of important elements that were underestimated by its proponents (De Brouwere et al. 1998). First was the degree of variability of the function, knowledge and experience of TBAs. In some regions, the TBA is an experienced woman who has survived several pregnancies herself and carries out several dozen deliveries a year. Elsewhere, the TBA may be a woman whose sole role is to reassure and give comfort to the mother during the few deliveries that she attends. Framing a strategy that does not take into account this wide variation would be technically invalid. Second was the amount of supervision needed to ensure the safety of TBA-attended childbirth. Since this amount is inversely proportional to the level of training, the TBA therefore needs much more supervision than a professional midwife. This need is underscored by the observation that some TBAs tend to delay or even discourage women with complications from going to the hospital ( Estrada 1983; Catfish 1987; Viegas et al. 1987). However, such supervision intensity is hard to sustain in a situation where the rural health physician is already overextended. What Works There is a global consensus on what works to address maternal death. This is embodied in a joint statement by WHO, UNFPA, UNICEF and the World Bank in 1999, calling on countries to ensure that all women and newborns have skilled care during pregnancy, childbirth and the immediate postnatal period (Reducing maternal mortality. A joint statement by WHO/UNFPA/UNICEF/World Bank. Geneva, World Health Organization, 1999). Such care is to be provided by a skilled attendant - an accredited health professional (midwife, doctor or nurse) who has been educated and trained in the skills needed to manage the abovementioned stages in pregnancy and childbirth as well as in the identification, management and referral of complications. To ensure the best possible outcome, childbearing women should have access to a continuum of care provided by a functioning health care system with the necessary infrastructure in place, including transport between the primary level of health care and referral clinics and hospitals (WHO 2004). In 2006, the Lancet came out with a 5-article series on maternal survival called The Lancet Maternal Survival Series. In the 2nd article, the authors contend that while the 13
concept of knowing what works in terms of reducing maternal mortality is complicated by a huge diversity of country contexts and of determinants of maternal health only a few strategic choices need to be made to attain the objective. They go on to make a compelling case for prioritizing just one strategy based on delivery in primary-level institutions (health centers), backed up by access to referral-level facilities, labeling it their best bet to bring down high rates of maternal mortality (Campbell et al 2006). They argue on the basis of the observation that most maternal deaths occur during labor, delivery or the first 24 hour postpartum, and most complications cannot be predicted or prevented (this quote from Campbell et al. is based on the results of the first report in the series: Ronsmans C, Graham WJ. 2006). They further argue that while the necessary level of skilled care could very well be delivered at home for mothers who prefer to give birth there, a strategy encouraging home deliveries has distinct disadvantages. For one, home conditions can be very basic and could limit the ability of the skilled attendant to deal with emergencies, especially since the attendant has only the family to rely on to assist rather than other providers such as doctors or nurses in health centers or hospitals. Moreover, home-based childbirths are inefficient in terms of not only the skilled attendants time but also that of the supervisor (who is most likely the already overburdened rural health physician). Therefore, based on the evidence that they present, the authors conclude that the best intrapartum-care strategy is likely to be one in which women routinely choose to deliver in a health centre, with midwives as the main providers, but with other attendants working with them in a team (Campbell et al. 2006). The Philippine Situation The maternal mortality ratio in the Philippines is 162 per 100,000 live births (NSO, 2006 Family Planning Survey). The 2003 National Demographic and Health Survey (NDHS) shows that 38% of live births in the five years preceding the survey were delivered in a health facility and 61% were born at home. The survey also shows that 60% of the births in the 5 years preceding the survey were assisted by health professionals (34% by a doctor, 25% by a midwife and 1% by a nurse) although 88% of women who had a live birth during the period saw a health professional for antenatal care. On the other hand, a hilot or TBA attended 37%. If the MDG goal for maternal mortality reduction is to be met, there is a need to implement a highly cost-effective intervention and to quickly ramp up its coverage. Facing this challenge may be made more difficult by a looming shortage of skilled health professionals, particularly in the rural areas. An informal survey of municipal health officers (MHOs) who participated in the mapping workshops reveals that most of them are either already nurses or studying to become one in the hope of joining the exodus for more lucrative nursing jobs abroad. This makes a strategic and cost-effective approach to addressing maternal mortality even more important.
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THE DOH STRATEGY IN REDUCING MATERNAL DEATHS IN THE F1 CONTEXT:
The Sustainable Delivery of an Integrated Package of Womens Health and Safe Motherhood Services in Strategically Located Health Facilities The strategy described in this report is based on the design of the Second Womens Health and Safe Motherhood Project (WHSMP2) currently being piloted in two provinces: Sorsogon and Surigao del Sur. This section therefore draws heavily from the Project Implementation Manual of WHSMP2. The current effort being reported here is the consequence of a policy decision to expand the pilot exercise to cover the sixteen FOURmula ONE sites, to further assess the feasibility of a nationwide rollout. The Intervention Model An integrated package of services that are critical to preventing maternal and neonatal death is delivered in selected health facilities. Facility selection is guided by a set of criteria, which tries to ensure comprehensive and effective coverage of populations at risk (with a focus on the poor and underserved) and the sustainability of facility finances and operations, mainly by ensuring the presence of sufficiently skilled staff and avoiding the designation of facilities with catchments that overlap significantly. This is envisioned to result in making emergency obstetric and newborn services available at facilities closest to homes while observing cost-effectiveness considerations as well as the need to provide facilities, particularly those in the frontline, with operating environments that are conducive to their operational and financial sustainability. To further this objective, DOH investments in the selected facilities shall not only be towards their upgrading to model standards but shall also ensure their compliance with DOH licensing and PhilHealth accreditation requirements. The package of services consists of maternal and newborn care, family planning and STI screening. The package is envisioned to be offered to women of reproductive age who may call on designated facilities for reproductive health concerns covered by any of the above services. Such an integrated approach to service delivery seeks to maximize client visits and avoid missed opportunities, aside from helping to ensure cost-effectiveness in the delivery of these critical interventions. The maternal and newborn care package is characterized by a paradigm shift from the risk approach which tries to identify at-risk pregnancies and anticipate complications through antenatal care visits to one which views complications as unpredictable and seeks to provide mothers with easy access to emergency obstetric care services (the EmOC approach). The strategy seeks to encourage women to give birth in strategically located facilities suitably equipped to render Basic Emergency Obstetric and newborn Care (BEmOC). Complicated pregnancies and those needing caesarian sections and blood transfusions are referred to facilities rendering Comprehensive Emergency Obstetric and newborn Care (CEmOC). The network of referral facilities is deployed in such a manner as to allow women to access the services they need within a timeframe that ensures a safe outcome.
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The effectiveness of the service delivery model is further enhanced by putting in place support systems that allows the delivery of 1) a reliable supply of safe blood for obstetric emergencies and 2) appropriate and adequate training for critical health staff. Demand Generation through a Behavioral Change Strategy Key to addressing the high maternal mortality ratio is the reduction of the incidence of home birth, especially those attended by TBAs. Estimates cited indicate that more than half of current births are at home, mostly attended by TBAs - a situation that is seen to have led to the current high mortality ratio. The TBA is usually seen as the neighborhood healer, consulted for various illnesses as well as for childbirth. The TBAs childbirth services usually go beyond assisting in the delivery. Massaging the mother, helping in household chores and minding the children are often part of the package. The effort to encourage the mother to give birth in health facilities instead of at home should therefore include measures to address the TBAs influence on the mothers choice on where to deliver. The strategy is to make the TBA an ally in pursuing advocacy objective. It is vital to recognize that the shift from home to facility birth would deprive the TBA of an important source of livelihood since she attends to the majority of home deliveries in the community. Thus, the goal should be not to remove the TBA from the scene but instead make her an important part of it by designating her member of the community-level Womens Health Team (WHT) led by the rural health midwife. The WHT may also include the Barangay Health Workers (BHWs) and has the following functions:
1. To track every pregnancy occurring in the community using the pregnancy tracking protocol. 2. To assist pregnant women accomplish a birth plan and to monitor compliance at each prenatal visit. 3. To provide the following maternal care services: prenatal, childbirth and postnatal. 4. To accurately record findings in the womans birth plan at every prenatal visit. 5. To counsel each expectant woman on: Care during pregnancy, childbirth and immediately after childbirth. Importance of newborn screening and the implications of its findings. Importance of follow-up visit to the facility after childbirth. Proper newborn care to include breastfeeding, nutrition and immunization. To refer clients to the appropriate health facility. To organize outreach activities for family planning and STI control. To provide counseling services to clients and act as agents for behavior change through interpersonal communication. To identify women of reproductive age (WRA) with unmet need for FP and STI services. To provide the following FP services: Re-supply of pills IUD insertion Distribution of condoms Counseling To discuss relevant womens health issues with the community.
6. 7.
8. 9.
10.
11.
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By assigning the TBA to assist the midwife in carrying out the functions of the WHT, one therefore merely changes the TBAs job description and opens the door for her to still look to childbirths as an important source of job satisfaction and livelihood (although facility births will be attended by a skilled professional, the TBA can still be tasked to perform auxiliary functions such as comforting the mother during labor, looking after the children and the household, etc.). Focused-group discussions with TBAs in the WHSMP2 sites reveal that TBAs look favorably at such an arrangement for the following reasons: 1. Being part of the formal health system adds to their stature in the community; 2. Monetary incentives offered by WHSMP2 to the WHTs for facility referrals (the Project pays WHTs 1,000 pesos for every referral of a poor mother to the facility and the RHU physicians have agreed to share their Philhealth reimbursements with the WHT) are seen by TBAs as a more predictable source of income than their current practice of providing home-based deliveries, despite the fact that it has to be shared with other providers involved in facility delivery and her share would most likely be less than the fees she normally charges for home deliveries. This is because not all of the TBAs clients in the community could afford to pay the fee that she charges. A significant number pay in kind (in terms of produce or livestock) while others just promise to pay if and when their finances allow. Reinforcing Incentives to Ensure Sustainable Financing To further reinforce the shift, WHSMP2 requires the local chief executive (LCE) to allot 500 pesos as the LGU counterpart towards the facility birth of every poor mother. This is to help defray the mothers expenses for transport, food and medicine. This scheme not only serves to break down the financial barrier to facility birth that poor mothers face but also encourages a behavioral change on the part of the LCE that would help sustain the shift to facility birth over the long term. Through advocacy, WHSMP2 encourages LCEs to enroll poor mothers in the PhilHealth sponsored program with the message that as mothers shift to facility birth as a result of the above incentives coupled with the advocacy efforts of WHSMP2, the LCEs constituents would expect the same level of financial support for the poor even beyond the life of the project. The best option is for the LCE to enroll the poor in the PhilHealth Sponsored Program. This would assure sustained financial support not only for facility births but for other services as well. To further strengthen the impact of this message, WHSMP2 reimburses half of the amount paid for premiums by the LGU if the LGU meets the annual target set by PhilHealth for enrollment in the Sponsored Program. To ensure the sustainable implementation of the service delivery model, a financing strategy is also put in place to enhance the financial autonomy of service delivery
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facilities. The strategy seeks to broaden financing sources by encouraging (1) the collection of user fees from non-poor users and the use of such revenue to fund operations as well as incentives for health workers and (2) PhilHealth accreditation of facilities and making full and effective use of insurance reimbursements.
Regulation
The model imposes facility standards in terms of infrastructure, equipment and staff skills. These standards are compliant with DOH licensing and Philhealth accreditation requirements. Investments are therefore focused on upgrading facilities to these standards.
Governance
A performance-based approach to the allocation of DOH grants to LGUs helps ensure the delivery of LGU counterpart inputs to implementation. Among these inputs are the enactment of LGU ordinances that provide a favorable policy environment for the implementation of the service delivery package as well as the enhancement of financial sustainability of facilities.
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THE FACILITY MAPPING EXERCISE

To ensure that the intervention model is implemented in a manner that is tailored to the local situation and responds to local needs, a participative facility mapping workshop is carried out at the provincial level. The workshop is participated in by the Provincial Health Officer and the technical staff of the provincial health office, the heads of hospital and the Municipal Health Officers. The workshop objective is to generate a consensus on the appropriate BEmOC-CEmOC network of facilities in the province. DOH representatives from both the central and regional levels help facilitate the discussions aside from contributing their own inputs. Their presence and active participation ensure that whatever agreements are reached result from a consensus at least at the technical level not only among the LGU participants but also between the DOH and the LGUs represented. To initiate the activity, participants are first given fairly comprehensive presentations on the rationale for establishing EmOC facilities, the Integrated Service Delivery Model and its support structure, and the facility mapping process. The workshop is then conducted in 2 stages. The first stage involves the selection of CEmOC facilities and is done in plenary. The second stage involves the selection of BEmOC facilities, where the participants are grouped by inter-local health zones (ILHZ) and are asked to map the BEmOCs within their respective ILHZ. The mapping activity is guided by the following criteria: 1. Population coverage There should be at least 1 BEmOC facility for a population of 125,000 and at least 1 CEmOC facility for a population of 500,000. 2. Travel time requirement A BEmOC facility should be as much as possible not more than 30 minutes away from each barangay in the catchment and a CEmOC facility should be not more than 1 hour away from each BEmOC in the catchment. 3. Adequacy of human resource A BEmOC Team should have a full staff complement of doctor, nurse and midwife. For BHS BEmOCs, a midwife should be assigned to the BHS full time with the municipal health officer or nurse alternately making supervisory visits. Thus, the number of BHS BEMOCs is constrained not only by coverage and sustainability considerations but also by the availability of a permanently assigned midwife (preferably a resident of the community) and by the ability of the doctor or the nurse to supervise the proposed BEmOCs, especially if the BHSs are in remote barangays.
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A CEmOC Team should be headed by an obsteric-gynecology specialist or a general practitioner trained on CEmOC service provision and at least 1 operating room nurse providing duty time per 8-hour shift. 4. Financial and Operational Sustainability Careful selection of BEmOC and CEmOC facilities should be observed to ensure that catchments do not overlap significantly as to hamper operational and financial sustainability. (This serves as an additional consideration in the application of the travel time criterion. For the catchment areas not to overlap significantly, BEmOCs should be at least 30 minutes away from each other and CEmOCs 1 hour apart). Each group is subsequently asked to present their BEmOc recommendations to the group in a plenary session to allow a wider discussion. Aside from justifying their choice of BEmOC facilities in terms of the above criteria, each group is asked to delve on the following issues as well: 1. Geography: to include presence of a road network and its condition and other natural obstacles common in the area e.g. terrain, island, etc.; 2. Potential communities and population that will be served, to include communities outside of the regular catchment; 3. Travel time from farthest catchment to the referral facility; and 4. Current maternal care capability, including human resource adequacy. Since the process is mainly dependent on the accuracy of the information provided by LGU participants, heads of facilities proposed as BEmOCs or CEmOCs are asked to render a written justification of their recommendations, in addition to the above reporting requirement. The hope here is that more careful thought and prudence would be encouraged if proponents know that their inputs become a matter of record. The presence of provincial and regional staff also serves as a validating mechanism since they usually do not hesitate to challenge inaccurate claims made by their municipal counterparts. In fact, in provinces where the provincial staff is seen as capable and willing to help (most are), their assistance is sought in facilitating the discussions and in resolving issues, especially if the resolution requires the intervention of one who is familiar with local conditions. Issues raised in plenary are thoroughly discussed. Only after all issues are resolved to everyones satisfaction is the map deemed final. Experience has shown that the ease and speed with which this is achieved is usually heavily dependent on the leadership exercised by the Provincial Health Officer and his or her staff. Most PHOs performed this task well, apparently partially driven by the need for them to subsequently defend the choices indicated in the map not only before the political hierarchy of the province but possibly before DOH management as well.
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THE FACILITY MAPS OF F1 LGUs Two types of maps are presented: 1) Facility Map that identifies the CEmOC-BEmOC network in the province and 2) Infectious Disease Map that identifies endemic areas for diseases under the disease free-zone initiative: filariasis, leprosy, malaria, rabies and schistosomiasis. While the selection of facilities was guided by technical criteria, some degree of flexibility was observed in its application in an attempt to tailor the model according to the unique needs and characteristics of each province. This section attempts to describe the facility mapping process and the unique features of each provinces facility map as well as the health officers justification for the choice.
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IF U G A O E m O B
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IF U G A O E n d e
IFUGAO 23
Ifugao, known for its magnificent rice terraces lies on the southeastern portion of the Cordillera mountain range. It is bounded on the north by Mountain Province, on the east by Isabela, on the west by Benguet and on the south by Nueva Vizcaya. The terrain is rugged, with mountains cutting across the viewpoint with elevations reaching beyond 1,000 meters and peaks above 2,000 meters. The mountains, however gradually slopes towards the flat lands of Nueva Vizcaya in the east. The province covers a total land area of 251,778 hectares characterized by river valleys and massive forest. It has a total population of 161,623 scattered in its 11 municipalities and 175 barangays.
(http://en.wikepedia.org/wiki/ifugao).
The Ifugaos are indigenous and have their own culture and tradition. Their belief systems are deeply rooted in their way of life. Their ethnicity coupled with the terrain and other natural obstacles could prove to be a challenge in times of health emergency. Thus home births are preferred by 71% (2,430 out of 3418) of pregnant women with around 30% of them assisted by traditional birth attendants (TBAs), with the rest having been attended by midwives, husbands, or gave birth by themselves as is commonly practiced. The Provincial Health Office (PHO) reported 6 maternal deaths in 2006, a ratio of 176 deaths due to pregnancy, labor and delivery for every 100,000 live births. The above maternal health situation and JICAs (Japan International Cooperation Agency) funding a Maternal and Child Health Program in the province resulted to the crafting of the Rationalization Plan that considered womens health and safe motherhood as an important program. In the Plan, the local health officials expressed the will to establish facilities that can provide comprehensive and basic emergency obstetric and newborn care (CEmOC and BEmOC). They however need technical assistance in identifying appropriate facilities for upgrading and in making sure that all women in Ifugao will have access to the service. A facility mapping exercise was thus conducted in the province last 23-24 May 2007. All Municipal Health Officers, Chief of Hospitals, Center for Health Development - CAR (Cordillera Administrative Region) Reproductive Health Program Coordinator, JICA Project Officer and staff assigned in Ifugao and the PHO technical staff actively participated in the activity. The occasion was used to clarify the rationale for establishing emergency obstetric and newborn care facilities in the province and investments in the womens health and safe motherhood intervention model, which has been adapted for implementation in all F1 sites. The exercise resulted to the identification of 2 facilities proposed to be CEmOC providers: Ifugao Provincial Hospital and Mayoyao District Hospital and 27 proposed BEmOCs: 4 Hospitals, 5 RHUs, and 18 BHSs, none of these are MCP (maternal care package) accredited. Ifugao needs to upgrade more BHSs to BEmOC standard because of the difficult terrain and the fact that people have to hike the trail in a number of communities.
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The CEmOC-BEmOC-municipality catchments in the province are configured as follows: CEmOC Facility: IFUGAO PROVINCIAL HOSPITAL (IPH) Catchment Municipalities: Asipulo, Alfonso Lista, Banaue, Hingyon, Hungduan, Kiangan, Lamut, Tinoc, Lagawe Proposed BEmOC Facilities
1. Alfonso Lista District Hospital Asipulo Rural Health Unit Alfonso Travel time from the farthest catchment is 1 2 hours. Asipulo Travel time to the hospitals is 56 hours. There is no hospital in Asipulo. This BHS is 8 hours away from the Asipulo RHU. Some sitios can be reached only by hiking the trail for 3 4 hours. Had 1 maternal death in 2006. This BHS is 9 hours away from the Asipulo RHU. Travel time to Banaue is less than 1 hour. Travel time to Batad from the Poblacion of Bannao is 2 hours; to Cambulo, it is 2 hours of hiking the trail. Bannao has no roads; transportation is only until Ducligan, a drop-off point. Pula has no road and therefore accessible only by hiking the trail. Umalbong is a depressed barangay that would take an hour to travel to the IPH. The facility needs to be upgraded to BEmOC since there is no hospital in the municipality. The nearest hospital is not as accessible. Travel time to Hungduan RHU is 30 minutes to 1 hour. The community is accessible by road and has transportation facilities.
Catchment
Travel Time/other Justifications
2.
3.
Camandag BHS, Asipulo
Camandag and the surrounding sitios.
4. 5. 6.
Duli BHS, Asipulo Banaue Rural Health Unit Batad BHS, Banaue
Duli and adjacent barangays Banaue Batad, Bannao and Cambulo
7. 8. 9.
Pula BHS, Banaue Umalbong BHS, Hingyon Hungduan Rural Health Unit
Pula, Ducligan, Bannao Umalbong Hungduan
10. Abatan BHS, Hungduan
Abatan
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Proposed BEmOC Facilities

11. Kiangan Rural Health Unit Kiangan
Catchment

Travel time from the RHU to IPH is 45 minutes to 1 hour by tricycle. The facility needs to be upgraded to BEmOC since there is no hospital in the municipality. Cababuyan is more than 30 minutes travel time to the IPH, a CEmOC facility. Travel time from the catchments to the proposed BHS BEmOC is 30 minutes to 1 hour. Serves remote barangays of Kiangan. Road access of Caba is via Lamut, travel time is 1 2 hours. Travel time from the catchments to this proposed BHS BEmOC is from 30 minutes to 1 hour. Travel time from this RHU to the Panopdopan District Hospital is 1 hour and 15 minutes; to IPH, a CEmOC facility, about an hour. This proposed RHU BEmOC can serve as a satellite of the hospital. This hospital is located 5 to 6 hours away from the capital town of Lagawe via Hungduan or 2 to 3 hours passing through Kaingan. The area is prone to landslides. Travel time from the catchments is 30 minutes to 1 hour.
12. Nagacadan BHS, Kiangan 13. Duit BHS, Kiangan
Barangay Ducligan and Cababuyan Duit
14. Caba BHS, Lagawe 15. Tupaya BHS, Lagawe
Caba Tupaya and other remote barangays of Tupaya Barangays of Lamut
16. Lamut Rural Health Unit
17. Tinoc District Hospital
Barangays of Tinoc, some barangays of Benguet and Nueva Vizcaya
18. Binablayan BHS, Tinoc
Remote barangays of Tinoc
The facility mapping exercise noted that Camandag, Duli and Nagcak are 3 barangays of Asipulo that are hard to reach and not very accessible as the travel time suggests:

Camandag BHS to Asipulo RHU: Camandag BHS to Nueva Vizcaya: Duli BHS to Asipulo RHU: Nagcak BHS to Asipulo RHU: Nagcak BHS to Nueva Vixcaya:
5 hours 6 hours 5 to 6 hours 12 hours 5 hours hike and 8 hours ride 26
The BHSs are in fact the only health facility in the community and despite the recommendation to upgrade them to BEmOC standard, the travel time requirement of 30 minutes from the homes is difficult to comply. Duli and Nagcak residents usually access services provided at the Veterans Regional Hospital in Nueva Vizcaya or the Nueva Vizcaya Provincial Hospital, which could be reached by 5 hours of hiking the trail and 8 hours travel. Currently, the Ifugaos are hoping that the plan to build a road to connect their villages to the center of Ifugao and Nueva Vizcaya will be realized soon. CEmOC Facility: MAYOYAO DISTRICT HOSPITAL (MDH) Catchment Municipalities: Mayoyao, Aguinaldo, Part of Lamut Alfonso Lista, Part of Banaue. Proposed BEmOC Facilities
1. Aguinaldo Peoples Hospital (APH)
Catchment
Barangays of Aguinaldo and some barangays of Mayoyao

Travel time from the catchments is 1 hour to 2 hours and 20 minutes; to Isabela about 5 hours. This hospital needs to be developed as a BEmOC provider since the RHU in the municipality do not provide childbirth services. Travel time from this proposed BHS BEmOC to Aguinaldo Peoples Hospital (APH) is 1 hour and 30 minutes; to nearby Alfonso, 1 hour. Travel time from this facility to APH is 3 to 4 hours and to nearby Natonin, 5 hours. Travel time to IPH is 45 minutes. Travel time to IPH is 45 minutes. This hospital is only 5minutes away from the Lamut RHU and about an hour to Santiago City in Isabela. Rather than closing the hospital as recommended by a DOH consultant, the province will enhance its BEmOC capability.
2.
Ubao BHS, Aguinaldo
Barangay Ubao, Muenaan and Chalalo
3. 4. 5. 6.
Mungayang BHS, Aguinaldo Tulaed BHS, Mayoyao Alamit BHS, Mayoyao Potia District Hospital, Lamut
Barangay Mungayang 6 barangays of Mayoyao 3 barangays of Mayoyao Barangays of Lamut, lower part of Aguinaldo, Paracelis town of Mountain Province, and some barangays along the border with Isabel.
7.
Namillagan BHS, Alfonso Lista
Namillagan and Halag
Halag is accessible by boat.
Proposed BEmOC
Catchment
Travel Time/other 27
Facilities
8. Caragasan BHS, Alfonso Lista Barangay Caragasan
Justifications
Travel time to the facility is within the 30-minute standard. Considered more strategic by the health officers for upgrading to BEmOC than the RHU. Travel time to Banaue RHU is 2 hours.
9.
Ducligan BHS, Banaue
Ducligan
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ILOCOS NOR
CEmOC CEmOC
No investment
ILOCOS NORTE
BHS BEmOC RHU BEmOC

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Ilocos Norte is the northernmost province on the western side of Luzon. Rugged mountains that are part of the Cordillera range seal it from Cagayan, Apayao and Abra on the east. A narrow coastal plain connects the province to Ilocos Sur to the south. The South China Sea lies to the west and the Babuyan Channel forms the northern coast. Except for the coastal plains and the Laoag River lowlands, most of the land is rugged and rocky. The province has a land area of 3,452 square kilometers and an estimated population of 517,140. It has 21 municipalities, 2 cities and 557 barangays. (http://www.geocities.com/lppsec/pp/ilocosnor.htm?200717). In terms of infrastructure, the Manila north road serves as the major artery to Ilocos Norte and links the province to other parts of the Ilocos region, Central Luzon and Cagayan Valley. The province has good major and secondary roads that provide access to the Cordilleras. It also has an international airport and 2 seaports. The province has a maternal mortality ratio of 90/100,000 live births, which is significantly lower than the national ratio. This could be largely due to the high percentage of births attended by a skilled provider. Of the 10,918 total live births recorded in 2005, 7,273 women or 67% opted to give birth at home attended by midwives and barely 4% by traditional birth attendants. (Rationalization Plan of Ilocos Norte). The Provincial Health Office is determined to continue the downward trend in MMR by encouraging women to give birth in facilities capable of providing emergency obstetric and newborn care (EmOC). The womens health and safe motherhood intervention model is therefore a timely input to their Rationalization Plan, which is part of their overall investment plan for health. The facility mapping exercise for the province was conducted on 26-27 July 2007. Thirty-nine (39) health officials and staff from the province and Center for Health Development Ilocos attended the workshop. The exercise resulted in the identification of 4 CEmOCs (1 of these is Mariano Marcos Memorial Medical Center, a tertiary hospital operated by the Department of Health) and 21 BEmOCs (18 RHUs and 3 hospitals).
The CEmOC-BEmOC network in the province is configured as follows:
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CEmOC Facility: BANGUI DISTRICT HOSPITAL (BDH) Catchment Municipalities: Adams, Dumalneg, Bangui, Burgos, parts of Cagayan Valley and Apayao BDH is 1 hour away from the Ilocos Norte Provincial Hospital.
Proposed BEmOC Facilities 1. Adams RHU Adams Catchment Travel Time/other Justifications Travel time to the RHU from the farthest barangay is 2 hours. Adams is a remote municipality with unpaved roads. The trek to the RHU sometimes involves river crossings. Travel time from the catchment barangays ranges from 30 minutes to 1 hour. Roads are unpaved but travel time from the farthest barangay in the catchment to the RHU is 30 45 minutes. Travel time from the barangays in the catchment ranges from 30 minutes to 1 hour. Travel time from farthest barangay in the catchment is 45 minutes.
2. Dumalneg RHU
Some parts of Bangui and Adams Pagudpud
3. Pagudpud RHU
4. Bangui RHU
Bangui
5. Burgos RHU
Remote and isolated barangays of Burgos
CEmOC Facility: DINGRAS DISTRICT HOSPITAL (DDH) Catchment Municipalities: Dingras, Solsona, Marcos, Nueva Era, Carassi, Banna. In designating DDH for upgrading to CEmOC, the plan to merge DDH and Dona Josefa Edralin Marcos Memorial Hospital (DJEMMH) (mainly because of the very low occupancy rate of the latter) was taken into account. The merger would be put into operation by having DJEMMH act as a satellite BEmOC to DDH, catering to the NSD cases from the catchment, Such a scheme would not only serve to decongest DDH of non-complicated cases but would also result in higher occupancy rates for DJEMMH, especially when mothers begin to shift from home to facility birth.
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Proposed BEmOC Facilities 1. Dingras RHU
Catchment Remote barangays of Dingras and part of Sarrat Solsona
2. Solsona RHU
Travel Time/other Justifications Average travel time from all barangays in the catchment is 30 minutes to 1 hour. Average travel time from all barangays in the catchment is 30 minutes to 1 hour. Average travel time from all barangays in the catchment is 30 minutes to 1 hour. Travel time from the farthest barangay is 3 4 hours. However, patients from 2 remote barangays are brought to Badoc and Pinili. Currently does not have an MHO, but the MHOs of Banna, Marcos and Solsona take turns in providing duty time to the RHU. No road link to Nueva Era. The RHU has already been operating on a 24-hour basis for 1 year, providing childbirth services
3. Marcos RHU
Marcos
4. Nueva Era RHU
Nueva Era
5. Carassi RHU 6. Banna RHU
Carassi Banna
CEmOC Facility: ILOCOS NORTE PROVINCIAL HOSPITAL (INPH) Catchment Municipalities: Pasuquin, Bacarra, Vintar, Sarrat, Laoag City, Piddig. Proposed BEmOC Catchment Travel Time/other 32
Facilities
1. Pasuquin RHU Mountain barangays along the border of Pasuquin and Vintar. Bacarra
Justifications
Travel time from the farthest barangay is 1 hour. Located 18 kms from Laoag City. Although travel time from the RHU to INPH is 15 minutes, upgrading the RHU to BEmOC would not only serve to decongest INPH of NSD cases but also help ensure that the remote barangays in the municipality are catered to. Travel time to the RHU from the farthest barangay is 45 minutes. Bacarra has a mountainous terrain with rough roads. It also has an island barangay.
2. Bacarra RHU
3.
Tandayan Community Hospital, Vintar
10 barangays of Vintar
Travel time from the farthest barangay is 1 hour. Vintar has the biggest land area in the province with a population of 17,858. The location of the hospital is remote and is bounded by rivers and mountains.
4.
Tandayan RHU, Vintar
22 barangays of Vintar 5 of which are in the Poblacion.
Travel time from the Tandayan Community Hospital to the RHU is 1 hour and 30 minutes. The hospital will help decongest INPH of childbirth admissions, particularly NSD cases. Travel time from Sta Catalina, the farthest barangay is 45 minutes.
5. 6.
Laoag City General Hospital Piddig Medicare Hospital
Part of Sarrat Piddig
CEmOC Facility: MARIANO MARCOS MEMORIAL MEDICAL CENTER (MMMMC) Catchment Municipalities: Badoc, Pinili, Currimao, Batac City, Paoay. 33
Mariano Marcos Memorial Medical Center is already a CEmOC-capable facility and will need no additional investments. Proposed BEmOC Facilities
1. Badoc RHU
Catchments
Remote barangays of Pinili, Banna, and Nueva Era

The municipality owns a DPS (Department of Safety) ambulance that can transport clients to MMMMC within the standard travel time of 1 hour. Travel time from the catchment barangays ranges from 30 minutes to 1 hour. The RHU, a mere 5 minutes from MMMMC, would help decongest the hospital of NSD cases. Paoay is prone to flooding. Some sitios are hard to reach and travel to the RHU involves a 1-hour boat ride and a 1-hour hike. The LGU is currently upgrading the RHU to a lying-in clinic.
2. 3.
Pinili RHU Batac City RHU II
Remote barangays of Banna, Batac and Nueva Era Batac and some barangays of San Nicolas
4.
Paoay RHU
Paoay and 2 barangays of Currimao
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NUEVA VIZC
35
NUEVA VIZCA
36
NUEVA VIZCAYA Nueva Vizcaya is located in the Cagayan Valley Region in Northern Luzon, at the juncture of the Cordillera and Caraballo mountain ranges. The province connects 2 broad expanses of flat plains: Ifugao on the north, Isabela on the northeast and Quirino to the east. Aurora province lies to the southeast, Nueva Ecija to the south and Pangasinan towards the southwest. It shares a long common border with Benguet in the west. The Caraballo mountain range, which cuts transversely between the southern part of the Cordillera and Sierra Madre mountain ranges on the eastern seaboard, dominates the province. Nueva Vizcaya is generally mountainous and rugged, cut by hills and valleys.
http://www.geocities.com/lppsec/pp/nvizcaya.htm?200717).
The province has a land area of 4,378.80 square kilometers, composed of 15 municipalities and 275 barangays and a population of 366,962 as of the 2000 census. More than 60% of the population is Ilocano while the rest are Ifugaos, Ibalois, Gaddangs, Isinais, Ikalahans, and Ilongots. Most of the inhabitants are concentrated in the narrow Magat River Valley region along the national highway that runs through the province. The Isinais occupy villages in the municipalities of Bambang, Aritao and Dupax Sur. The Gaddangs inhabit villages in the towns of Bagabag, Solano and Bayombong. The Ikalahans are Igorots that dwell in the highlands of Imugan and Kayapa in the southwestern part of the province. http://www.geocities.com/lppsec/pp/nvizcaya.htm?200717). The Provincial Rationalization Plan identified Maternal and Child Health (MCH) as one of the priority programs. The Plan, however, is not clear as to what approach is to be taken to achieve the desired reduction in maternal and infant mortality. The womens health and safe motherhood intervention model adopted by the DOH for implementation in all F1 sites is a logical move that the province should take on in the light of its current maternal health situation. The PHO reported 8,880 live births in 2006 and 6 maternal deaths: post-partum hemorrhage (a preventable condition) has caused the death of 4 women while 2 were cases of eclampsia from far flung Aritao and Kayapa. This translates to a maternal mortality ratio (MMR) of 68 per100,000 live births. Although TBA-assisted childbirths are relatively low (25% in 2006 and 22% from January June 2007), most cases of maternal deaths are attributed to delayed referral by the attending TBA, in a home birth setting. The facility mapping exercise for the province was conducted on 14-15 August 2007. The health officers and staff of the province actively participated in the exercise. The resulting facility map consists of 3 CEmOCs (including Veterans Regional Hospital, a DOHoperated Regional Hospital) and 11 BEmOCs (2 hospitals, 5 RHUs and 4 BHSs). Maternal care package (MCP) accreditation has not been granted by PhilHealth to any of the facilities in Nueva Ecija. One (1) facility, the Kayapa RHU is Sentrong Sigla Level 2 certified.
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Proposed CEmOC Facility: NUEVA VIZCAYA PROVINCIAL HOSPITAL (NVPH)
Catchment Municipalities: Bambang, Aritao, Sta Fe, Dupax Sur, Dupax Norte, Alfonso Castaneda, Kasibu.

NVPH is located in Bambang, an area that is accessible to transportation because of the municipalitys good road network. Its catchments include 5 barangays of Kayapa: Nansiakan, Magpayao, Baan, San Fabian and Pinayag and 3 barangays of Dupax Norte and Sur: Lamo, Mabasa, and Gabut. Travel time form the barangays of Kayapa ranges from 30 minutes to 4 hours; from barangays of Dupax: 15 30 minutes. Serves an estimated population of 108,000. Current staff complement: 2 obstetric-gynecology specialist, 3 nurse anesthesists and operating room nurses every shift. Catchment
Sta Fe Barangay Kinabuan and other remote barangays of Dupax Sur Barangay Belance and other remote batangays of Dupax Sur 4 barangays of Dupax Norte, 6 barangays of Dupax Sur and some barangays of Kasibu

1. Sta Fe Rural Health Unit 2. Kinabuan BHS, Dupax Sur 3. Belance BHS, Dupax Norte 4. Dupax District Hospital, Dupax Norte

Travel time to NVPH: 1 hour.
Travel time to NVPH: 4 hours

Travel time to NVPH: 6 hours; to Dupax District Hospital: 5 hours Travel time to NVPH is 30 minutes The roads are not passable during the rainy season, thus travel time to the proposed hospital BEmOC involve a 16 hour hike to avail of public transportation. The facility serves a population of 52,555. Travel time to NVPH: 6 hours. The municipality is an isolated area with no road connection to neighboring towns. The only access is via Bambang. It has no hospital but residents have access to hospitals in San Jose City Nueva Ecija
5. Alfonso Castaneda RHU
Proposed BEmOC
Catchment
Travel Time/other 38
Facilities
6. Konkong BHS, Kasibu 5 remote barangays of Kasibu
Justifications
Travel time to NVPH: 4-5 hours Travel time to Kasibu Municipal Hospital: 1 hour. The facility serves a population of 2,000. The roads are good and public transport is accessible. Travel time to NVPH: 5-6 hours.
7. Kasibu Municipal Hospital
Barangays of Kasibu and neighboring towns
Proposed CEmOC Facility: VETERANS REGIONAL HOSPITAL (VRH) Catchment Municipalities: Bagabag, Solano, Bayombong, Quezon, Villaverde, Diadi, Ambaguio VRH is located along the highway in Bayombong and is strategically located to serve clients from remote municipalities. Some residents of the catchment have access to facilities in neighboring provinces: Residents of the municipality of Diadi may access health facilities in Ifugao and Santiago City in Isabela. Travel time is 2-3 hours. Ambaguio residents prefer to go to the Ifugao Provincial Hospital, which is 2-3 hours away and where most providers share their ethnic background. The town of Solano has 2 private hospitals that can serve those who can afford private rates. Proposed BEmOC Facilities
1. Bagabag Rural Health Unit
Catchment
Barangays of Diadi, Solano, Bagabag, Quezon and some barangays of Ifugao

Travel time to VRH: 30 minutes Travel time to Ibung BHS, Villaverde: 30 minutes Travel time from the catchment barangays to the RHU ranges from 10 30 minutes. Serves a population of 125,000.
2. Quezon Rural Health Unit Travel time to VRH: 1 hour Travel time to Bagabag RHU: 30 minutes 3. Ibung BHS, Villaverde 9 barangays of Villaverde and some barangays along the boundary with Solano Travel time to VRH: 30 minutes Serves a population of 18,445.

4. Ambaguio Rural Health Unit
Catchment
8 barangays of Ambaguio, 2

Travel time to VRH: 2 hours
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barangays of Kayapa and some barangays of Ifugao.
Travel time to Ibung BHS, Villaverde: 3 hours Travel time from the catchments to the RHU is 1-4 hours by walking. Ambaguio is a mountainous municipality with only 2 barangays having road access. Serves a population of around 12,000.
Proposed CEmOC/BEmOC Facility: LT TINDANG MEMORIAL HOSPITAL (LTMH) Catchment Facilities: Kayapa, some barangays of Sta Fe, Ambaguio and neighboring Ifugao. The proposed CEmOC facility is located in Kayapa, a remote mountain municipality on the southwestern side of the province with difficult terrain. Kayapa has 30 barangays, but only 18 have access to the RHUs and hospital. In fact, access to the hospital from the remote barangays could involve 4 to 18 hours of hiking. However, residents of Kayapa have other options: those from upper Kayapa may opt to travel 2-3 hours to Baguio or Ifugao, while those from lower Kayapa may go to NVPH in Bambang which is 1 hour away. Eighty percent of the population is indigent with only 10-20% enrolled with PhilHealth. There is no other health facility in the area that could be upgraded to BEmOC. Thus, it was decided that LTMH would double as BEmOC facility. This is not seen to be a problem since the relatively small population of the catchment minimizes the possibility of client congestion.
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PANGASINAN BEmOC/CEmOC Facility Map
B o lin a o Anda
PANGASINAN
Bani
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Pangasinan is located on the west central area of the island of Luzon along the Lingayen Gulf. A crescent-shaped province occupies 5,368.82 square kilometers of verdant farmlands, hills, forests and rivers. It is bounded by the mighty Cordillera Mountains to the east, the Zambales ranges to the west, the rice plains of Tarlac to the south and the Lingayen Gulf and the China Sea to the north.(http://en.wikipedia.org/wiki/Pangasinan). The 2000 census places the population of the province at 2,434,086 distributed in 44 towns, 4 cities and 1,364 barangays. (http://www.pangasinan.gov.ph). Relative to health, the province has 14 hospitals with a total capacity of 505 beds, 68 Rural Health Units (RHUs), and 414 Barangay Health Stations (BHSs). All 6 core referral hospitals are PHIC (Philippine Health Insurance Corporation) accredited and Sentrong Sigla certified. Of the 68 RHUs, 38 are PHIC accredited and 61 are Sentrong Sigla certified. The Rationalization Plan of the province proposes the upgrading of primary hospitals to BEmOC standards. These primary hospitals were previously recommended for closure or merging with RHUs by a health consultant engaged by DOH. LGU health officials attending the Facility Mapping Workshop are of the view that the recommendation, while it may have merit from the financing viewpoint, is not politically feasible. They are more receptive to the alternative of taking advantage of the strategic location of these hospitals and have them focus on the provision of BEmOC services. They are optimistic that the shift from home to facility birth would eventually improve currently low occupancy rates. Although the current maternal mortality ratio (MMR) for the province is relatively low at 37/100,000 live births, traditional birth attendants (TBAs) still attend to around 12% of childbirths at home. (PHO Report 2006, Pangasinan). The establishment of more accessible BEmOCs should further encourage the shift to facility birth and lead to a continued decline in maternal mortality. To guide the provincial health officials in identifying which among the facilities should be tasked to provide BEmOC and CEmOC services, and to make sure that these services are equitably distributed across the province, a facility mapping activity was organized and conducted from 24 to 25 July 2007. All Municipal Health Officers (MHOs) and Chief of Hospitals (COHs) as well as the technical staff of the Provincial Health Office (PHO) attended the activity. The facility mapping exercise resulted in the recommended upgrading of 6 hospitals to CEmOC and 7 facilities to BEmOC, of these, 3 are hospitals, 3 are RHUs and 1 BHS. Because of the relatively good road network in Pangasinan, it was not difficult to comply with the travel time requirement in the choice of strategically located facilities. All the recommended facilities for CEmOC upgrading are at most 1 hour away from BEmOCs in its catchment. However, these hospitals have heavy patient loads, partly because of their accessibility. Care was therefore exercised to ensure that the facilities that would comprise the CEmOC-BEmOC network are dispersed in such a manner as to allow the network to absorb the expected increase in loading (as a result in the shift from home to facility birth) in a way that would enable each facility to effectively perform its assigned function. 42
On the other hand, the facilities recommended for BEmOC upgrading are so located as to comply with the required 30 minute maximum travel time from the catchment barangays. However, as in most provinces, there are exceptions: mothers from a few hard to reach barangays will need to travel at least 1 hour to reach their proposed BEmOC facility. The following shows the configuration of the CEmOC-BEmOC clusters in Pangasinan: CEmOC Facility: MANGATAREM DISTRICT HOSPITAL (MDH) Catchment Municipalities: MANLELUAG ILHZ: Aguilar, Bugallon, Labrador, Lingayen, Mangatarem, Urbiztondo MDH is very accessible and can easily be reached using available public transportation facilities. It has the capacity to serve a large population with 2 obstetric-gynecology specialists and an anesthesiologist. Its current occupancy rate is 80%. Proposed BEmOC Facilities
1. Aguilar RHU
Catchment
Aguilar, Labrador, Lingayen, Labrador, Bugallon
Travel Time/other Justification

Travel time from barangays in the catchment is 30 minutes
Only 1 BEmOC facility is proposed for this cluster because of the proximity of the catchment municipalities to facilities in the neighboring inter-local health zones (ILHZs). CEmOC Facility: BAYAMBANG DISTRICT HOSPITAL (BDH) Catchment Municipalities: MANGABUL ILHZ: Alcala, Basista, Bautista, Bayambang, Sto Tomas. BDH is 30 minutes away from the Pangasinan Provincial Hospital. However, its heavy patient load necessitates the designation of another capable CEmOC hospital within the area. BDH will double as a BEmOC provider and will serve clients from Camiling, Tarlac as well. This ILHZ is prone to flooding because of its proximity to the Agno River. CEmOC Facility: PANGASINAN PROVINCIAL HOSPITAL (PPH) AND REGION I MEDICAL CENTER (RMC) Catchment Municipalities: PALARIS ILHZ: Binmaley, Calasiao, Malasiqui, Mangaldan, Mapandan, Sta Barbara, San Fabian, and San Jacinto, San Carlos City PPH and RMC will share the load of high-risk maternity clients in this cluster. PPH is located in San Carlos City while RMC is in Dagupan City. Both hospitals are accessible to the catchment municipalities. RMC is a DOH operated tertiary hospital. For this cluster, only Mapandan Community Hospital is recommended for upgrading to BEmOC because 1) there is a lying-in clinic in San Carlos City, 2) there is another 43
hospital in Malasique that is BEmOC capable, and 3) Mangaldan Infirmary can provide childbirth services. The other barangays within the catchment can access these facilities for NSDs. Proposed BEmOC Facilities
1. Mapandan Community Hospital (MCH)
Catchment
Binmaley, Calasiao, Malasiqui, Manaoag, Mangaldan, Mapandan, Sta Barbara, San Fabian, San Jacinto

MCH will help decongest Pangasinan Provincial Hospital of childbirth admissions.
CEmOC Facility: DASOL COMMUNITY HOSPITAL (DCH)Catchment Municipalities: WESTERN PANGASINAN ILHZ: Agno, Anda, Bani, Bolinao, Burgos, Dasol, Infanta, Mabini and Sual. The terrain in the area is difficult. Thus, transportation modes include boats, kuligligs and motorcycles. Peace and order is a problem because of its remoteness . Proposed BEmOC Facilities
1. Bolinao Medicare Hospital 2. Bolinao RHU II 3. Agno RHU I
Catchment
Barangays of Bolinao, Anda, Bani 6 barangays and 1 Island barangay of Bolinao, and 3 barangays of Anda Barangays of Agno, Burgos, some barangays of Mabini, Dasol

Serves a population of around 100,000. The RHU is located in Santiago Island and is the only facility that is accessible to residents. Travel time from the barangays in the catchment is between 30 minutes to 1 hour.
While the workshop participants noted the need for a BEmOC facility to serve the municipality of Infanta, it was decided not to recommend Infanta RHU 1 for BEmOC upgrading because it currently does not have a doctor and nurse. Patients from this municipality will have to access services in neighboring Sta Cruz, Zambales or BEmOCs in nearby municipalities. CEmOC Facility: URDANETA DISTRICT HOSPITAL (UDH) Catchment Municipalities: PILGRIMS ILHZ: Urdaneta City, Asingan, Binalonan, Laoac, Manaoag, Pozorrubio, San Manuel, Sison and Villasis. Because of limited funding for a huge province like Pangasinan and the relative ease experienced by residents in catchment municipalities to reach UDH and the BEmOCs in nearby municipalities, the workshop participants decided not to propose for the upgrading to BEmOC of a facility in this ILHZ. UDH shall therefore double as a BEmOC provider. The Lying-in Clinic in San Manuel will continue to provide childbirth services.
CEmOC Facility: EASTERN PANGASINAN DISTRICT HOSPITAL (EPDH)
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Catchment Municipalities: LAYUG ILHZ: Balungao, Natividad, Rosales, San Nicolas, San Quintin, Sta Maria, Tayug, and Umingan. EPDH is located in Tayug. It will be serving 8 municipalities with a population of around 286,515. Its location is strategic enough for a CEmOC facility that could be reached within an hour travel from municipalities in the catchment area. Proposed BEmOC Facilities
1. Umingan Medicare Hospital
Catchment
Barangays of Umingan, Balungao, some barangays of San Quintin, Sta Maria

The terrain is difficult thereby making access to transportation difficult as well. Thus, upgrading the hospital to BEmOC to serve the residents of catchment communities is imperative. The road network does not reach the area. Travel is therefore along narrow hiking trail. An accessible BEmOC BHS is therefore a necessity.
4. Fianza BHS, San Nicolas
Remote barangays of San Nicolas
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ORIENTAL MIN
Puerto Galera
ORIENTAL MINDORO
San Teodoro
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Oriental Mindoro is an island province located in the MIMAROPA region of Luzon that shares the eastern half of the large Mindoro Island. On the north, the narrow Verde Island Passage lies between the province and the Batangas coast. To the east, the Tablas Strait separates Mindoro from the islands of Romblon. Southwards lie the Semirara and Panay islands. (http://www.geocities.com/lppsec/pp/ormindoro.htm?200717). The varied topography of the province is dominated by rugged mountain ranges on the west and fertile valleys towards the eastern coast. The Halcon mountain range runs from north to south and serves as a natural boundary with Occidental Mindoro. Lake Naujan is in the northern part of the province. The plains stretch from Baco, Calapan, Naujan and Victoria in the north, Pinamalayan and Bonganbong in the middle and Roxas to Mansalay in the south
(http://www.fortunecity.com/oasis/acapulco/215/region4/ormindoro/ormindoro.htm).
The province has a total land area of 4,364.7 square kilometers subdivided into 1 city, 14 municipalities and 426 barangays. Its projected population as of 2004 is 738,043 of which around 10 15% is considered cultural minorities known locally as mangyans. There are at least 7 mangyan tribes in the province: 1) Alangans occupy a distinct area in the municipalities of Naujan, Baco, San Teodoro and Victoria.2) Bangons populate the interior part of the mountains of Bongabong, Bansud and Gloria. 3) Taubuids known as pipe smokers occupy parts of Socorro, Pinamalayan and Gloria. 4) Buhids are pot makers and they dwell in small villages of Roxas, Bansud, Bongabong and Mansalay. 5) Hanunoos inhabit the municipalities of Mansalay, Bulalacao and Bongabong. 6) Tadyawans occupy the remote areas of Naujan, Victoria, Socorro, Pola, Gloria, Pinamalayan and Bansud. 7) Irayas reside in Puerto Galera, San Teodoro and Baco.
(Rationalization Plan of Oriental Mindoro).
The mangyans are spread throughout the island and have a distinct culture and a way of life that clearly distinguish them from the rest of the population. For instance, among the mangyans, pregnancy and childbirth is strictly a family affair. Thus, no one but the husband attends to the wife during childbirth. Prenatal and postnatal care is also considered not necessary, even considered taboo sometimes. Civil registration of marriages, births and deaths is also not done in this culture. (Rationalization Plan of Oriental Mindoro). The Provincial Health Office (PHO) reported in 2004, a maternal mortality ratio of 61/100,000 live births, an increase of more than 50% from the 2003 MMR of 25/100,000. The 2004 infant mortality rate (IMR) on the other hand, was 8/1,000 live births with pre-maturity and stillbirth affecting 2/1,000. (PHO Accomplishment Report, 2004 as cited in the Provincial Rationalization Plan).
The facility mapping exercise noted 17 infant deaths in 2006, 16 of which happened in only one municipality, Bansud. In the same year, Bansud, Gloria and Bulalacao reported 1 maternal death each. The count most probably did not include deaths among the mangyan
tribes. While the Rationalization Plan failed to include maternal and infant mortality reduction among the objectives, the PHO nevertheless expressed awareness of the gravity of the issue and agreed to undertake activities that will lead them to implement the integrated womens health and safe motherhood (WHSM) intervention model (Rationalization Plan of Oriental Mindoro).
The facility mapping exercise for the province was participated in by all Municipal Health Officers (MHOs), Chief of Hospitals (COHs) and the technical staff of the PHO. It resulted in the identification of 3 facilities proposed to be CEmOC providers and 21
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facilities proposed to be BEmOC providers, 4 of which are hospitals, 5 are RHUs and 12 are BHSs. The following CEmOC-BEmOC cluster configuration for the province shows how these facilities are strategically deployed: CEmOC Facility: ORIENTAL MINDORO PROVINCIAL HOSPITAL (OMPH)
Catchment Municipalities: Calapan City, Baco, San Teodoro, Puerto Galera, Victoria, Naujan OMPH is MCP acrredited. Proposed BEmOC Facilities
1. San Teodoro RHU
Catchment
San Teodoro
Travel Time/Other Justifications

Travel time to OMPH is 1 hour. Travel from the farthest barangay is a 1-hour hike. This RHU should be upgraded to BEmOC since there is no other health facility in the area and it houses the only doctor. Travel time to the RHU from the farthest barangay is 4 hours due to rough roads. Travel time from the RHU to OMPH is 1 - 2 hours; to San Teodoro RHU, a BEmOC - 1 hour. The most common modes of transportation are: jeepney, tricycle, motorized banca. Travel time from the BHS to the Naujan Community Hospital is 1 hour. Located in barangay Masaging, Naujan. Access to the BHS is mostly by motorized banca and is therefore difficult when the sea is rough. Travel time to Naujan Community Hospital is 1 hours; another 1 hours to reach the CEmOC facility. Located in barangay Inarawan. 2 barangays in the catchment can be very hard to reach during the rainy season. Travel Time/Other Justifications
Travel time to OMPH, is 30 minutes to 1 hour.
2.
Puerto Galera RHU
13 barangays of Puerto Galera of which 6 are mangayan barangays: Baclayan, Villaflor, Aninuan, Sabang, Tabinay and San Isidro.
3.
Naujan East BHS, Naujan
4 coastal barangays: Masaging, Herrera, Montemayor and Montelago.
4.
Naujan West BHS, Naujan
9 barangays 1 of which is a Mangyan barangay.

5. Naujan Community Hospital
Catchment
70 barangays of Naujan.
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Naujan is a big municipality in terms of land area and population. The hospital is adequately staffed and operates 24 hours. It has an ambulance. 6. Victoria RHU 32 barangays of Victoria, 8 of which are coastal barangays, 6 are upland barangays inhabited by Mangyans. Barangays of Baco The hospital is MCP accredited. Travel time from the barangays is 30 minutes. Travel time to OMPH, a CEmOC is 1 hour. Requested by the PHO.
7.
Bayanan BHS, Baco
CEmOC Facility: PINAMALAYAN COMMUNITY HOSPITAL (PCH) Catchment Municipalities: Pinamalayan, Gloria, Socorro, Pola, Bansud PCH is located along the Strong Republic Nautical Highway in barangay Papandayan. It is approximately 4 kilometers from Pinamalayan town proper and has an accessible transportation system. The town also has a domestic airport with 2 flights per week to Manila. PCH, a proposed CEmOC facility is currently applying for a secondary hospital license. It is adequately staffed with 2 general surgeons, 1 anesthesiologist, 5 pediatricians, 1 internist, 2 obstetric-gynecologists, 6 general practitioners, a visiting cardiologist, dermatologist, and radiologist. The hospital also accepts referrals from nearby towns of Concepcion, Romblon and Marinduque. Travel time from the proposed BEmOCs to PCH takes 1 to 2 hours. However, travel from the municipalities of Bansud and Gloria is difficult because of the insurgency problems in the area. The CEmOC-BEmOC municipality cluster is as follows:
1. Socorro BHS, Socorro
Catchment
7 barangays of Socorro: Batong Dalig, Mabuhay I and II, Happy Valley, Pasi I and II and Lapog. 2 barangays of Pola: Tagbakin and Matulatula 2 mountainous barangays: Bugtong na Tuog and Concepcion.
Travel Time/other Justifications Travel time from the barangays is 30 to 45 minutes. Travel time from the mountain barangays is 45 minutes to 1 hour by motorcycle. Travel time to PCH is 1 hour.
Located in barangay Pasi I.

2. Pola RHU
Catchment
23 barangays of Pola

Travel time from the
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barangays to the RHU ranges from 15 minutes to 1 hour and 45 minutes using jeepney, tricycle, motorcycle or boat Pola is a mountainous municipality with 2 barangays inhabited by Mangyans: Matulatula and Putting Cacao. There is no other health facility in the area except this RHU. An increased number of stillbirths have been noted in recent years.
3. Pinamalayan West BHS, Pinamalayan
Remote barangays of Pinamalayan and some barangays of Gloria.
Serves a population of 34,000. The BHS is located in barangay Pambisan Malaki. Travel time from the BHS to the CEmOC (PDH) is 45 minutes to 1 hour. Travel time from the BHS to the RHU is 30 minutes to 1 hour. Travel time to the BHS is 30 minutes to 1 hour Located in barangay Ranzo. Travel time to CEmOC facility is 2 hours. Bansud is a remote barangay where travel is by foot only. The remoteness of the communities and the absence of transportation have resulted in 16 infant deaths and 1 maternal death in 2006.
4. Pinamalayan East BHS,
22 barangays and adjacent barangays of Pola and Socorro 6 barangays and 8 sitios inhabited by Mangyans
5. Bansud RHU
6. Gloria BHS, Gloria
Remote barangays of Gloria as well as Bansud and Pulang Lupa.
The RHU is centrally located. Travel time from the farthest barangay is 2 hours by tricycle. Travel time from the BHS to the CEmOC facility is 2 hours. Located in barangay Banutan. Recorded 1 maternal and infant death in 2006
CEmOC Facility: ROXAS DISTRICT HOSPITAL (RDH) Catchment Municipalities: Bongabong, Roxas, Mansalay, Bulalacao
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RDH is located in barangay Odiong and is strategically located. It can easily be reached within an hour from the proposed BEmOC facilities. It has the potential to serve an estimated population of 200,000. It also accommodates referrals from Tablas Island of Romblon. It has an authorized capacity of 25 beds, and has a women center, 2 operating rooms, 2 delivery rooms and 1 labor room. RDH is a PhilHealh MCP accredited and is adequately staffed with 1 obstetricgynecology consultant and 1 on-call private obstetric-gynecologist. Proposed BEmOC facilities
1. Bongabong Community Hospital (BCH)
Catchment
36 barangays and adjacent barangays of neighboring municipalities.

Travel time to RDH is 1 hour. Average travel time from the barangays in the catchment is 30 45 minutes. The hospital is MCP accredited, DOH licensed and fully operational
2.
Roxas BHS Roxas
4 remote barangays of Roxas inhabited by mostly Mangyans: San Vicente, Maraska, San Rafael and Happy Valley 3 barangays of Bongabong: Batangan, Morente and Lisap 1 barangay of Mansalay: Bonbon
Located in barangay San Mariano, Roxas. The presence of armed groups in the area makes it vulnerable to social and health problems. The barangays in the catchment are so remote that the BHS is reached by either horseback or hiking.
3. Mansalay Medicare Hospital
Mansalay
Mansalay has the largest Mangyan population in the province. The facility is MCP accredited. The sitios are accessible only by foot, thus travel time to the BHS is 1 to 4 hours. Located in barangay Panaytayan.
4. Mansalay BHS, Mansalay
50-70 sitios inhabited by Mangyans in mountain communities.
Proposed BEmOC facilities

5. Bulalacao BHS, Bulalacao
Catchment
2 island barangays, 2 mountain

Travel time to the Bulalacao
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barangays inhabited by Mangyans: San Isidro and Cabugao
Community Hospital is 1 hour by either motorcycle or boat. Travel to the CEmOC is a 3 hour jeepney ride. Travel time from the mountain barangays is 1 1 hours by motorcycle. Located in barangay Milagrosa; access is on rough road that is inaccessible during the rainy season. The community also has to deal with problems related to insurgency. The BHS recorded 1 maternal death in 2006. Requested by PHO. Requested by PHO Travel time to the Bulalacao Community Hospital is 1 hour by either motorcycle or boat. Travel to the CEmOC is a 3 hour jeepney ride. Travel time from the mountain barangays is 1 1 hours by motorcycle. Travel time from the farthest barangay to the community hospital is 45 minutes to 1 hour. Roads are rough and unpassable during the rainy season, isolating 9 barangays. The facility is MCP accredited
6. 7. 8.
Benli BHS, Bulalacao Milagrosa BHS, Bulalacao Bulalacao Community Hospital
15 barangays of Bulalacao and 1 island barangay (barangay Maasin)
The LGU health officials consider the establishment of BEmOC facilities particularly in the remote areas inhabited by mangyans crucial to reducing infant and maternal death in the province. For the past years, the PHO succeeded in having facilities in the province MCP (maternal care package) accredited. Facility accreditation and the Philhealth reimbursements that it allows encourage mothers to give birth in a facility and health workers to provide quality service. Below are the MCP accredited facilities, all of which have been recommended for upgrading to either BEmOC or CEmOC. Among 52
those proposed to be CEmOC facility, only Pinamalayan Community Hospital has been granted MCP accreditation.

Oriental Mindoro Provincial Hospital Roxas District Hospital Bongabong Community Hospital Mansalay Medicare Hospital Gloria Medicare Hospital Naujan Community Hospital Pinamalayan RHU Bulalacao Community Hospital Mansalay Medicare Hospital
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ROMBLON BE
Banton Concepcion
ROMBLON Romblon province located in the MIMAROPA region (Region IV-B) spans the Sibuyan Sea and forms the link between the Tagalog Region and Bicol Region. The provinces main islands are Tablas, Romblon and Sibuyan forming the largest and most populated areas. These islands are surrounded entirely by the Sibuyan Sea on the north, east and south while the Tablas Strait separates the islands from Mindoro. Further south, the island of Panay lies across a narrow channel from Carabao Island. It lies south of Marinduque and Quezon, east of Mindoro, north of Aklan, and west of Masbate. It has a total land area of 195 square kilometers subdivided into 17 municipalities and 219 barangays. It is a small province with a population of 264,357 as of the 2000 census. (http://en.wikipedia.org/wiki/Romblon). The provinces Rationalization Plan indicated an urgent need for health reforms in the light of a worsening health situation seen to be brought about by a decline in the public health service delivery system due to budgetary and human resource constraints. Access within the province is also difficult given the natural obstacles that are unique to Romblon with its small island municipalities. It is therefore no surprise to find 73% of pregnant women opting to deliver at home with 44% attended by
traditional birth attendants (TBAs). Three maternal deaths were reported in 2006. (PHO Report, August
2007).
The facility mapping activity for Romblon was conducted on 5-6 June 2007 as part of the activities that would lead to a Rationalization Plan for the province. This Plan would serve to guide current and future investments in health. The exercise was participated in by the Municipal Health Officers, Chief of Hospitals, and the Provincial Health Office Technical Staff. This resulted in the identification of 5 hospitals for upgrading to CEmOC and 9 facilities for upgrading to BEmOC. Of the 9 proposed BEmOC facilities, 3 are hospitals and 6 are RHUs. The CEmOC-BEmOC cluster in Romblon is configured as follows: CEmOC Facility: ROMBLON PROVINCIAL HOSPITAL (RPH) Catchment Municipalities: Ferrol, Odiongan and Calatrava RPH is located in Odiongan, Romblon, one of the main islands. The workshop noted the following special considerations:
San Andres Municipal Hospital is only 30-45 minutes away from the RPH, however, it has to be upgraded to BEmOC since it will service patients coming from Calatrava, who have no access to Tablas Island District Hospital in San Agustin or other health facility near the island. Travel time from Ferrol takes 25 minutes, from Calatrava, 1 hour and San Andres: 30 45 minutes.
Proposed BEmOC FacilityCatchmentTravel Time/other Justifications1. San Andres Municipal

HospitalBarangays of San Andres and Calatrava.Estimated travel time to the proposed CEmOC is 45 minutes. Travel time to the hospital from the farthest barangay is 2 hours. Travel time to the hospital from the municipality of Calatrava is 1 hour. Located in Barangay Calatrava in San Andres town, with a catchment population of 15,000. The roads are rough and mountainous.
CEmOC Facility: ROMBLON DISRICT HOSPITAL (RDH) Catchment Municipalities: Banton, Malipayon (Corcuera), Concepcion, Magdiwang and Romblon. RDH will be providing general health services to the 38,828 people of mainland Romblon and 3 small barangays surrounding the mainland: Alad, Logbon and Cobrador. Access is not difficult because Romblon has a seaport. Travel time from the farthest catchment within the mainland is 1 hour. However, coming from the municipal islands of Banton, Malipayon and Magdiwang, travel time is 1.5 2.5 hours.
Proposed BEmOC FacilityCatchmentTravel Time/other Justifications1. Banton RHUBantonTravel

time from the farthest barangay to the RHU is 30 45 minutes by motorcycle and 45 minutes to 1 hour by boat.
The RHU is 2.5 hours away from the proposed CEmOC. Banton is an island mountainous community with narrow and steep roads. The estimated population is 6,972.Proposed BEmOC FacilityCatchmentTravel Time/other Justifications2. Malipayon Municipal Hospital, Corcuera15 barangays of CorcueraTravel time from the farthest barangay is 30-45 minutes by motorcycle. Travel time to Romblon District Hospital (CEmOC) 2.5 3 hours by motorboat. Coprcuera is an island municipality with mountainous terrain and rough, narrow roads. It has an estimated population of 12,000.3. Concepcion RHUConcepcionConcepcion is a mountainous island municipality with rough and narrow roads and with an estimated population of 5,500. Travel time from the farthest barangay to the RHU takes 20-40 minutes. Will refer patients needing CEmOC services to Oriental Mindoro Provincial Hospital (OMPH), Calapan City via Pinamalyan where theres a regular boat trip from Romblon. Travel time via this route is 2-3 hours by boat and another 2-3 hours by land transport to OMPH
CEmOC Facility: SIBUYAN DISTRICT HOSPITAL (SDH) Catchment Municipalities: Cajidiocan, Magdiwang and San Fernando The facility mapping exercise noted the following:
Travel time from SDH to Romblon is 5 hours by boat. Travel time from the farthest catchment is 2 hours by jeep, another 2 hours by boat for a total of 4 hours. Barangay Agtiwa in San Fernando is so remote and its road so bad that it is usually washed out during the rainy season, isolating the barangay. The mayor plans to construct a BHS in the area and suggests that this be eventually upgraded to BEmOC. Also accommodates referrals from Masbate. Potential population to be served: 80,000.
Proposed BEmOc FacilitiesCatchmentTravel Time/other Justifications1. Magdiwang RHU9 barangays

of Magdiwang, 2 barangays of Cajiodiocan: Cantagda and Danao, 3 barangays of San Fernando: Agtiwa, Mabini and Mabolo) and the Burias settlers of barangay Poblacion.Travel time to the proposed CEmOC facility is 1 - 4 hours. Magdiwang is part of Sibuyan island. Rough roads characterize the municipality 2. San Fernando RHU12 barangays of San FernandoTravel time from the farthest barangay is 1 hour and from the RHU to the proposed CEmOC, 45 minutes. San Fernando is a coastal, mountainous municipality in Sibuyan Island. It has a population of 22,731. Roads in the island are rough and rendered impassable during the rainy season. Transportation is difficult as there is only 1 jeepney trip a day. However, when emergencies arise, there are private vehicles for hire although the fee may be beyond the reach of poor mothers.
CEmOC Facility: DON MODESTO MEMORIAL HOSPITAL (DMMH) Catchment Municipalities: Looc, Sta Maria, Alcantara and Ferrol
This proposed CEmOC facility is located in Looc and is 24 kms (1 hour travel) from the Provincial Hospital. DMMH also caters to patients coming from nearby municipalities of Sta Fe and Tablas Island. The following were given consideration during the facility mapping workshop:

Ferrol RHU is only 30 minutes away from Looc and Odiongan. Travel time from Alcantara is about 1 hour and from Sta Maria, it is about 1.5 hours. San Jose Municipal Hospital is proposed to be upgraded to BEmOC, a move that is supported by the Mayor. This facility currently does not have a doctor, but the San Jose RHU doctor currently provides duty time to the hospital. The occupancy rate of the hospital is poor at 15 patients per month and has been recommended to be merged with the RHU, a move that the LGU strongly opposes. One way to operationalize the merger is to upgrade the hospital to BEmOC so that it operates in tandem with the RHU. Occupancy should improve as mothers shift from home to facility birth, attracted in part by the improved services occasioned by the facility upgrading.
Proposed BEmOc FacilitiesCatchmentTravel Time/other Justifications1. Sta Fe RHU11 barangays of

Sta FeTravel time from RHU to proposed CEmOC is 1 hour. Sta Fe has a mountainous terrain, traversed by rough and narrow roads. The RHU serves a population of 14,459.2. Alcantara RHUBarangays of Alcantara as well as some barangays of Sta Maria.Travel time to the RHU from Calagonsao, the farthest barangay is 30- 45 minutes, but from
the mountain barangays, travel time is 1 2 hours.

Travel time from the RHU to the proposed CEmOC is 20-30 minutes.
The municipality of Alcantara has bad roads 3. San Jose Municipal Hospital5 island barangaysThe farthest barangays: Inihawan and Tipoc-poc are 45 minutes away. San Jose is an island municipality with an estimated population of 9,000. Its roads are bad and hardly passable during the rainy season. Being an island, it becomes isolated when weather is bad and the sea rough.
CEmOC Facility: TABLAS ISLAND DISTRICT HOSPITAL (TIDH) Catchment Municipalities: Sta Maria, San Agustin and Calatrava TIDH, the only hospital in the island is located in the municipality of San Agustin, which is 1.5 hours away from the farthest catchment municipality. From TIDH to Romblon Provincial Hospital is about 1hour on rough and mountainous road that could be almost impassable during the rainy season.
Since the population is small (40,526), the participating health officers decided not to upgrade any more facility in the island to BEmOC. TIDH is therefore envisioned to double as a BEmOC facility. It is seen to be well-equipped to perform these functions. TIDH is fairly accessible. Travel time from Sta Maria is 45 minutes, from Alcantara RHU, a BEmOC travel time is 30 minutes, and from Calatrava, 30-45 minutes.
C A P IZ E m O C /C B
CEmOC B H SB E m O C R H UB E m O C HOSP EmOC B
C A P IZ E n d e
RHU CAPIZ The province of Capiz is located in the H O S P Region at the northeastern Western Visayas portion of Panay Island (an island formed by the Panay and Banica rivers). It borders
Aklan and Antique to the west, Iloilo to the south and faces the Sibuyan Sea to the north. Bodies of water bound it: the Mindoro sea and the rivers of Panay, Loctugan, and Ibisan. The coast is flat and irregular with extensive swamps and marsh land that extend towards the southwest into the mountainous interior of Panay. It has a total land area of
2,633.2 square kilometers occupied by 1 city, 16 municipalities, 473 barangays and a population of 654,156 as of the 2000 census. (http://en.wikipedia.org/wiki/Capiz and
http://www.geocities.com/lppsec/pp/capiz.).
The geographic characteristics of the province subject the people of Capiz to natural obstacles that appear to affect even their health seeking behavior. The province has had 2 maternal deaths in 2006 and 4 as of June 2007. The numbers reflect a gap in maternal care service delivery that needs to be addressed. In an effort to generate a Rationalization Plan that would guide investments in health, the Provincial Health Office (PHO) spearheaded a province-wide mapping of public health facilities. The resulting map identifies the various health facilities in the province and their location, as well as services that each offers. The map shows 8 public hospitals, 16 Sentrong Sigla certified Rural Health Units (RHUs), 1 Sentrong Sigla Phase 2 Level 1 certified City Health Office (CHO) and 189 Barangay Health Stations (BHS), 51 of which are functioning as birthing clinics. (Rationalization Plan, Province of Capiz). Maternity Care Package (MCP) accreditation has been granted by PhilHealth to 2 RHUs and the CHO. The WHSM facility mapping exercise was carried out on 13-14 June 2007. All Municipal Health Officers, Chief of Hospitals and the technical staff of the Provincial Health Office attended the activity. Overall, the MHOs and COHs actively participated and gave insightful inputs. As a result, 2 hospitals: Roxas Memorial Hospital and Mambusao District Hospital were recommended for upgrading to CEmOC and 20 facilities were proposed to be BEmOC providers (3 hospitals, 10 RHUs and 7 BHSs). Three (3) of the 9 RHUs are already MCP accredited. As agreed, the CEmOC BEmOC configuration for Capiz is as follows:
CEmOC Facility: ROXAS MEMORIAL PROVINCIAL HOSPITAL (RMPH) Catchment Municipalities: Roxas City, Panay, Ivisan, Panit-an, Pilar, Pres Roxas, Pontevedra, Maayon. Proposed BEmOC FacilitiesCatchmentTravel Time/other JustificationsRoxas City Health OfficeRoxas City, some barangays of Panti-anThe city health office is less than 30 minutes from RMPH and would normally not qualify to be a BEmOC. The designation of the CHO as BEmOC is mainly to decongest RMPH of NSD cases so that it could focus on attending to complicated deliveries.
The CHO is MCP accredited. The city has a population of 137,380.Loctugan BHS, Roxas City15 barangays of Roxas CityTravel time from farthest catchment barangay is 30 minutes.Panit-an RHUBarangays of Panit-anCurrently providing childbirth service with
high service utilization. Its proximity to Roxas City, and its ability to attract clients will help further decongest RMPH of NSD admissions.
Bantigue BHS, Panay2 other island barangays of PanayTravel time from the farthest catchment is about 40 minutes by boat and another 30 minutes by land transport. Ma-ayon RHU32 barangays (10 upland barangays) of Ma-ayon and barangays of neighboring municipalities of Dao (barangay Ilas), Panit-an (barangays Cabangahan, Ambilay and Cabugao), and Cuartero ( barangays Sinabsaban, Maindang and San Antonio)Travel time from the farthest barangay is 1 hour.
Proposed BEmOC FacilitiesCatchmentTravel Time/other JustificationsPilar RHU5 coastal barangays:

Dayhangan, Balogo, Casanayan, San Ramon and BinauhanTravel time from farthest barangay is 30 to 45 minutes. The catchment is generally coastal with rough roads accessible only to motorcycles. The community has had 2 maternal deaths in 2007 due to post-partum hemorrhage. Both were home deliveries. Pres Roxas RHUPres Roxas, adjacent upland and lowlan barangays of Pilar, 5 barangays of Pontevedra, and 1 barangay of Maayon.The RHU is MCP accredited.Ivisan RHUIvisan and adjacent barangaysHas a small island that can be reached only by boat (45 minute trip). The road is generally mountainous and steep.Bailan District Hospital, PontevedraBarangays of Pontevedra, Panit-an, Panay and MaayonTravel time to RMPH is 40 minutes.
Note that Barangay Dayhangan in Pilar town is at the border of Iloilo. Thus most of its residents go to Iloilo health facilities for health services. CEmOC Facility: MAMBUSAO DISTRICT HOSPITAL (MDH) Catchment Municipalities: Mambusao, Jamindan, Sigma, Sapian, Dao, Dumarao, Cuartero, Tapaz, Dumalag.
Proposed BEmOC FacilitiesCatchmentsTravel Time/other JustificationsDumalag Rural Health UnitDumalagTravel time from the farthest barangay is 30 45 minutes. It takes 45 minutes from this RHU BEmOC to MDH.
Has a slightly mountainous terrain. The RHU is MCP accredited.Dumarao Rural Health Unit33 barangays of Dumarao, barangay Passi of Iloilo and some barangays of Dumalag and Cuartero.Located in a remote and mountainous area. The RHU reported 2 maternal deaths in 2007.Dacuton BHS, DumaraoDacuton, barangay San Antonio of Cuartero and barangays Lemery and San Rafael of Iloilo.Located in an upland area.
Proposed BEmOC FacilitiesCatchmentsTravel Time/other JustificationsSan Nicolas BHS, TapazSan NicolasTravel time to Tapaz District Hospital is 45 minutes to 1 hour by motorcycle.
Located in an upland area with road and foot access. Road condition is difficult during the rainy season.Tapaz District HospitalTapaz, part of Dumalag, Jamindan, Bingawan and CalinogTravel time to MDH, a CEmOC facility, is 1 hour and 20minutes.Sapian RHUSapianTravel time from the farthest barangay is 30 to 45 minutes.Cuartero RHU5 barangays in the Poblacion area The RHU currently functions as a birthing facility. Reported 2 maternal deaths in 2006.Carataya BHS, CuarteroBarangay Carataya and neighboring barangaysTravel time to RHU is 40 minutes and to RMPH 50 minutesMangoso BHS, SigmaMangoso, adjacent barangays of Mansacul, Balucuan and Matinaba.Travel time from the farthest barangay ranges from 45 minutes to 1 hour by tricycle. The road is generally rough.
Sen Gerry M Roxas Memorial District Hospital, DaoDao, Dumarao, Dumanlag, Cuartero and part of Sigma.Travel time to the facility is about 40 to 45 minutes. Relatively accessible to transportation because of good roads. Serves a population of 295,000. The hospital is PhilHealth accredited and provides newborn screening services.Lucero BHS, JamindanLucero, 8 other adjacent barangays, and barangay Altavas in Aklan.Travel time to the BHS is about 20 to 30minutes. Generally an upland community. Serves a population of 853.Buruias BHS, MambusaoBurias and 5 neighboring barangaysTravel time is 20 minutes. A mountainous community near the border of Jamindan and Sapian in the Province of Aklan.
NEGROS ORIENT
CEmOC BHS BEmOC RHU BEmOC HOSP BEmOC ILHZ CVGLJ
NEGROS ORIENT
RHU HOSP
The province of Negros Oriental occupies nearly all of eastern Negros, which faces the Tanon Strait. It is separated from Negros Occidental by a chain of rugged mountains along the length (north to south) of the island. The mountains of Kanlao and Cuernos de Negros (Horns of Negros) are the highest peaks in the range. Much of the island is hilly except for a narrow area of flat land along the coast. The shoreline is irregular and fringed with coral reef. (http://www.geocities.com/lppsec/pp/negor.htm200717)
Endemic Diseases
Malaria Leprosy
NEGROS ORIENTAL
Negros Oriental is more culturally oriented towards Cebu and the people have always considered themselves Bisaya (a reference to Cebuanos) rather than Ilonggo. The province has a total population of 1,130,088 (2000 census) occupying a land area of 5,097 square kilometers and consists of 4 cities, 21 municipalities and 557 barangays. Dumaguete City is its progressive capital. The Rationalization Plan of the province attributed the high infant and under-five mortality rates to inadequate supply of medicines, untrained hilots assisting in deliveries, failure to give mothers tetanus toxoid injections and non-performance of newborn screening. Maternal deaths have largely been attributed to the lack of training of midwives, untrained birth attendants, mothers not submitting to prenatal care and poor access to health facilities. The Plan thus expressed the need to conduct a maternal death review to ascertain the cause of maternal deaths and lamented that not one of their facilities have the capability to provide emergency obstetric care, whether comprehensive or basic. The concern over maternal health is understandable. In 2006, of the 21,071 total births recorded, 78 % occurred at home with 45% being assisted by traditional birth attendants (TBAs). This resulted to 11 deaths or a maternal mortality ratio (MMR) of 52/100,000 live births. From January to June this year, 6 maternal deaths (an MMR of 90/100,000 live births) have already been reported out of the total 6,688 live births. Seventy percent of mothers gave birth at home and 34% of them were attended by a TBA. The provincial facility mapping exercise held on 7-8 August 2007 was well attended. Present were all the local health officers (provincial and municipal) as well as representatives of the Center for Health Development Central Visayas (the Assistant Regional Director and the MCH Coordinator). It is worth noting that there was an effort made during the facility mapping exercise to be consistent as much as possible with the existing Inter-local Health Zone arrangements and the Rationalization Plan. Four hospitals were designated as CEmOC providers: 1) Negros Oriental Provincial Hospital, 2) Guihulngan District Hospital, 3) Bais District Hospital and 4) Bayawan District Hospital. Their location ensures a comprehensive coverage for CEmOC services across the province. The number of facilities identified is justified by the population (almost 1.2 million) and the geography of the province. The geographic characteristics of the province (e.g., being an island, the terrain, road conditions, etc.) played a more important role in the choice of BEmOC facilities. Twenty four (24) were chosen, consisting of 10 hospitals, 1 barangay health station (BHS), and 13 city/rural health units (CHO/RHU). Currently, the province only has 2 facilities that are MCP (maternity care package) accredited: Amlan RHU and Bindoy RHU. Amlan RHU is proposed for BEmOC upgrading. There are also facilities currently providing childbirth services that were not considered in the facility map because it did not pass the criteria for selection of CEmOC and BEmOC facilities: Siaton RHU, Dauin RHU, Bacong RHU, Valencia RHU and San Jose RHU. As agreed, these RHUs will continue to provide NSD (normal spontaneous delivery) service to low risk women until such time that their respective LGUs are able to finance their upgrade to BEmOC standard. CEmOC Facility: NEGROS ORIENTAL PROVINCIAL HOSPITAL (NOPH) Negros Oriental Provincial Hospital (NOPH) is the main CEmOC facility for the Metropolitan and SIAZAM Inter-local Health Zone (ILHZ) and will serve as the main referral facility for the following BEmOC facilities projected to serve a population of at least 400,000:
Proposed BEmOC FacilitiesCatchmentTravel Time /other Justifications1. Dumaguete City Health Office11 barangays of
Dumaguete CityTravel time to the CHO from the farthest barangay is 30 minutes by jeepney or tricycle. Located adjacent to the NOPH, however, its designation as a BEmOC facility will help decongest the NOPH of childbirth admissions. The city government also plans to build a 10-bed lying in clinic that will be attached to the CHO. The city has good roads and easy access to transportation. Will serve an estimated population of 100,000.
2. Amlan Rural Health UnitAmlan, San JoseTravel time to NOPH is 40 minutes. Travel time to Sibulan is 30 minutes. This RHU is MCP accredited.
Proposed BEmOC FacilitiesCatchmentTravel Time /other Justifications3. Sibulan Rural Health UnitSibulan,
San Jose, Dauin, Bacong, ValenciaTravel time to NOPH is 15 minutes. The catchment area is generally mountainous with poor roads.4. Siaton Dsitrict HospitalSiatonThis facility is 20 minutes away from the Siaton RHU and 30 minutes away from the Zamboanguita RHU.5. Zamboanguita Rural Health Unit10 barangays of Zamboanguita of which 3 are hard to reach, some residents of Siaton and DauinTravel time to the RHU from the farthest catchment is 15 20 minutes by ambulance. Travel time to NOPH, a CEmOC facility is 1 hour. Serves a population of 29,000. The only transportation available in the remote barangays is the LGU provided vehicle for its Libreng Sakay Program.
CEmOC Facility: BAIS DISTRICT HOSPITAL (BDH) Catchment Municipalities: Bais, Bindoy, Tayasan, Mabinay, Tanjay, Pamplona Bais District Hospital (BDH) serves as the main CEmOC facility that will receive referrals from the BEmOC facilities within the BINATA and MAMABATAPA ILHZ. Proposed BEmOC FacilitiesCatchment Travel Time/other JustificationsBindoy District
HospitalBindoyTravel time to Nabilog Community Hospital is 45 minutes; to BDH, 30 minutes.Nabilog Community Primary Hospital, TayasanTayasanThis facility is 45 minutes away from Bindoy District Hospital.Mabinay Medicare HospitalMabinay Located in the Poblacion, the travel time to Inapoy Community Hospital is 45 minutes. Travel time to Bais is 1 hour.Proposed
BEmOC FacilitiesCatchment Travel Time/other
JustificationsInapoy Community Hospital, MabinayMabinay, particularly the mountain barangays, some barangays from nearby Negros OccidentalTravel time from the barangays is 30 minutes to 1 hour.Bais City Health OfficeBais CityThis facility is 1 hour away from Dumaguete City and more than an hour away from the municipality of Bayawan.Tanjay City Rural Health Unit 114 barangays of Tanjay CityLocated 15 kms from BDH.
The city government plans to set up an emergency clinic within the RHU and the health officers envision this to be a good input to BEmOC service provision..Tanjay City Rural Health Unit 210 barangays Tanjay City of which 5 is considered hard to reach Travel time from the farthest barangay is 1 3 hours to Bais City. Located 9 kms away from the city. Serves a population of 40,640 and will thus help decongest BDH of childbirth admissions.Pamplona Rural Health UnitPamplonaTravel time from the catchment barangays is 30 minutes; while to RHUs of neighboring towns, the travel time is 1 hour or more. CEmOC Facility: BAYAWAN DISTRICT HOSPITAL (BDH) Catchment Municipalities: Bayawan City, Sta Catalina, Basay,
Bayawan District Hospital will be the main CEmOC facility for the STA BAYABAS ILHZ, which has a potential client population of around 220,000. It is strategically located at the center of the ILHZ, between the municipalities of Basay and Sta Catalina. The following are the BEmOC facilities under its cluster:
Proposed BEmOC FacilitiesCatchment Travel Time/other JustificationAmio Community Primary Hospital,

Sta CatalinaSta CatalinaWill serve residents of remote barangays .Kalumbuyan Community Primary Hospital, Bayawan CityBayawan CityWill unload Bayawan District Hospital of childbirth admissions once the latter starts providing CEmOC services. Basay Rural Health UnitBasayTravel time to Bayawan District hospital is 30 minutes. Has an existing lying-in clinic.
This workshop noted that Sta Catalina RHU is a childbirth service provider and will continue to provide the service until such time that Amio Community Primary Hospital (ACPH) is able to provide the service efficiently to the whole catchment.
CEmOC Facility: GOV WILLIAM VILLEGAS MEMORIAL HOSPITAL (GWVMH) (formerly Guihiulngan District Hospital)
The health officers of the CVGLJ ILHZ agreed to designate Gov William Villegas Memorial Hospital (GWVMH), formerly Guihulngan District Hospital as the main referral facility for women who will need CEmOC services. GWVMH will receive referrals from the following BEmOC facilities: Proposed BEmOC FacilitiesCatchmentTravel Time/other JustificationCanlaon District HospitalCanlaon
CityThis proposed BEmOC hospital will share the patient load with the City Health Office.Luz Sikatauna Community Primary Hospital, GuihulnganGuihulnganWill help decongest the proposed CEmOC facilityGuihulngan Rural Health Unit 2GuihulnganTravel time from the barangays in the catchment is 30 minutes to 1 hour.Magsaysay BHS, GuihulnganMountain Barangays of GuihulnganTravel time to Guihulngan RHU is 1 hour and 30 minutes.Pacuan Community Primary Hospital, La LibertadPoblacion barangays of La LibertadWill help decongest the proposed CEmOC facility of childbirth admissions. La Libertad Rural Health UnitRemote barangays of La LibertadTravel time to Pacuan Community Primary Hospital is 1-2 hours Proposed BEmOC FacilitiesCatchmentTravel Time/other JustificationVallehermoso Rural Health UnitVallehermosoTravel time is 30 minutes. Travel time to neighboring towns is more than 1 hour.Jimalalud Rural Health UnitJimalaludTravel time is 30 minutes. Travel time to neighboring towns is more than 1 hour.
It is noted that while the health units recommended for upgrading to BEmOC standard appear to be near each other with travel time that ranges from 15 30 minutes, the rural health units will serve clients from the difficult to reach areas with the hospital BEmOCs serving the rest of the municipalities and helping to decongest the CEmOC facility of childbirth admissions.
Further, the City Health Office of Canlaon City as well as the Rural Health Unit 1 of Guihulngan will continue to provide childbirth services since they have existing LGU funded lying-in clinics. However, because they were not seen to be strategically located, the workshop participants agreed that investments in these facilities may not be cost-effective.
BILIRAN BEmO
Maripipi
BILIRAN Endemic D
Maripipi
BILIRAN Biliran is an island province in the Eastern Visayas region that has a total land area of 555.42 square kilometers. It is bounded by the Visayas Sea to the north, by Carigara Bay to the south, by the Samar Sea to the east and by the Strait of Biliran to the west. It is composed of 8 municipalities and 132 barangays with a population of 140,274 as of the 2000 census. (www.biliran.lgu.gov.ph). The main island has a slightly flat to rolling and rough terrain with narrow coastal areas and mountainous interiors except for the municipalities of Naval and Caibiran that have wider plains and rolling terrain extending about 7 kilometers from the coast. Mountain ranges occupy the major portion
of the island municipality of Maripipi. (www.biliran.lgu.gov.ph). While Biliran is an island, it is not isolated from the rest of the region. A bridge connects the island to the province of Leyte. The province is therefore considered a gateway to cities of Ormoc and Tacloban as well as other parts of the country that are accessible by land transportation. Ferryboats also ply the Naval Cebu route. (www.biliran.lgu.gov.ph). In terms of health infrastructure, the province has 8 Rural Health Units (RHUs), 35 Barangay Health Stations and 4 Community Hospitals, 3 of which function as emergency clinics. Despite easy access to these health facilities, the maternal and infant health picture of the province is not encouraging. In 2006, the Provincial Health Office (PHO) recorded 3,606 childbirths, 1,876 or 52 % of which were diagnosed as risk pregnancies. Traditional birth attendants (TBAs) assisted in 1,831 (51%). Understandably, maternal and infant deaths for the year were high with a Maternal Mortality Ratio (MMR) of 277/100,000 live births and an Infant Mortality Rate (IMR) of 19/1,000 live births. (2006 Natality Mortality Report, PHO, Biliran). This situation has lead the Provincial Board to pass Resolution 166 in the same year regulating the practice of TBAs and supporting the Maternal and Child Health Program of the province. Currently, this program is being supported by a grant from the Japan International Cooperation Agency (JICA). The Rationalization Plan of the province under the FOURmula One for Health Program (F1) sought to have obstetrics-gynecology specialists in hospitals, accredit 8 RHUs under the PhilHealth Maternal Care Package (MCP), and procure MCH equipment for all levels of care. The Facility Mapping exercise for the province was undertaken 2-3 August 2006 and was actively participated in by municipal health officers and the provincial health staff. Since the province is already a recipient of JICA assistance, it is important to ensure that the entry of additional funds from other donors does not result in redundant inputs. The Facility Mapping Exercise and the subsequent Needs Assessment Exercise would be useful in this regard.
CEmOC Facility: BILIRAN PROVINCIAL HOSPITAL (BPH) Catchment Municipalities: Naval, Biliran, Cabugcayan, Calbiran, Culaba, Kawayan, Maripipi, Almeda. Proposed BEmOC FacilitiesCatchmentsTravel Time/other Justification1. Culaba Rural Health
UnitCulaba1 - 2 hours travel to BPH. Serves a population of 13,285 MCP accredited.2. Bacolod BHS, CulabaCurrently functioning as birthing facility 3. Caribiran Rural Health UnitCaribiran1 - 2 hours travel to BPH. Serves a population of 22,978 4. Maripipi Rural Health UnitMaripipiAn island municipality with a population of 9,750; is 1 hours from BPH. MCP accredited.5. Viga BHS, MaripipiCurrently functioning as birthing facility6. Agutay BHS, MaripipiCurrently functioning as birthing facility7. Cabucgayan Rural Health UnitCabucgayanTravel time to BPH is 1 hour. Serves a population of 20,734. MCP accredited8. Pawikan BHS, CabucgayanCurrently functioning as birthing facility9. Balaquid BHS, CabucgayanCurrently functioning as birthing facility10. Naval RHUBarangays of NavalCurrently providing BEmOC services 11. Higatangan
Barangay Health Station, NavalBarangay Higatangan, NavalTravel time to BPH is 1 hour. An island barangay with a population of 2,206. Assigned midwife resides in the island.12. Kawayan RHUBarangays of KawayanCurrently a BEmOC service provider13. Tucdao Barangay Health Station, KawayanBarangay Tucdao, KawayanTravel time to BPH is 1 hour. The barangay is remote with bad roads and a population of 4,678.14. Madao BHS, KawayanCurrently functioning as birthing facility.15. Tucdao BHS, KawayanCurrently functioning as birthing facility. Proposed BEmOC FacilitiesCatchmentsTravel Time/other Justification16. Biliran RHUBarangays of BiliranCurrently a BEmOC service provider17. Julita Barangay Health Station, BiliranBarangay Julita, BiliranTravel time to BPH is 1 hour. Serves a population of 3,423 18. Almeria RHUAlmeriaCurrently a BEmOC service provider
As agreed during the workshop, only the Biliran Provincial Hospital (BPH) will be designated to provide comprehensive emergency obstetric care (CEmOC). Given the geographic characteristics of the province, BPH is easily accessible to most municipalities particularly client referrals from the facilities chosen to provide basic emergency obstetric and newborn care (BEmOC). Exceptions are clients referred from Culaba, Caribiran and Maripipi RHUs, as travel from these BEmOCs would be around 30 minutes longer. With JICA committing to provide assistance in terms of maternal and child health inputs on a provincewide scale, investments in the facilities recommended for emergency obstetric care upgrading is expected to be minimum.
EASTERN SAMAR
M aslog
Can -avid
EASTERN SAMAR E
Maslog
EASTERN SAMAR Eastern Samar is part of the Eastern Visayas region. As its name implies, the province is located at the eastern portion of the Samar Island, facing the Philippine Sea to the east and Leyte Gulf to the south. Bordering the province to the north is Northern Samar and to the west is Samar Province. It has a total land area of 4,339.6 square kilometers and is subdivided into 22 municipalities, 1 city and 597 barangays with a population of 375,822 as of the 2000 census. (http://www.eastern samar.gov.ph)
Can -avid
Peoples access to health services varies widely as the geography of the province is characterized by mountainous terrain with rough roads and flood prone areas, thereby making travel by land difficult especially during rainy weather. The presence of numerous natural obstacles such as rivers and small islands also restricts health service utilization. The provincial website includes a discussion on the Objectives for Health, Nutrition and Family Planning. The third objective mentioned is about reducing the maternal mortality ratio (MMR) from 260 (2.6/1,000 live births) to 200/100,000 (2.0/1,000 live births) live births and the infant mortality rate (IMR) from 12 to 10/1,000 live births. To allow the province to device a cost-effective strategy to address maternal mortality, a facility mapping exercise was conducted on 2-3 August 2007 participated by the municipal health officers (MHOs), chief of hospitals (COHs) and Provincial Health Office (PHO) technical staff as well as representatives from the Center for Health Development (CHD)Eastern Visayas. The exercise resulted in the identification of 5 facilities proposed to be CEmOC providers: Eastern Samar Provincial Hospital in Borongan, Albino Memorial Hospital in Balangiga, Taft District Hospital, Felipe Adrigo Memorial Hospital in Guian, and Oras District Hospital. On the other hand, 36 facilities were proposed to be upgraded to BEmOC, of which 4 are hospitals, 14 are RHUs and 18 are BHSs. The choice of BHS BEmOCs was influenced by several factors: 1) many areas are so remote, that getting a transportation is difficult (if available at all) and usually the only way to get to a facility is by walking, 2) the presence of island municipalities and island barangays that could be isolated by bad weather, 3) the need to assign at least a midwife to serve in the proposed BHS BEmOC and for the MHOs and Public Health Nurses (PHNs) to commit to conduct supervisory visits and to be available on call when the midwife attends to deliveries in the BHS. The facility mapping exercise also tried to conform to the inter-local health zone arrangement of the province. The CEmOC-BEmOC clusters are configured as follows:
CEmOC Facility: EASTERN SAMAR PROVINCIAL HOSPITAL (ESPH)

Catchment Municipaliies: Borongan City, San Julian, Maydolong, Balangkayan, and Llorente; with a total population of 123,315.
Proposed BEmOC FacilitiesCatchmentTravel Time/other JustificationsBorongan RHU 1Remote

barangays of Borongan: Amantacup, Balacdas, San Pablo and Can-aga.To reach the facility, women will have to walk for 3 4 hours. The catchment includes satellite barangays that could be accessed only by traversing dangerous terrain.Borongan RHU 2Other barangays of Borongan not covered by RHU 1 as well as barangays along its boundaries with Maydolong: Patag and CamadaThe farthest barangay could be reached by either hiking or taking a pump boat, for a 4 hour ride. The RHU will likewise cater to clients from barangays that are hard to reach mainly because of their remoteness, the difficult terrain and the unstable peace and order situation.San Julian RHUWhole municipality of San JulianThe facility can be reached by 2 hours of hiking a rugged trail.
Maydolong RHUPobalacion area of the municipality as well as other adjacent barangays The RHU can easily be reached within 30 minutes due to the good road conditions and the presence of adequate transportation. The RHU also has an existing lying-in clinic.San Gabriel BHS, MaydolongCatchment barangays and 2 interior barangays of Balangkayan: Malvar and Magsaysay.Travel time from the farthest barangay is 4 hours due to poor roads.Cabay BHS, BalangkayanCatchment barangays The
facility can be reached by a 5-hour hike from the farthest barangays: Malvar, Magsaysay, Hulag, Balogo. No access roads to satellite barangays.
Proposed BEmOC FacilitiesCatchmentTravel Time/other JustificationsLlorente Community HospitalWhole

municipality of Llorente; 2 barangays of Balangkayan: Maramag and Cabay and barangay San Miguel of Hernani.Travel time from Babanikhon, Burak, Magtino, Makaanga and Canduros to the hospital is 2 hours by motorized banca. Poor roads characterize the peripheral barangays of the town of Llorente. CEmOC Facility: ALBINO M
MEMORIAL HOSPITAL (AMMH)
Catchment Municipalities: Balangiga, Giporlos, Lawaan, Quinapondan Travel time to AMMH: from Balangiga: 5 minutes from Giporlos: 15 minutes from Lawaan: 20 minutes from Quinapondan: 30 minutes Proposed BEmOC Facilities CatchmentTravel Time/other Justifications
Guinmaayohan BHS, Balangiga4 barangays of Balangiga: Guinmaayohan, Maybunga, Bangon and Cag-ulango. Barangay San Isidro of neighboring Lawaan.Travel time from the barangays to the BEmOC BHS is 1 4 hours of hiking the trail from Bangon and Maybunga; 30 minutes by boat from Bangon and by motorcycle from Cag-ulango. Travel time to the CEmOC facility is 2 hours. The mountainous roads of the catchment area is usually rocky, muddy and slippery and can be negotiated only by motorcycles. Serves a population of 1,604.Roxas BHS, Giporlos3 barangays of Giporlos: Roxas, Huknan and San Miguel.This BHS can be reached by either a 1-hour hike from Huknan and San Miguel or a 30-minute motorcycle ride from Huknan. The CEmOC facility can be reached in 2 hours by motorcycle from the BHS. The area is generally mountainous with very rough road, which is not accessible even by motorcycle during the rainy season. Rivers also cuts across some barangays, further isolating them during heavy rains. Serves a population of 1,184.
Proposed BEmOC Facilities CatchmentTravel Time/other JustificationsAnislag BHS, Quinapondan4

barangays of Quinapondan: Anislag, San Isidro, Cagdaja and Cantenio.The BHS can be reached by 30 45 minutes of hiking the trail from the catchment barangays. Travel time to the CEmOC is 2 hours. The trip involves a hike and a bus ride. The area is generally mountainous with very rough road, which could not be accessible even by motorcycle on rainy days. Rivers also cuts across some barangays further isolating them during heavy rains. Serves a potential population of 2,100.
For this cluster, 3 BHSs are recommended for upgrading to BEmOC to provide services to women in remote barangays.
The RHUs in the catchment were not recommended for upgrading because of their proximity to the CEmOC facility, which will double as BEmOC service provider. However, the RHUs of Lawaan and Balangiga being already MCP accredited, will continue to provide childbirth services as the LGUs concerned upgrade these facilities to BEmOC standards. The facility mapping exercise also took into account the planned turnover of the Quinapondan Community Hospital to the Quinapondan Municipal LGU for its subsequent merger with the Quinapondan RHU. This is part of the LGU health facility rationalization effort. CEmOC Facility: TAFT DISTRICT HOSPITAL (TDH) Catchment Municipalities: Taft, Sulat, Can-avid, Dolores and Maslog o TDH is more than 1 hours to ESPH o It has a complete human resource complement for a CEmOC facility. The Chief of o Hospital is a diplomate in obstetric and gynecology. o It has an operating and delivery room. o TDH is PhilHealth accredited. Proposed BEmOC FacilitiesCatchmentTravel Time/other JustificationsMalinao BHS, Taft7 barangays of
Taft: Malinao, San Rafael, Binalo-an, San Pablo, Mabuhay, Lumatod and GayamTravel time from the farthest barangay is 1 hour and 25 minutes. This BHS will serve a population of 4,784. Sulat Rural Health Unit9 barangays of Sulat: Mara-mara, Riverside, Bay-bay, Loyola Heights, Tabi, Maglipay, Abucay, San Francisco, Del RemediosTravel time to TDH is 30 minutes. Will serve a population of 7,087 PhilHealth accredited San Vicente BHS, SulatBarangay San VicenteTravel time from the farthest barangay is 1 hour by boat or tricycle It is an island barangay. Serves a population of 1,257 The LGU of Sulat is willing to invest in a sea ambulance. Sto Tomas BHS, Sulat4 barangays of Sulat: Sto Tomas, Sto Nino, Candalakit, and San IsidroTravel time from the farthest barangay is 45 minutes. Serves a population of 4,341. San Juan BHS, Sulat4 barangays of Sulat: San Juan, San Mateo, Mabini, A-etTravel time from the farthest barangay is 45 minutes Serves a population of 1,778. A midwife assigned at the BHS also resides in the barangay.Can-avid Community Hospital8 barangays of Can-avid: Guibuangan, Mabuhay, Canteros, Carolina, Rawis, Solong, Obong, Malogo Travel time from the barangays to the BEmOC hospital is 30 minutes to 1 hours. Common modes of transportation within the Poblacion are motorcycle and pedicab. The rest of the barangays are accessible only by motorboat or hiking the trail. The hospital is about 17 kms away from TDH, a CEmOC facility. The hospital is PhilHealth accredited.
Proposed BEmOC FacilitiesCatchmentTravel Time/other JustificationsCamantang BHS, Can-avid8

barangays of Can-avid: Jepaco, Barok, Balogon, Boco, Salvacion, Can-ilay, Caghalong, and PandolTravel time to the facility ranges from 30 minutes to 4 hours by motorized banca. Barangay Jepako however is accessible only via a 45-minute hike.
Travel time from Camantang to the RHU is 1 hour and 30 minutes. Generally characterized by difficult and mountainous terrain with rivers cutting across the area. Transportation is therefore expensive, if at all available. Dolores Rural Health Unit46 barangays of DoloresTravel time to TDH is only 40 minutes. Serves a population of 39,000.
The LGU of Sulat has recommended 3 of its BHSs for upgrading to BEmOC standard and is willing to provide an emergency stand-by vehicle in each of the BHSs for emergency purposes. This report also notes the recommendation by the health officers to upgrade Can-avid Community Hospital to BEmOC rather than the RHU despite the planned merging of the 2 facilities, with the RHU becoming the main facility as reflected in the Rationalization Plan. The LGU is contesting the recommendation to merge the facilities as they view the hospital as a necessary infrastructure in the locality. The low occupancy rate of 24% is understandable of the 10-bed hospital given that the population of the municipality is also small at 18,000. Upgrading the hospital to BEmOC will enhance its capacity to be responsive and deliver quality health service. Its occupancy rate is also expected to improve as mothers shift from home to facility birth.
CEmOC Facility: FELIPE ADRIGO MEMORIAL HOSPITAL (FAMH) (Formerly: Southern Samar General Hospital) Catchment Municipalities: Guiuan, Mercedes, Hernani, Salcedo, Gen MacArthur Proposed BEmOC Facilities CatchmentTravel Time/other JustificationsHomonhon Island Community
Hospital7 barangays of Homonhon IslandTravel time from farthest barangay: 2 hours Travel time to FAMH: 3 hours by boat. An island within the municipality of Guiuan with a population of 5,250. Staff Complement: 1 doctor, 3 nurses, 6 midwives This is a 10-bed hospital.Manicani BHS, Guiuan5 barangays and 1 adjacent small island Manicani is an island barangay, which is 30 minutes to 1 hour away from FAMH by boat. Travel time from the farthest barangay to this BHS BEmOC is 1 hour. Serves a population of 2,635. A resident midwife is assigned in the area.Sulangan RHU, Guiuan4 mainland and 9 island barangays of GuiuanTravel time from farthest barangay to this BEmOC RHU is only 30 minutes. The Public Health Nurse resides in the area. Two midwives are assigned to the facility and 1 of them resides in the area.
Suluan BHS, MercedesBarangay Suluan, GuiuanTravel time to FAMH is 3-4 hours by boat. An island barangay, generally isolated and depressed, with a population of 1,241. Staffed by a resident midwife.
Proposed BEmOC Facilities CatchmentTravel Time/other JustificationsHernani RHU13 barangays of

Hernani and 3 barangays of LlorenteNo road network, thus the RHU BEmOC could be reached by walking for 6 8 hours from the farthest barangay. The CEmOC Facility could be reached in 1 - 2 hours from the poblacion. A remote municipality with a population of 7,144. A doctor, a nurse and a midwife staff the facility.Salcedo Rural Health Unit38 barangays including an island barangayTravel time from the farthest barangay: 1 - 1 hour and 45 minutes either by land or water transport facility. The municipality has 41 barangays with poor roads and no regular transport. A doctor, a nurse and a midwife staffed the RHU, which is MCP accredited.General MacArthur Community HospitalMunicipality of MacArthur and barangays along the boundaries of Salcedo, Hernani and Quinapondan.Travel time to the CEmOC facility is 45 minutes to 1 hour. The hospital is a 10-bed facility with full staff complement: doctor, nurses, and midwives.Pinggan BHS, Gen MacArthur8 barangays of MacArthurTravel time from the farthest barangay is 7 hours by land. This BHS BEmOC staffed by a midwife serves communities with difficult terrain, with no regular transport.
Camcueves BHS, Gen MacArthur6 Barangays of Gen MacArthurTravel time to the CEmOC facility is 3 hours. Travel time to BHS BEmOC from the farthest barangay is 6 hours by land transport.
CEmOC Facility: ORAS DISTRICT HOSPITAL (ODH)

Catchment Municipalities: Oras, Maslog, San Policarpio, Jipapad, Dolores and Arteche Catchment population: 80,000. Travel time: to ESPH: 2 hours From Maslog and Jipapad: 4 5 hours
Proposed BEmOC FacilitiesCatchmentTravel Time/other JustificationsOras RHU 14 barangays of Oras

2 of which are hard to reach: Trinidad and NagaTravel time from farthest catchment is 4 hours by hiking the trail. Travel time to ODH is 45 minutes. The RHU is located along the Oras river in barangay Agsam with a total population served of 2,238.Oras RHU2 (located in barangay Cadian)15 barangays of OrasTravel time to the RHU is 15 minutes to 1 hours from the barangays. ODH can be reached within 1 2 hours. Rivers characterize the catchments thus, the main mode of transportation is motorized banca. Maslog RHU12 barangays of Maslog, 2 of which are considered hard to reach.Considered an interior municipality of the province, it would take 4-5 hours of travel to the nearest community hospital and 5 6 hours to reach ODH, a CEmOC facility.
This RHU has an MCP accreditation.San Policarpio RHU17 barangays of San Policarpio.The Center is geographically accessible to all barangays by motorcycle. However, access to 3 barangays is only by hiking, Agsaman BHS, Jipapad 3 remote barangays of JipapadThe catchments are hard to reach. Travel time to the Main Health Center is 4 hours of hiking.Proposed BEmOC FacilitiesCatchmentTravel Time/other JustificationsArteche RHUPoblacion area and neighboring barangaysTravel time to ODH, a CEmOC facility takes 2 2 hours. Accessible to all barangays either by using a public utility vehicle, motorcycle or by hiking. Serves a population of 15,047 This facility is PhilHealth accredited.Concepcion BHS, Arteche5 barangays along the riverbank. Travel time from the farthest barangay is 15 minutes to 1 hour by motorboat and by hiking the trail. Travel time to ODH is 2-3 hours. The BHS is located along the Oras river.Carapdapan BHS, Arteche2 remote barangays of ArtecheThe BHS can be reached in 15 minutes via motorcycle.Tangbo BHS, Arteche5 barangays of Arteche, 4 of which are hard to reach.Travel time from the barangays of Campacion, Tibalawan and Inayawan is approximately 2 4 hours by hiking the trail and riding a motorcycle. Travel time to ODH is 30 minutes.
SO UTH ERN B L
CEmOC
SOUTHERN LEYTE Southern Leyte, one of the 6 provinces of Eastern Visayas, straddles the southern third of the island of Leyte and includes under its jurisdiction, the islands of Panaon and Limasawa. The deep Surigao Strait separates the island of Panaon from Mindanao. The provinces coastal areas are relatively flat while the
B HB Em O C S
interior is mountainous. It is bounded by the province of Leyte to the north, by the Surigao Strait to the east, Bohol Sea to the south and Canigao Channel across Bohol to the west.
(http://www.geocities.com/lppsec/pp/sleyte.htm?200717).
Southern Leyte has numerous small rivers in addition to at least 11 major rivers: Canturing River in Maasin, Amparo River in Macrohon, Divsoria River in Bontoc, Subang Daku River in Sogod, Lawigan and Hitungao Rivers in San Juan, Das-ay and Pondol Rivers in Hinunangan and Maag River in Silago. Its total land area is 173,480 hectares subdivided into 1 city, 18 municipalities and 501 barangays.
(http://www.geocities.com/lppsec/pp/sleyte.htm?200717).
The geographic characteristics of the province affect peoples access to social services. As the 2006 Provincial Health Office Report pointed out, 50 % of women who gave birth in the same year opted to deliver at home with 17% availing of the services of traditional birth attendants. Risk pregnancy was noted in 43% of pregnant women. The Provincial Health Office (PHO) sought technical assistance to enable them to rationally plan for an investment in womens health and safe motherhood. While the province reports no maternal death, provincial health managers appear aware of the need to be proactive for them to be able to sustain this situation. The facility mapping exercise for the province was conducted on 30-31 July 2007. The exercise was meant to guide the health officers identify facilities that can be upgraded to CEmOC and BEmOC based on defined criteria. This activity is an initial step towards setting up a responsive program aimed at improving womens health. The facility mapping exercise was attended by the Municipal Health Officers, Chief of Hospitals and PHO technical staff. It resulted in the selection of 4 hospitals for upgrading to CEmOC and 14 facilities for upgrading to BEmOC, 3 of which are hospitals, 9 are RHUs and 2 are BHSs. The following is the CEmOC-BEmOC network configuration in the province: CEmOC Facility: SOUTHERN LEYTE PROVINCIAL HOSPITAL (SLPH) Catchment Municipalities: Maasin City, Limasawa, Macrohon, Malitbog and Padre Burgos. SLPH is located in Maasin City. Except for Limasawa Island, the rest of the catchment municipalities have easy access to this facility. Two of its catchment municipalities have facilities that were granted maternal care package accreditation: Limasawa Island RHU and Malitbog RHU Proposed BEmOC FacilitiesCatchmentTravel Time/other JustificationMaasin City Health Unit
2Catchment barangays within the city proper and neighboring barangaysThis facility should be upgraded to BEmOC to help decongest SLPH of childbirth admissions.Maasin City Health Unit 324 barangays of Maasin CityFrom the farthest barangay, the facility can be reached in 45 minutes. All barangays have access to transportation. Serves a population of 25,000.Macrohon RHU15 barangaysTravel time to the facility is 45 minutes to 1 hour. Mountainous terrain and bad roads characterize the municipality.Limasawa Island RHU6 barangaysTravel time to the mainland is 2 hours by boat. Limasawa is an island municipality that becomes isolated during the habagat or southwest monsoon season.
The RHU is MCP accredited.Padre Burgos Community Hospital7 hard to reach barangays.This facility has a lying in unit. The terrain is generally mountainous with bad roads. Malitbog RHU37 barangays 12 of which are in the mountains Travel time to the facility from the mountainous barangays is 1 hours by hiking the trail and riding a motorcycle. The RHU is MCP accredited
The workshop decided to recommend the upgrading of Maasin City Health Units 2 and 3 to BEmOC to help decongest the SLPH of childbirth admissions considering the heavy patient load of the hospital.
CEmOC Facility: SOGOD DISTRICT HOSPITAL (SDH) Catchment Municipalities: Sogod, Bontoc, Libagon, Liloan, Tomas Oppos Travel time from Libagon to Sogod: 30-40 minutes From Bontoc to Sogod: 30-40 minutes This cluster has 1 municipality whose facility was granted MCP accreditation by PHIC: Tomas Oppos RHU. Proposed BEmOC FacilitiesCatchmentTravel Time/other JustificationLiloan Community HospitalLiloan
and neighboring barangaysThe facility is accessible to all barangays in the catchment and will help decongest SDH of childbirth admissions.
CEmOC Facility: ANAHAWAN DISTRICT HOSPITAL (ADH) Catchment Municipalities: Anahawan, St Bernard, Silago, San Juan, Hinundayan Travel time to SLPH: 3 hours from the farthest catchment municipality. One municipality has 2 facilities with MCP accreditation: Silago RHU and St Bernard RHU. Proposed BEmOC FacilitiesCatchmentTravel Time/other JustificationSt Bernard RHU12 coastal
barangays and 7 mountain barangays Travel time to the facility from the farthest coastal barangay is 1 hour; from the farthest mountain barangay, 1 hours. Travel time to ADH 30 45 minutes. The roads are good. The RHU serves a population of 26,297. The RHU is PhilHealth and MCP accredited, has Sentrong Sigla Level 1 certification, and has applied for newborn screening accreditation.
Proposed BEmOC FacilitiesCatchmentTravel Time/other JustificationMa Asuncion BHS, St BernardRemote

indigenous people communities of St BernardTravel time to the RHU is only 30minutes. The community is generally mountainous. This BHS is currently providing childbirth services.Silago RHU15 barangays Silago and 9 disputed barangays; 2 hard to reach barangays: Catmon and PuntanaTravel time to the RHU from the farthest baranagy is 30 minutes to 1 hour.
The RHU is MCP accredited.Hinatunggan BHS, SilagoRemote barangays of SilagoTravel time to Silago RHU is 20 30minutes. Currently functioning as a birthing facility. Because of the difficult terrain, transportation is not always available.
CEmOC Facility: PINTUYAN DISTRICT HOSPITAL (PDH) Catchment Municipalities: Pintuyan, San Francisco, San Ricardo, Hinunangan Travel time to ADH: 4 hours to SDH: 3 hours PDH is categorized as level 1 facility, which means, it is not allowed to perform surgeries and has been recommended to be merged with the Pintuyan RHU. However, this move is being opposed by the local government units involved. The workshop recommended that the merger be put into operation by upgrading the hospital to BEmOC operating in tandem with the RHU. Its occupancy problem may also be addressed by encouraging mothers to give birth in the facility instead of at home. Proposed BEmOC FacilitiesCatchmentTravel Time/other JustificationSan Francisco RHUSan FranciscoThe
area is hard to reach and residents have difficulty accessing health facilities in neighboring municipalities. San Ricardo RHUSan RicardoSame as aboveHinunangan Community Hospital2 municipalities: Hinunangan with 40 barangays of which 2 are islands and 5 are hard to reach with 2 sitios. and Silago with 15 barangays 9 of which are disputed with Abuyog, Leyte.Travel time to this hospital BEmOC from the farthest barangay is 2 3 hours by motorcycle.
MISAMIS OCCIDEN
MISAMIS OCCIDENTAL Misamis Occidental occupies a bend of the Zamboanga peninsula that stands sentinel to the long narrow Panguil Bay. It is bounded on the west by the provinces of Zamboanga del Norte and Zamboanga del Sur and separated from Lanao del Norte by Panguil Bay. The terrain is rolling and rises
Sapan Dalaga
sharply towards Mount Malindang in the west. The province is lucky to lie outside the typhoon belt, giving it an even climate and mild weather throughout the year.
(http://www.geocities.com/lppsec/pp/micamisocc.htm?200717).
The province has a total land area of 2,207 square kilometers and an estimated population of 491,825. It consists of 3 cities, 14 municipalities and 490 barangays. (http://www.misocc.gov.ph/all_abouthtml). The Rationalization Plan submitted by the Provincial Health Office reflects the concern over the outcomes of the current maternal and child health service delivery system. The plan aggressively pushes for the upgrading of health facilities to enable them to deliver basic and comprehensive emergency obstetric care (BEmOC and CEmOC) to their constituents. This effort is mainly driven by the occurrence of 6 maternal deaths in the province in 2006, 4 of which were caused by postpartum hemorrhage, a preventable condition. This brings the maternal mortality ratio (MMR) of the province to 161/100,000 live births. While midwives assisted 62% of these childbirths, a considerable 38% are still being handled by traditional birth attendants (TBAs). To assist the province plan for their womens health and safe motherhood (WHSM) investments, a facility mapping exercise was conducted on 8-9 May 2007. The exercise initiates the effort to identify local needs in so far as implementation of the WHSM intervention model is concerned. The exercise was attended by all health officers from the different municipalities and cities as well as the technical staff of the PHO and coordinators from the Center for Health Development-Northern Mindanao. It resulted in the identification of 3 hospitals proposed to be CEmOC providers and 7 proposed for BEmOC upgrading: 6 RHUs, 1 Puericulture Center. The Misamis Occidental Provincial Hospital, will function as a BEmOC provider as well in its catchment area. No facility in the province has been accorded MCP (maternal care package) accreditation by Philhealth yet. The health officers therefore welcome the prospect of speeding up the effort towards accreditation with the planned facility upgrades that the facility mapping and needs assessment generates
CEmOC Facility: CALAMBA DISTRICT HOSPITAL (CDH) Catchment Municipalities: Calamba, Sapang Dalaga, Baliangao and Concepcion
Proposed BEmOC Facilites CatchmentTravel Time / other JustificationsSapang Dalaga RHUSapang

DalagaTravel time is 30 minutes from the barangays in the catchment to the RHU
Proposed BEmOC Facilites CatchmentTravel Time / other JustificationsBaliangao RHUBaliangaoTravel time is 30 minutes from the barangays in the catchment to the RHUConcepcion
RHUConcepcionTravel time is 30 minutes from the barangays to RHU This facility needs to be upgraded to BEmOC, since travel time from the RHU to the core referral hospital is 2 hours by public utility jeepney.
CEmOC Facility: MISAMIS OCCIDENTAL PROVINCIAL HOSPITAL (MOPH)
Catchment Municipalities: Oroquita City, Lopez Jaena, Aloran and Panaon The facility mapping considered the following recommendations from the health officers: Since MOPH is centrally located and is connected to the catchment municipalities by good roads and efficient public transport system, it can be reached within 30 minutes from each of the catchment municipalities. For this reason, it will double as a BEmOC provider.
The Puericulture Center in Ozamis City, which has been proposed to be BEmOC provider, will help decongest the MOPH of childbirth admissions. It is less than 30 minutes away from the MOPH. CEmOC Facility: S. M. LAO MUNICIPAL HOSPITAL (SMLMH) Catchment Municipalities: Ozamis City, Sinacaban, Tangub, Bonifacio, Jimenez, Clarin, Don Victoriano Chiongbian
Proposed BEmOC FacilitiesCatchmentTravel Time/other Justifications Sinacaban RHUSinacaban and TudelaTravel time is 30 minutes from the barangays to RHUTangub RHUTangub, Bonifacio and JimenezTravel time is 30 minutes from the barangays to RHUOzamis City Health OfficeOzamis City and ClarinTravel time is 15 30 minutes from the barangays to the CHO Puericulture CenterPuericulture Center, Ozamis CityOzamis CityTo help decongest the SMLMH, a CEmOC facility of childbirth admissions.Proposed BEmOC FacilitiesCatchmentTravel Time/other JustificationsDon Victotiano Chiongbian RHUDon Victoriano ChiongbianTravel time is within 30 minutes to 1 hour from the barangays to the RHU. Travel time from the RHU to the core referral facility is 2 to 4 hours. Reported 1 maternal death in 2006.
The workshop participants made a conscious effort to make the facility map consistent with the Rationalization plan. For instance, the workshop decided not to recommend either Tudela Municipal Hospital or the Tudela RHU for BEmOC upgrading as these facilities had been previously identified for merging. The decision actually conforms to the mapping criteria since Tudela is only around 10-15 minutes away from Ozamis City which will host a BEmOC and CEmOC facility.
NORTH CO BA TA TO
A ada lam
NORTH COTABATO North Cotabato is a landlocked province located in the SOCCSKSARGEN region of Mindanao. It is bounded on the north by Bukidnon, on the northwest by Lanao del Sur, on the southwest by Maguindanao, on the south by Sultan Kudarat and on the east by Davao del Sur. Mountains to the east peak at Mount Apo. The Piapayungan Range along the west side separates the province from Lanao del Sur. The Pulangi River basin runs in the middle of these 2 highland areas and spreads towards the southwest to the plains of Maguindanao. (http://www.geocities.com/lppsec/pp/cotabato.htm?200717). Indigenous people consisting of the Manobos, Tbolis, Iranun and Maguidanaos inhabit the province. The Manobos are the most populous. In fact, Kidapawan, the capital city, is a Manobo cultural center. (http://www.geocities.com/lppsec/pp/cotabato.htm?200717). Well-paved roads link North Cotabato to the progressive cities of Gen Santos City, Davao City and Cagayan de Oro City. The province has a total land area of 8,250 square kilometers and consists of 1 city, 17 municipalities and 543 barangays with an estimated population of 973,134. (http://www.geocities.com/lppsec/pp/cotabato.htm?200717). The province however has been the center of armed encounters between the Philippine Armed Forces and Mindanaos rebel groups. Kidnappings and petty crimes are rampant. This conflict has affected health service delivery and consequently, peoples health. In 2006, 7 maternal deaths were reported. A facility mapping for the province was held 12-13 July 2007. This resulted in the identification of 3 CEmOC facilities and 11 BEmOC facilities of which 3 are hospitals, 6 are RHUs, and 2 are BHSs.
Proposed CEmOC Facility: NORTH COTABATO PROVINCIAL HOSPITAL (NCPH)
Catchment Municipalities: Kidapawan City, Magpet, Tulunan, Carmen, Mlang, Makilala, Kabacan, some barangays of Lower President Roxas, some baranagys of Matalam Proposed BEmOC FacilitiesCatchmentTravel Time/other Justifications
1. Kidapawan City Hospital 40 barangays of the city, some barangays of adjacent municipalities: Magpet, Makilala, President Roxas
Located in barangay Amos, which is far from the city proper. The hospital is a 10-bed facility with delivery room and serves a population of 124,595.The city had 3 maternal deaths in 2006 due to eclampsia. The city is relatively peaceful.
Proposed BEmOC FacilitiesCatchmentTravel Time/other Justifications2. Magpet Rural Health Unit35

barangays of Magpet.Travel time from the farthest barangay is 1 hour by motorcycle. The municipality of Magpet is located in the northeastern tip of the province. Rolling to scattered hills, wide and narrow valleys and mountain ranges with plains and small lakes dominate its landscape. Its forest cover is the largest in Mindanao. Mt Apo is located in the eastern part of the municipality. The peace and order situation is relatively stable. The municipality had 2 maternal deaths in 2006. Serves a population of around 45,000. 3. Father Tulio Favale Municipal Hospital, TulunanBarangays of Tulunan 11 of which are hard to reach and neighboring municipality of Maguindanao.Travel time from the farthest barangay is 30 minutes to 1 hour.
Tulunan has a rugged, mountainous terrain.4. Carmen RHU28 barangays of CarmenTravel
time from the catchments to the RHU ranges from 30 minutes to 2 hours and from the RHU to NCPH, 1 hour.
Serves a population of 55,889. The municipality is also characterized by difficult to reach sitios and peace and order problems. The RHU is a Level 1 Phase 2 Sentrong Sigla certified.
Proposed CEmOC Facility: ARAKAN VALLEY DISTRICT HOSPITAL (AVDH) Catchment Municipalities: Antipas, Arakan, Upper President Roxas, some barangays of Lower President Roxas, Matalam, some barangays of Carmen. The proposed CEmOC facility is located in the municipality of Antipas. Proposed BEmOC FacilitiesCatchmentTravel Time/other Justifications1. Arakan RHU28 barangays of
Arakan, some barangays of Magpet, Antipas, 5 barangays of Pres Roxas and those along the borders of Davao and 5 barangays of the Municipality of Kitaotao, Bukidnon.Travel time to the RHU from San Miguel, the farthest barangay is 1.5 hours by motorcycle Arakan is characterized by rolling and scattered hills, wide and narrow valleys and mountain ranges. It also has patches of plains and small lakes. There is no threat to peace and order. The RHU recorded 2 maternal deaths in 2006.2. Sarayan BHS, Upper Pres. RoxasBarangays of Carmen, Antipas, upper and lower Pres Roxas, Arakan and MatalamTravel time to AVDH is 1 hour. Travel time from the catchment barangays to the proposed BHS BEmOC is 30 minutes to 1 hour using skylab or jeepney. Characterized by a sloping, mountainous terrain with rough roads. The municipality of Carmen has been the site of intermittent armed encounters. Barangay Sarayan and its surrounding barangays have the Manobo tribe and Muslims as members.
Proposed CEmOC Facility: DR AMADO DIAZ PROVINCIAL FOUNDATION HOSPITAL (DADPFH) Catchment Municipalities: Midsayap, Banisilan, Alamada, Pigcawayan, Pikit, Aleosan, Libungan The proposed CEmOC facility is located in the municipality of Midsayap and can be reached within the standard travel time of 1 hour from each of the proposed BEmOC facilities within the cluster. In determining the facilities proposed for BEmOC upgrading, individual views of the health officers were carefully considered especially in conflict areas where the safety of the health staff is a major consideration. Attention was particularly given to the case of Banisilan, a municipality that is occupied by Manobos and Muslims and is considered critical for 2 reasons: 1) there is armed conflict in the area, and 2) the political leadership was still being contested months after the election. But despite this apparent difficult situation, the MHO was committed to remain in the area to serve. He remained hopeful that upgrading the Salama BHS to BEmOC would bring about significant improvements in
health services despite the unstable peace and order situation. Proposed BEmOC FacilitiesCatchmenTravel Time/other Justifications1. Banisilan RHU20 barangays of
Banisilan.The RHU is projected to serve a population of around 47,000 and is only about 30 45 minutes to Wao, Lanao del Sur, where patients needing higher level service are currently referred. Banisilan is a rural municipality with flat and rolling terrain.2. Salama BHS, BanisilanDifficult to reach barangays of Banisilan.The proposed BHS BEmOC is only 1 hour from the proposed CEmOC. Located south of Banisilan, it serves a population of around 17,000 mostly Muslims and Manobos. The area has been considered critical because of the presence of armed insurgents resulting in years of continued poor health service delivery.2. Alamada Provincial Community Hospital17 barangays of Alamada, settlers from Kaolo, Davao del Norte,
some barangays of Banisilan and Libungan, some barangays of Bukidnon and barangay Wao of Lanao del Sur.Travel time from Dado, the farthest sitio is 1 2 hours. Travel time from barangays in Banisilan (Bao and Malitbug) is 2 hours via Kitub river. The facility is located in Sitio Magsaysay, Barangay Kitacubong, Alamada, an area surrounded by the mountains of Banisilan and Lanao del Sur. The roads that leads to the facility are passable using habal-habal This hospital is the only health facility in the area that serves a population of 50,173 Christians and Muslims. This 10-bed hospital is PHIC accredited.
Proposed BEmOC FacilitiesCatchmenTravel Time/other Justifications3. Pigcawayan RHU40 barangays

of PigkawayanTravel time to the CEmOC facility is 20 25 minutes. Travel time from the farthest barangay to the proposed RHU BEmOC is 1 hour. 4. Pikit RHU42 barangays Pikit is composed of 70% Muslims and is another municipality that is the site of a
number of bloody encounters between the military and Muslim rebels. The encounters lead to displacement of families that often result in a worsened health situation for those affected.
A G U S A N D E LB S E
CEmOC BHS BEmOC RHU BEmOC
AGUSAN DEL
AGUSAN DEL SUR

Agusan del Sur prides itself as the largest province in the CARAGA region in terms of land area, estimated at 8,965.5 square kilometers. Along its borders (starting on the north going clockwise) are the provinces of Agusan del Norte, Surigao del Sur, Davao Oriental, Compostela Valley, Davao del Norte, Bukidnon and Misamis
Oriental. (http://en.wikipedia.org/wiki/Agusan_del_Sur) The province is an elongated basin formation with mountain ranges on the eastern and western sides forming a valley, which occupies the central longitudinal section of the land giving its characteristic flat and rolling landscape crisscrossed by an abundance of rivers and streams. The Agusan River flows from the Compostela Valley in the south towards Agusan del Sur in the north runs along the middle of the valley and empties into Butuan bay. The river has 12 waterways supplied by streams and creeks: Wawa, Gibong and Simulao rivers on the eastern side and Ojot, Pusilao, Kasilayan, Libang, Maasam, Adgawan, Cawayan, Umayam, and Ihaon rivers on the western side. These waterways divide the province into 7 highway municipalities: Prosperidad, San Francisco, Rosario, Bunawan, Trento, Sta Josefa, and La Paz and 7 geographically isolated river towns: Sibagat, Bayugan, Esperanza, San Luis, Talacogon, Veruela and Loreto. It has at least 5 tribal groups: Aeta, Mamanwa, Bagobo, Higaonon and Manobo. The Manobos live along the national highway and river towns towards the boundary with Compostela Valley, while the Higaonons occupy the western side of Agusan River, mostly in the town of Esperanza towards the boundary with Bukidnon. The other tribes are scattered among the other towns. It has an estimated population of 559,294 as of the 2000 census, composed predominantly of immigrants from the Visayas. (http://en.wikipedia.org/wiki/Agusan_del_Sur) The landscape of the province play an important role in peoples lives and heavily influence their health seeking behavior. A health situation report prepared by the Provincial Health Office (PHO) in 2003 showed a high preference towards homebirths at 83.71%, 42% of which were assisted by traditional birth attendants (TBA) and 44% by midwives. The preference for TBA assisted homebirth persists despite a 48.99% risk pregnancy. (Agusan del Sur PHO Report, 2003). Relative to their current maternal care index, the Rationalization Plan of the province calls for the upgrading of strategically located primary and secondary level facilities to enable them to provide emergency obstetric care and save womens and childrens lives. (Rationalization Plan of Health Facilities, Agusan del Sur). A facility mapping exercise was conducted in the province on 18-19 July 2007. The Municipal Health Officers, Chief of Hospitals, Provincial Health Office Technical Staff as well as the Maternal and Child Health and FOURmula One for Health Program Coordinators of the Center for Health Development - Caraga actively participated in the activity. The exercise resulted in the identification of 3 facilities for upgrading to provide CEmOC services: Democrito O Plaza Memorial Hospital, La Paz Municipal Hospital and Bunawan District Hospital and 28 facilities for upgrading to BEmOC, of which 1 is hospital, 5 are RHUs (Rural Health Units), and 22 are BHSs (Barangay Health Stations). Three facilities have Maternal Care Package (MCP) accreditation from PhilHealth: Trento RHU, Talacogon RHU and Zillovia BHS also of Talacogon. Trento RHU was not recommended for further upgrading to BEmOC because of its proximity to other BEmOC facilities and to the CEmOC facility in Banawan. Instead the MHO of Trento proposed that Sta Maria BHS be upgraded to BEmOC to serve the interior barangays of the municipality, all of which are accessible only by motorcycle because of the rough road. The health officers originally wanted to have 45 (1 hospital, 8 RHUs, 36 BHSs) of their facilities upgraded to BEmOC standard. The recommended number is actually justifiable given the geographic (rough terrain isolated by rivers) and demographic (populated by indigenous minority groups) characteristics of almost 50 % of their municipalities. Moreover, while the recorded maternal death was only 1 in 2006 and 1 this year, again given the remoteness of a substantial number of villages and the indigenous population in the province, it is highly possible that there were more that were not reported. However, given the limited resources allotted to the province, the group decided to recommend only the most strategically located facilities. The following shows the CEmOC and BEmOC Cluster configuration: CEmOC Facility: DEMOCRITO O. PLAZA MEMORIAL HOSPITAL (DOPMH) Catchment Municipalities: Prosperidad, San Francisco, Rosario, San Luis, Talacogon, Bayugan, Sibagat, Esperanza
Proposed BEmOC Facilities Catchment Travel Time/other Justification Azpetia BHS, Prosperidad 6 hard to reach barangays with IP communities of Prosperidad: Magsaysay , San Martin, San Lorenzo, Libertad , Mabuhay, Salimbogaon
Travel time to the CEmOC facility is 45 minutes. Travel time from the barangays to the proposed BHS BEmOC ranges from 30 minutes to 1 hour. The barangays are hard to reach because of the difficult terrain and irregular transportation schedule. A motorcycle is the only mode of transportation available. Its remoteness sometimes makes the catchment vulnerable to peace & order disruptions. This BHS BEmOC will serve a population of 9,078.Sta Irene BHS, Prosperidad4 barangays of Prosperidad, 3 of
which are hard to reach:La Purisima, San Jose, San Joaquin,

Travel time from Sta. Irene BHS to CEmOC Facility is 45 minutes.
La Perian
Travel time from the barangays to proposed BHS BEmOC: 15 minutes to 3 hours; La Purisima is the farthest barangay. The proposed BEmOC BHS is accessible since it is located along the highway. It serves a population of 9,379.
Proposed BEmOC Facilities Catchment Travel Time/other JustificationLucena BHS, Prosperidad7 barangays of Prosperidad, 5 of which are hard to reach: San
Pedro, Napo, Aurora, San Roque, La Union,San Vicent, San Rafael The CEmOC facility is just 40 minutes away from the BHS BEmOC. From the barangays, travel tine to the proposed BEmOC BHS is from 30 minutes to 2 hours, with San Roque being the farthest barangay. This proposed BEmOC BHS is very accessible to transport facilities and serves a population of 13,358. Lapinigan BHS, San Francisco5 barangays of San Francisco: Mati,Caimpogan, Buenasuerte, Pasta, Ormaca Travel time from the barangays to the proposed BHS BEmOC is about 15 minutes to 1 hour with Pasta as the nearest and Mati and Buenasarte as the farthest. The catchment area is characterized by rough road (with only the national highway being cemented), rolling terrain and muddy portions that can be reached only by motorcycle. Mati registered 1 maternal death this year. The BHS is a Sentrong Sigla Level 1 accredited and serves a population of around 8,000, 30% of which are IPs.
Rosario Rural Health Unit11 barangays of RosarioTravel time to the RHU from the farthest barangay is 1 hour. The municipality has a population of 32,000, of which 60% are considered indigenous people. The RHU has a birthing home attached to it. Proposed BEmOC Facilities
Catchment Travel Time/other JustificationMarfil BHS, RosarioRemote barangays of RosarioTravel time to the BHS is 1 hour.
Serves an indigenous population of 2,400. The catchment barangays are located in a hilly area along the boundary with Surigao Sur. The remoteness of the area made the LGU decide to construct a birthing facility.Laminga BHS, San Luis4 barangays of San Luis: San Pedro, Baylo,Coalicion,Laminga The proposed BHS BEmOC could be reached 8 hours of hiking the trail from the farthest sitio. The area is prone to flash flooding during the rainy season. The BEmOC will serve a total population of 7,261, 90% of which are IPs.Talacogon Rural Health Unit3 barangays of Talacogon: Labnig, Sabang, Gibong and the whole Poblacion area.Travel time to the CEmOC facility is 1 hour by jeepney Roads are cemented in the Poblacion. Sabang and Gibong are river barangays and the main mode of transport is pumpboat. The travel time to the proposed BEmOC facility is 2 to 3 hours. This proposed BEmOC facility will serve a population of 26,800 and is MCP accreditedZillovia BHS, TalacogonZillovia, Talacogon and barangays along the boundaries with San LuisTravel time to this proposed BEmOC BHS is 1 hour. The area is characterized by rough roads and is prone to flooding. This proposed BEmOC BHS serves a population of 13,000 and is MCP accredited
Proposed BEmOC Facilities Catchment Travel Time/other JustificationBayugan Rural Health Unit18 barangays of Bayugan within the Poblacion area and
outlying barangays: Taglatawan, Bucac, Fili, JCA, Hamogaway, Osmena, Noli, Maygatasan, Pinagalaan, Mahayag, Sto. Nino, Mabuhay, Tagubay, Cortez, Del Carmen, Sta. Irene, Panaytay and CanayuganThe 18 barangays with an estimated population of 46,000 would gain access to the facility within 30 minutes. Travel is on an all weather road, with rough patches and mountainous terrain.Grace Estate BHS, Bayugan6 barangays of Bayugan: Magkiangkang, Mt. Olive, Mt. Carmel, Villa Undayon, New Salem and Getsemane.Travel time from the farthest barangay would take 30 minutes. Serves an estimated population of 10,000.Berceba BHS, Bayugan3 barangays of Bayugan: Calaital, Mt. Ararat and San JuanTravel time from the farthest barangay is within 30 minutes. Serves an estimated population of 6,775.Magsaysay BHS, Sibagat6 barangays of Sibagat: San Isidro, Sta Cruz, del Rosario, Sta Maria, Magcalape, VillangitTravel time from the barangays to the proposed BEmOC BHS ranges from 30 minutes to 1 hour.
The area is generally mountainous.Padiay BHS, Sibagat3 barangays of Sibagat: Banagbanag, Perez, KulambuganTravel
time from the barangays to the proposed BEmOC BHS ranges from 30 minutes to 1 hour. The terrain is generally mountainous.Guadalupe BHS, Esperanza5 barangays of EsperanzaTravel time from the 5 barangays to the Poblacion could take 1 to 2 hours.
Travel is on an all weather road with rough patches.Salug BHS, Esperanza3 barangays of EsperanzaSalug is a mountainous barangay where access is dependent on the weather. When the weather is good, travel time could take 1 hour. On bad weather, it could take the whole day to reach the Poblacion.Balobo BHS, Esperanza4 barangays of
EsperanzaThe BHS will serve mountainous barangays. Travel time to the Poblacion could take 1 to 3 hours. CEmOC Facility: LA PAZ MUNICIPAL HOSPITAL (LPMH)
Catchment Municipalities: La Paz, Talacogon and Loreto Travel time from LPMH to DOPMH: 2 3 hours. Proposed BEmOC FacilitiesCatchmentTravel Time /other JustificationsLoreto Municipal
HospitalLoretoThe area is virtually isolated from the rest of the province by mountains and rivers. Transportation is difficult. Thus, upgrading the hospital to BEmOC standard is considered by the health officers as very necessary.San Vicente BHS, Loreto5 barangays of Loreto: Sta Teresa, San Mariano, San Isidro, Sto Nino, JohnsonTravel time from the barangays to the BHS ranges from 35 minutes to 1 hour. Roads to the barangays are rough and can be accessed only by a motorcycle.Binucayan BHS, Loreto5 barangays of Loreto: Kauswagan, Sabud, Mabuhay, Bugdangan, FerdinandGenerally mountainous and can be reached only by motorcycle with a travel time that ranges from 1 - 3 hours to the Poblacion. The BHS serves a population of 75% indigenous people, some of whom are displaced by armed conflict.Langasian BHS, La Paz2 brgys of La Paz: Angeles & Bataan 5 sitios: Minangkig, Madga, Manguingi, Pinamuyanan and Ipil Travel time to the Poblacion is 1 to 2 hours using the following modes of transport: motorcycle (which has a very irregular schedule), outboard motor, dug canoe or bamboo raft. This BHS will serve a population of 95% indigenous people. Sitio Manguingi registered a maternal death in 2006.Comota BHS, La Paz2 brgys of La Paz :San Patricio & Lydia 6 sitios: Libon, Manguicao, Leyo, Balitos, Asuncion & Magbuya Travel time to the Poblacion is 1 to 2 hours using the following mode of transport: motorcycle, which has a very irregular schedule, outboard motor, dug canoe or bamboo raft. This BHS will serve a population of 95% indigenous people.CEmOC Facility: BUNAWAN DISTRICT
HOSPITAL
Catchment Municipalities: Bunawan, Trento, Sta Josefa and Veruela Proposed BEmOC FacilitiesCatchmentsTravel Time /other JustificationsSan Marcos BHS, BunawanBarangay Mambalili, BunawanMambalili is a remote barangay that could be accessed from the Poblacion either by a 2-hour pumpboat ride or 1hour motorcycle ride during the dry season.
The community is a river barangay, with flood prone areas and rough roads. This proposed BEmOC BHS will serve a population of 1,049.Nueva Era BHS, BunawanSitio Mandayao part of Poblacion (Tabuk), BunawanIs a river barangay, with flood prone areas and rough roads accessible only by motorcycle. Travel time from the Poblacion is 1 hour. This proposed BEmOC BHS will serve a population of 722.Sta Maria BHS, Trento5 barangays of Trento: San Roque, San Isidro, Cebolin, Pangyan, SalvacionWill serve interior barangays with rough roads that can be accessed only by motorcycle. Travel time ranges from 1 hour to 2 hours. This proposed BHS BEmOC serves a population of 8,252.
Trento RHU is MCP accreditedSta Josefa Rural Health Unit9 barangays of Sta Josefa: Tapaz, Aurora, Patrocenio,Sta. Isabel,- Angas, San Jose, Concepcion,, Awao, Sayon Travel time is 30 to 45 minutes from the farthest barangay. Located in the Poblacion and is accessible to all barangays in the municipality.
Proposed BEmOC FacilitiesCatchmentsTravel Time /other JustificationsVeruela Rural Health Unit3

barangays of Veruela: San Gabriel, Magsaysay, La Fortuna and some barangays of TalacogonTravel time from the catchments to the BEmOC facility: 1 to 2 hoursLa Fortuna BHS, Veruela3 remote barangays of Veruela: Bacay II, Don Mateo, CaiganganTravel time to the BHS from the barangays: 2 to 3 hours. This proposed BHS BEmOC will serve remote interior barangays that are prone to flooding.
LESSONS LEARNED The Facility Mapping Exercises conducted in the F1 sites generate the following important lessons which should prove useful as the activity is rolled out to other provinces:
1. Parochial concerns eventually give way to the greater good of establishing a cost-effective provincial facility network. The initial tendency of most MHO participants is to lobby for the designation of their RHU as a potential BEmOC, as this would result in the RHU being a recipient of grants for upgrading. However, after the intervention model and its objectives have been fully explained to them, such parochial objectives eventually take a backseat to the higher goal of identifying strategically-located BEmOCs to comprise the provincial facility network. This shift in outlook is facilitated when the PHO exercises leadership during the deliberations and is seen to be adept at handling the touchy task of explaining to the political hierarchy (especially the municipal mayors) the resulting deployment of grant funds across municipalities. 2. Flexibility is key. While a major objective of the exercise is to advocate for the adoption of the DOH strategy for addressing maternal mortality and while the choice of facilities that would receive DOH grants is to be guided by a set of objective criteria, it is important not to be too prescriptive in implementation. It is helpful to keep in mind that the model will only be effective if it responds to the needs of the local population and that its effectiveness rests on a deployment that adapts well to the local situation and melds seamlessly into the local health system. Adopting such an attitude eases acceptance of the model and lays the foundation for eventual ownership over it by those tasked with the challenge of frontline implementation. 3. Timing is important. Although most workshop participants initially viewed the activity with reluctance, they eventually came around to appreciate the activity as one that offers them an effective tool for objectively allocating their resources and for amicably settling conflicting claims over these resources. However, the universal lament is that why such an activity, which logically should precede an investment planning process, is introduced at such a late stage in the process. Hopefully, this would be remedied in the succeeding roll-out provinces. 4. Consider the political context. The workshop discussions emphasize that nothing much can happen at the local level without involving the local chief executive in the loop. Public health is no exception. It is unfortunate that the mapping activity coincided with the national elections (another lesson learned on scheduling). The takeover of new incumbents made it difficult for some MHOs to commit (most did commit after consulting with their LCEs). The elections also sometimes led to an escalation of armed conflict, especially in remote barangays. This made some MHOs reluctant to propose BEmOCs in areas where the political situation remained unstable. 5. Be sensitive to the capability and will of frontline providers. Some MHOs are aggressive in ensuring that their constituents have easy access to BEmOC facilities, while others are reluctant to take on the responsibility of having to supervise these facilities, especially if the facilities in question are remotely located. An issue of common concern is the legal liability the MHO assumes whenever the midwife attends to a facility birth. The concern understandably becomes serious enough when the facility is remote and hard to supervise that it acts as a constraint to proposing the facility for BEmOC upgrading even if technical considerations require that it to be so upgraded. There are times when the wishes of the local chief executive (who is the MHOs employer) figures into the decision matrix. All of these factors need to be identified and discussed in the process of navigating towards a group decision. 6. However, do not underestimate their (MHOs) willingness to collaborate and help each other out. The discussions on the issue of supervising remote facilities has revealed a deep sense of camaraderie among frontline health workers in a province. They are usually ready to
pitch in to assist an MHO in a neighboring municipality. Many appear willing to contribute their time to help fill in the staff time needed to keep a neighboring RHU BEmOC operational on a 24-hour basis (the model requires a doctor to be always available on call). Of note is an instance during one of the provincial workshops when an MHO volunteered to help supervise deliveries in a BHS that was proposed for upgrading to a BEmOC when the MHO who had jurisdiction expressed reluctance to travel to it at night because of the remoteness of the facility and the uncertain peace and order situation in the area. Sometimes all it takes is for the facilitator to try to maintain an environment that encourages a free and open discussion of these issues for such collaborative solutions to emerge. 7. Enlist the active involvement of the Center for Health Development (CHD). The CHD staff is usually familiar with the territory and the people. This knowledge becomes invaluable during issue-resolution sessions, especially if the regional representative is someone the participants look up to. Besides, they will inevitably become involved when the time comes to ramp up coverage. One should therefore try to keep them in the loop from the start.
NEXT STEPS The next activity should focus on generating the inputs that F1 provinces need to update their Provincial Investments Plans in accordance with the results of the Facility Mapping Exercise. This could expeditiously be accomplished by using the Integrated Needs Assessment Tool which was developed and field tested in WHSMP2 sites. The tool seeks to determine what each facility needs to upgrade services to either BEmOC or CEmOC standard by first taking stock of current resources and capabilities and then comparing these with the requirements of the service delivery model. The Needs Assessment Exercise is envisioned to generate the following outputs: o o o o o A strategy for human resource development and training Needed infrastructure improvement A list of equipment and drugs that need to be procured Systems that need to be developed to enhance financial sustainability Recording mechanisms that need to be put in place to allow progress monitoring
From these, one could generate inputs to the PIPH that are focused on enhancing the capability of the provincial service delivery network to address the maternal mortality situation of the province.
References
De Brouwere V, Tonglet R, Van Lerberghe W. Strategies for reducing maternal mortality in developing countries: what can we learn from the history of the industrialized West? Tropical Medicine and International Health, Vol. 3 No. 10 pp. 778782, October 1998. Tucker J, Florey CdV, Howie P, Mellwaine G and Hall MH. Is antenatal care apportioned according to obstetric risk? The Scottish antenatal care study. Journal of Public Health Medicine. 1994, Vol. 16, 60 70 in De Brouwere, et. al. Oona M R Campbell, Wendy J Graham, on behalf of The Lancet Maternal Survival Series steering group. Strategies for reducing maternal mortality: getting on with what works. Lancet 2006;368: 1284-99. Reducing maternal mortality. A joint statement by WHO/UNFPA/UNICEF/World Bank. Geneva, World Health Organization, 1999. Making pregnancy safer: the critical role of the skilled attendant. A joint statement by WHO/ICM/FIGO. Making Pregnancy Safer,Department of Reproductive Health and Research. Geneva. World Health Organization 2004. National Statistics Office. National Demographic and Health Survey, 2003. National Statistics Office. Family Planning Survey, 2006.

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Technical Assistance to the Health Sector Policy Support Programme

ESTABLISHING THE WOMENS HEALTH AND SAFE MOTHERHOOD FACILITY NETWORK

Bienvenido P. Alano Jr., PhD

Number of CEmOC Facilities 2 4 3 6 3 5 2 4 1 5 4 3 3 3

RATIONALE The Global view

THE DOH STRATEGY IN REDUCING MATERNAL DEATHS IN THE F1 CONTEXT:

THE FACILITY MAPPING EXERCISE

Travel Time/other Justifications

Camandag BHS, Asipulo

Camandag and the surrounding sitios.

Duli and adjacent barangays Banaue Batad, Bannao and Cambulo

Pula, Ducligan, Bannao Umalbong Hungduan

10. Abatan BHS, Hungduan

Proposed BEmOC Facilities

Travel Time/other Justifications

12. Nagacadan BHS, Kiangan 13. Duit BHS, Kiangan

Barangay Ducligan and Cababuyan Duit

14. Caba BHS, Lagawe 15. Tupaya BHS, Lagawe

Caba Tupaya and other remote barangays of Tupaya Barangays of Lamut

16. Lamut Rural Health Unit

17. Tinoc District Hospital

Barangays of Tinoc, some barangays of Benguet and Nueva Vizcaya

18. Binablayan BHS, Tinoc

Remote barangays of Tinoc

5 hours 6 hours 5 to 6 hours 12 hours 5 hours hike and 8 hours ride 26

Travel Time/other Justifications

Ubao BHS, Aguinaldo

Barangay Ubao, Muenaan and Chalalo

Namillagan BHS, Alfonso Lista

Namillagan and Halag

Halag is accessible by boat.

Ducligan BHS, Banaue

BHS BEmOC RHU BEmOC

The CEmOC-BEmOC network in the province is configured as follows:

Some parts of Bangui and Adams Pagudpud

Remote and isolated barangays of Burgos

Proposed BEmOC Facilities 1. Dingras RHU

Catchment Remote barangays of Dingras and part of Sarrat Solsona

4. Nueva Era RHU

5. Carassi RHU 6. Banna RHU

Tandayan Community Hospital, Vintar

Tandayan RHU, Vintar

22 barangays of Vintar 5 of which are in the Poblacion.

Laoag City General Hospital Piddig Medicare Hospital

Part of Sarrat Piddig

Travel Time/other Justifications

Pinili RHU Batac City RHU II

Paoay and 2 barangays of Currimao

Proposed CEmOC Facility: NUEVA VIZCAYA PROVINCIAL HOSPITAL (NVPH)

Proposed BEmOC Facilities

Travel Time/other Justifications

Travel time to NVPH: 4 hours

5. Alfonso Castaneda RHU

7. Kasibu Municipal Hospital

Barangays of Kasibu and neighboring towns

Travel Time/other Justifications

Proposed BEmOC Facilities

Travel Time/other Justifications

barangays of Kayapa and some barangays of Ifugao.

PANGASINAN BEmOC/CEmOC Facility Map

Travel Time/other Justification

Travel Time/other Justification

Travel Time/other Justification