LPP-Matching Grant Program Performance and Evaluation Report Dasmariiias, Cavite Philippines Alberta S.M. Vargas Cecilia S. Acuh Nimfa B. Ogena Marilou Palabrica-Costello The Population Council LPP-Matching Grant Program Performance and Evaluation Report, April 2001. This study was funded by the United States for International Development (ISAID) under the terms of Cooperative Agreement number HRN-AM)-98-00012-00 and Subpmject number 5801-13017.455. LPP-Matching GRnt Program Pcrforrmna .ad Evaluation Report: Dr ' . GVib. i PhdIppines SUMMARY The Department of Health, with the support of the United States Agency for International Development (USAJD) and technical assistance from the Managanent Sciences for Health (MSH) implemented the LPP-Matching Grant Program (MGP).' FRONTIERS Manila staff carried out two phases of the LPP-Matching Grant Pmgram Evaluation Study, the program performance and impact evaluation. The program performance evaluation was conducted in four Local Government Umts &GUS)' from June 1999 to March 2000, of which Dasmariilas is part. The objectives are twofold: Firstly, to evaluate the relative effectiveness of various interventions funded by the MGP for reaching under-served and high-risk population with needed services; and secondly. to provide immediate feedback to improve program implementation. Grezter impact and expansion of service delivery is expected in four areas: (1) increased cowrage for fully immunized children (FIC), (2) vltamin A supplementation WAC), (3) tetanus toxoid two plus ('IT?+) for women, (4) and increased use of modern contraceptim (CPR) and reducing unmet need for family planning. Adopt~ng the "input-pmcus-oi tput-outcome" framework, the study used program-based data through careful monitoring of activities, focusing on the inputs, processes and outputs. Population growth rate in Damariaas has been explosive at 18.43 prceot (1999). The enatic population growth since 1980 is related to panems of urban resettlement d rapid economic development in the mid-1990s. Many women are transient and mobile. Majority of women in need of services work in factories and cannot mc health centers during regular clinic schedules. Poor performance on lT2+ and CPR are amibuted to both client and facility related factors. Of all the senice delivery areas, the hfGP plan focused on improving TT2+ and family planning services. Activities were designed to carefully track the city's large, mobile population through masterlisting (CBMIS), optimize existing perso~el for TT2+ during EPI regular schedules, home and industrial site visits form+, training of traditional birth attendants (TBAs) on aseptic techniques LPP-Matching Gnat Rognm Pafomvacc and Evaluation Rcpon: Dmmda, Cavite. I Philippi and TM+ and FP referrals, and provision of IUD kits and equipment for BHSs with trained midwives and escort services for potential BTL clients. Damariaas was granted an MGP allocation of PhP400.000 (appx. USS10.000). It was the demonstration site for a number of important activities. Implementation of MGP activities started in August 1999, with a mass m+ campaign. CBMIS dal revealed that immunization of women in industrial sites contributed 24.5 pacent to the :otal number of immunized women of reproductive age. Clients for TM+ increased by a factor of three. Hilots were responsible for effective referrals of 4.7 to 8.9 pacent of total lT2+ clients and 4.1 to 35.6 percent of total new FP acceptors. W~th the MGP, Darmariaas performance on lT2+ helped improve the provincial coverage hm 43 pacent in 1998 to 61.3 percent in 1999. New family planning acceptors for all methods ird by 10 percent. Support of the local executive is vitally important for making the Matching Grant Program acceptable to the local government unit. A monitoring mechanism with timely feedback is needed to track implementation of MGP senices. Such a mechanism should be designed during the planning phase of the program. Health workers should be given technical assistance for all aspects of the CBMIS, including data gathering, analysis and linkage to service delivery. Making the CBMIS tnrly community-based may be Limited by the capabilities of the BHWs. The interventions focused so much on TT2+ that otk services seemed denoted, as reflected in the LGU's MGP statistics. Util.zation did not automatically follow provision of IUD equipment to sevaal BHSs. Other strategies should accompany this type of intervention. MGP highlights its fast trdc mechanisms, but health personnel needed time to plan for more innovative interventions and to become immersed in the new activities. Local health people should realize that more resources are available in the community. LPP-Matchmg Grant Rognm Performance and Evaluation Rcport: D+smuihs C.~~ u Pbilippina CONTENTS ... LIST OF TABLES ............................................................................................................. in LIST OF FIGURES ........................................................................................................... iii ABBREVIATIONS ............................................................................................................ .c. ACKNOWLEDGMENTS ................................................................................................. vi I. BACKGROUND ...................................................................................................... 1 II. THE APPPLICATION PROCESS .......................................................................... 7 III. SOCIO-DEMOGRAPHIC AND HEALTH PROFILE OF DAS~AS .............. 8 TV. MGP PROGRAM ...................................................................................................... 1 1 N. ACTUAL MGP INTERVENTIONS ........................................................................ 12 V. IMPLEMENTATION AND RESULTS .............................................................. 14 VI. THE OUTPUTS AND OUTCOMES .................................................................. 24 LPP-Mabhiog Gnnt Program Performance md Evaluation Report: Ihsmuiaos, Cavitc. u -a, Piuhppmcs LIST OF TABLES Table 1. Indicators for TT2+, FP and FIC covaagq RHU Jl, 1998-1999, fd and 4* Quarten ...................................................................................................................... 25 Table 2. Program Goals vis-A-vis 1998 NDS .................................................................... 34 Table 3. Health facilities and resources. ........................................................................... 35 Table 4. Health Budget and Expenditures, 1996-1998 ..................................................... 36 Table 5. MGP and LGU Budget Counterparts .................................................................. 37 Table 6. Pre- and- MGP Senice Delivery, Dasmariaas ................................................... 38 Table 7. Accomplishment of Critical Steps ...................................................................... 39 Table 8. Matrix of the inputs, process and outputs of the Provision of IT Irununization through the BHS EPI Team Approach ................................................................. 40 Table 9. Matrix of the inputs, process and outputs of the Home follow-up of TT Defaulters ................................................................................................................... 40 Table 10. Matrix of the inputs, process and outputs of the MaterlistingKke Fig and Provision of services .................................................................................................. 41 Table 11. Summary of CBMIS Tally Sheets of 28 barangays of RHU ll, February 2000 ............................................................................................................ 42 Table 12. Matrix of the inputs, process and outputs of IT immunization to women workers through industrial sites visits ........................................................................ 43 Table 13. Number of women given TT during the industrial sites visits, I ............. 43 Table 14. Matrix of the inputs, process and outputs of Training TBAs to include . . motlvabng women for TT and FP .............................................................................. 44 Table 15. Topics of the Hilot training, RHUs I and U .................................................. 45 Table 16. Matrix of the inputs, process and outputs of the Provision of WE Kits to I0 BHSs ........................................................................................................................... 46 Table 17. Matrix of the inputs, pmess, outputs of Escort Services for VSS Clients ...... 46 Table 18. Summary of inputs, effects on outcome and sustainability of the different inte~entions/innovatiom ........................................................................................... 47 LPP-Matching Grant Rognm Performance ad Evaluation Report: Drcmurh . . *.Cllrn. LU Phillppim LIST OF FIGURES Figure 1. Conceptual Framework showing links of the program components to the outcome indicators and the different categories of evaluation indicators ........... 4 Figure 2 Dasmarifias Population, 1903 - 1995 .................................................................. 13 Figure 3 Health Budget of Dasmarifias, Cavite ............................................................... 15 Figure 4 Health Budget as Percentage of LGU Budget .................................................. 15 Figure 5 RHUl Program Inidcaton 1995 and 1998 ..................................................... 17 Figure 6 RHU2 Program Indicators 1995 and 1998 .................................................... 17 Figure 7 Comparative data on the number of women given m+ in 2 RHlJs, pre-and MGP period.. ........................................................................... .35 Figure 8 Comparative data on FP use in 2 RHUs, pre-and MGP period .......................... 35 Figure 9 Comparative data on FIC in 2 RHUs, pre- and MGP period ............................. 35 Figure 10 Comparative data on vitamin A coverage in 2 RHUs, pre- and MGP period.35 LPP-Matching Grant Program Performance and Evaluation Report Dammih. Cavite. N Philippines ABBREVIATIONS BCG BHW BHS BTL CBMIS CHO CPR DHRFO DPT DOH FHSIS FIC FP GMC IUD LGU LPP MGP MOA MOE MSH MWRA NFP NDS NGO NSO OPV PHO PMC RHM RHU SJDM SMDH SPDH TI￾m+ USAID VAC WRA - Bacille Calmett Gourain - Barangay Health Worker - Barangay Health Station - Bilateral Tubal Ligation - Community Based Monitoring and Information System - City Health Office - Contraceptive Prevalence Rate - Department of Health Regional Field Office - Diphtheria, Pertussis Tetanus - Department of Health - Field Health Services Information System - Fully Immunized Child - Family Planning - Growth Monitoring Chart - Intra-Uterine Device - hd GO~tXllInent unit - LGU Performance Program - Matching Grant program - Memorandum of Agreement - Maintenance and Operation Expenses - Management Sciences for Health - Married Women of Reproductive Age - Natural Family Planning - National Demographic Survey - Non-government Organization - National Statistics Office - Oral Polio Vaccine - Provincial Health Office - Pre-Marriage Counseling - Rural Health Midwife - Rural Health Unit - San Jose del Monte - Sta. Maria District Hospital - Sapang Palay District Hospital - Tetanus Toxoid - Tetanus Toxoid Two Plus - United States Agency for International Developn ent - Vitamin A Coverage - Women of Reproductive Age LPP-Matching Grant Program Performance and Evaluation Report: Dvmuiaar &%-iIc, v PMppincs ACKNOWLEDGMENTS The Population Council appreciates the support of USAIDIMada-Office of Population, Health and Nutrition (OPHN) for providing financial assistance in the conduct of the Program Performance Evaluation of the Matching Grant Pmgram. The technical assistance, inputs and cooperation of the field coordinators of Management Sciences for Health (MSH) during fieldwork and consultations are gratefully acknowledged. The Local Government of Dasmarinas, and the Department of Health Regional Office helped in mobilizing designated point persons during infontation gathering done by the field evaluator of Population Council. The rural health physicians, nurses, midwives and baranguy health workers of the RHUs. as well as the local offices and non￾government organizations in the municipality, have also been supportive and patient in assisting the field evaluator through data retrieval and indepth inte~ews. Population Council also expresses appreciation to the local offi:ials, progtam managers and community leaders who extended their hospitality and coomon in the entire evaluation period of the program. Lastly, the numerous men and women, who in many ways had been betpful in the process evaluation of the Matching Grant Program, are dul) recognized. LPP-Matching Grant Pmgram Performance and Evaluation Report l' " s. GVm, vi Philippioes I. BACKGROUND After the implementation of the Local Government Code of 1991, which involved the devolution of national functions to local governments units (LGUs) in the Philippines, weaknesses in the local health situation surfaced. It began posing a challenge to policy makers and program implementen advocating for improved primary health care scnices. In response to this challenge, a five-year initiative from 1995 to 2000 called the Local Government Performance Program (LPP) was designed and implmented by the Dep-ent of Health (DOH) with technical assistance hm the Management of Sciences for Health (MSH). The program document describes LPP as intending "to improve the health of mothers and children through increased utilization of family planning aod child health (MCH) and nutrition services." LPP Grants were "intended to serve as an incentive, encouraging LGUs to adopt the best practices in distributing commodities, training staff, equipping service delivery sites, providing voluntary sterilization services, and using (Ec)."' After an assessment review of the LPP was undertaken in June 1998, several recommendations were advanced to improve its implementation. The assessment rrpori noted that while the LPP is an effective vehicle for developing LGU management ad service delivery capability, some weaknesses and limitations were recognized. Tbe report described the LPP as "hihighly centralized," 'hot performance-basxl" and "not sustainable." Hence, LPP, the report concluded, is not the most approp5ate mcam for achieving impact on health objectives. The report recommended a 'follrw-on initiative that puts greater emphasis on impaci, building on the strengths of tx LPP. while overcoming its limitations." I Jack Reynolds, et al, 1998. Midtom Assessment of Intermediate Rmlr lof Smtegic Obiuriw 3 "Increased Public Provision of Family Plvlaiog and Maternal and Child Serviaz." POF'TECH Rep& No. 97-1 27-067. LPP-Matching Grant Rognm Performance md Evaluation Report D+smtriau, C.,m, I Philippioes The Matching Grant Program: The "Follow-On Initiativen of LPP The above recommendations became the basis for the development by the Management Sciences for Health of the Matching Grant Program (MGP:l. Lo mhast to the more general and more directive approach of the LPP to strengthen LGU health programs, the MGP is particularly designed to stimulate the LGUs to focus directly on strengthening service delivery while giving the local government units more latitude in determining their local programs. Consequently, the MGP was desiped with the following features:' Target mid-sized component cities and municipalities, initially those with a population of 100,000 and above where actual primary health care sm.~ces are provided. Employ a "grantee-friendly" application process, with the LGU defining its om goals and program direction. Provide flexible funding of up to P 500,000 and access to technical assistance. Encourage LGU to increase fund allocation and expenditure for MGP-zssisted programs through a "matching" or counterpart funding. In particular, the MGP aims to achieve impact and expand senice delivery m four target areas: 1. Fully immunized children (FIC) 2. Vitamin A supplementation coverage (VAC) 3. Tetanus toxoid two plus m+) coverage for women 4. Use of modem contraception (modem CPR) to reduce unmet need for funily planning (FP) ' MSH, 2000. "Matching Grant Rognm (MGP): An innovative and Responsive Program for Expodmg Smce Delivery and Enhancing Qlullty of Care." pp. 1-2. LPP-Matching Grant hgnm Performance and Evaluation Repon: Ihmnriav Cavicc. 2 Philippims TT was determined by the MSH in consultation with the USAID Mission - that it is important to build an evaluation component into the MGP to scrve two purposes: (I) to document the program implementation and highlight the processes and bst practices to guide and refine early MGP implementation, and (2) to assess MGP's impacts on improving the critical reproductive health programs of local governments Hence, upon the request of the USAID Mission, FRONTIERS Philippines conducted an evaluation study of the newly launched MGP in February 1999. Objectives of the MGP Evaluation Study The overall goal of the study is to inform policy makers in regards to the MGP, particularly in terms of its effectiveness as a mechanism for strenghening local government health programs, especially in the areas of: Reproductive health and family pl&g Maternal and child immunization Micro-nutrient deficiency prevention The specific objectives of the study are the following: To evaluate the different strategies of MGP for reaching under-sewed and high￾risk population with specific service needs, and To evaluate evidence of direct impacts in selected LGUs, as measured by the level of performance relative to critical program areas such as: FP use immlmization (FIC and lT2) and Vitamin A supplementation. Research Design The conceptual framework used for evaluating the MGP's perforn~ance followed the "input-process-output-outcome" model as represented in Figure 1. LPP-Matching Grant Rognm Pcrforrmoa and Evaluation Repon: Damadas. Cavitc. 3 Phillppioes Specific to eacb LGU implementing MGP ** Long-term impact will not be meascmd in this evaluation study. Figure 1. Conceptual framework showing links of itn? progam components to the outcome indicators, and the different categories of evaluation indicators Phase 1 of the MGP evaluation was planned to provide inputs to the development of the MGP itself. As a new approach of providing resources and technical assistance to LGUs, it is important to provide detailed feedback on the processes and m%hanisms that evolve early'in the project life. Hence Phase I constitutes basically a monitoring and evaluation activity. LPP-Matching Grant hgnm Performance and Evaluation Repon: thamibs Gvite. 4 Phrlrppincs Phase 1: Process and Performance Evaluation The Shcdv Siles. Four LGUs sites hm the first batch of 12 MGP reauits were selected for evaluation in June 1999. However, because two of the fint 12 were wt ready by June to be part of the process documentation, the site selection was dly made only from 10 initial MGP recruits. The bases for selecting the first four are as follows: I) one LGU would be selected for each of the operating clusters' set up by MSH. 2) the work plans of the selected LGUs must contain a suitable mix of activities1 intervmtions that are expected to contribute to the four outcomes of interest, and 3) consideraticn was given to LGUs whose work plan contains innovations or unique approaches that o~uld contribute to the MGP. With these considerations, the following LGUs were selected for e\ aluation under Phase 1 : PROCESS PERFORMANCE EVALUATION Sms I. San Jose Del Monte, Bulacan-Cluster A 2. Dasmarinas, Cavite----------Cluster B 3. Tacloban, Leyte--------Cluster C 4. Digos, Davao del Sur----- Cluster D Reseurch M&odology. MGP activities in these four selected sites wae observed, measured on a regular basis whether program activities were being implemented according to plan and assessed on how well these program activities were performed and utilized. Field observations, informal interviews with stakeholders and analysis of local statistics are sources of information for this phase of the study. While ewry effort was made to ensure complete documentation of the MGP, there were key activities that were not observed by the field evaluator.' In order to address this gap, key informant 1 The clusten are ubirnry operational divisions of thc counuy ut up by MSH. thc impkocoting ageny of the DOH for the MGP. Cluster A coorim of Regions I. 2.3 and CAR; Clurta B hs Regw 4.5 and NCR; Cluster C includes Regions 6.7.8 and 9; Cluster D is composed of Regions 10. I I. 12. Canga d ARMM. ' For example, the pknning stage for rome of the MGP amas was not observed because &k rmorrd before the evaluation study turn wu organized. LPP-Matchug Gnnt Prognm Performance and Evahutioo Report: Dasmda. C.Um, 5 PluhpQines interviews wen conducted to elicit information on what exactly happened during the planning activities. Phase Two: Impact Evaluation Strictly speaku~g his phase is an outcome evaluation (Refer to Figm 1). It uses a non-equivalent pretest-posttest control group design for evaluating the more immediate effects or outcomes of MGP program. Ideally, the selection of the intervention LGUs would have been et random hm the second batch of MGP recruits. However, because MSH and the DOH were implementing a "first come, first served" policy for recruiting U;U& it was not possible to randomize the selection process. The selection of the three intervent on LGUs was further limited by two additional factors: 1) the rate at which MGP is being implemented (LGUs who had not yet been oriented and did not have a work plan for conducting a baseline assessment could not be part of the selection process for the impact evaluation), and 2) since the intervention LGU had to have a control LGU hm the same province. This precludes the selection of LGlJs where all MGPqualified units of the province have been recruited at the same time, leaving no possible control. In effect, the intervention LGUs were selected mainly becaw of the availability of a suitable control LGU within their province. All the selected LGUs are Class A cities and mtmicipahtie;, i.e., they arc all in the highest income category classification of the Dept. of Finance. The three sites chosen were Taytay in Luzon, San Carlos in Visayas and Tagum in Mindacao. Intervention and control LGUs wen matched on the following critma: 1) both come from the same province to control for administrative and other fonns of support provided at province level, 2) similar population sizes, 3) same income class, and 4) similar performance indicators on the four outcomes of interest for the MGP (RC, lT2, VAC and Family Planning). The intenmtion LGU should not have initiated MGP community activities before the baselme assessment can be made Because of considerable differences in the state of economic development. impa:t pairs were selected for each of Luzon, Visayas and Mindanao - the three major geognphic divisions LPP-Matching Grant Rognm Perfonnancc ad Evaluation Report: Dammh, &vie. 6 Philippine of the country. In consideration, the following were the final sites selected for the impact evaluation: MGP Area CONTROL Tayta~ (Luzon) Binagonan (Luzon) San Carlos (Visayas) Cadiz (Visayas) Tagum (Mindanao) Panabo (Mindanao) It must be noted that the third set of impact sites (Tagum-Panabo) was eventually dropped due to some implementation delays.Only two sets, Tapy-Binagonan aod San CarlosCadiz were included in Phase 2 of the study. Population surveys and a modified and shortenedS version of situation analyses were conducted befort and after the implementation of the MGP in two sites. 11. THE APPPLICATION PROCESS Dasrnariiias, a class A municipality of Cavite, was one of the first MGP applicants in the Southern Tagalog region (Region rv). After its receipt of the ldta of invitatiodrequest for application from the DOH Regional Office in March 1999, a letter of intent (LOO was submitted by the LGU to the DOH in April 1999. Nm days upon its submission of the LOI, an orientationlplanning session was conducted with representatives from MSH, DOH, as well as regional and provincial hralth offices. The MSH Field Coordinator assisted and facilitated the revisions of the MGP plan. Service providers in the two RHUs identified problems and interventions addressing health-related problems, which focused on improving TT2+ and family planning senices while sustaining performance coverage in child immunization and vitamin A supplementation. Inputs from the regional or provincial 1ev:ls included such I The client-provider interaction insmurmt w not used in &is study. LPP-Matching Grant Rogram Pcrforman~c and Evdmtion Report: Dasuurhr, C.uitc 7 Philippum policy issues as identifying personnel for training and logistics-related issues, such as how much supplies are needed for certain activities. The DOH Regional Office eventually reviewed and approved the MGP plan for funding. Dasmariaas was selected as an MGP recipient because of innovations in its plan to include industrial establishments in service delivery and train traditional bii attendants (TBAs) to encourage women to come for family planning and tetanus toxoid immunization. The municipality was considered a demonstration (pilot) site for a number of initial activities such as the program orientation and planning, and the community-based monitoring information system (CBMIS). It took 95 working days for Dasmariaas to receive its MGP funds hm the start of the application process. which is longer than the 75 average working days of the first batch of LGU grantees. Nevertheless, the RHU physician still thought that the pm between planning and the receipt of funds was too rapid for implementation of the program. It was also thought that a longer processing period would have given the staff enough time to prepare for new activities. 111. SOCIO-DEMOGRAPHIC AND HEALTH PROFILE OF DASMAIURAS Demographic Characteristics Dasmariiias is one of the rapidly industrializing towns in the pro\& of Cavite (Refer to Map in Appendix A) with an estimated population of 363,083 in 1999. Based on the 1995 census, the annual growth rate is 18.43 percent. The resettlement of urban squatters in Dasmarifias in the '80s and economic development in the 90s may help explain the rapid population growth in Dasmarifias. I1 is the site of tke First Cavite Industrial Estate, which currently is home to more than 50 factories, including electronics, food and garment manufactures. Another growth factor is related to several LPP-Matching Grant Program Pcrfannancc and Evaluation Rcpom D .a QVm. 8 PMppims Figurn 3. Dasmariiias Population, 1903-1995 Sorim: NSO large univzsities and educational institutions opening in the pad decade, which made Dasmaths the 'University Town of Cavite" (refer to Appendix, Table 2). Together, thesc factors imply higher demands for primary health care senices for many women who are relatively mobile. Majoity of women needing services work in factories and have no access to services offered by heath facilities during regular clinic schedules. Service providers have difficult) in identifying women who are part of the transient and mobile population. Health Semces Infrastructure Appendix Table 1 shows the summary of health facilities and resources of the municipality. The Cavite provincial government operates its own municipd hospital. The town supports two Rural Health Units (RHlJs) and 74 Barangay Health Stations (BHSs) to serve its primary health care needs. Each RHU is independent, having its om staff. facilities and catchment areas. While the midwife-to-population ratio is close to the 1:5000 ratio set by the DOH, the government physician-to-population ratio is far hm optimum for both RHUs. The town also has a dearth of BHWs, which the RHU medical doctors attribute to women's preference to work for additional income than to volunteer at the health centers About two-thirds of the municipal health budget goes to perso~el and the rest is for maintenance and operations (MOOE). Actual expenditures (refer to Appendm. Table 2) show that while funds for personnel are 90 percent utilized, only about half of the MOOE budget was used in 1998. (Refer to Appendix, Tables 4 and 5) LPP-Marching Grant Program Performance md Evaluation Report: D " C.viu. 9 Philippines Figure 3. Health Budget of Dasmarinas, Cavite Service Reporting System Figure 4. Health Bur%@ u Pmporrion of LGU Budgef The data provided for service provision in the four program areas are facility￾based data hm the municipal Field Health Service Information System (FHSIS) (See Appendix Table 3). Hence, denominators used to calculate these rates are hm population estimates based on national rates of increase. In an area like Dammih, which is growing much faster than the national growth rate, this leads to cumerators that far exceed denominators, which leads to problems in data interpretation. Furthermore, those who can afford private sector senices create a dilemma for the Municipal Health Office (MHO) because private practitioners do not reporl immunization and family planning service statistics. In addit~on, the MC(O can neither ensure the correction of misconceptions nor assist in the provis~on >f appropriate counseling services in the private sector. LPP-Matching Graot Program Pcrfonnancc md Evaluation Repon: Damaih Cavia. 10 Phihppiner IV. MGP PROGRAM Issues in Study Areas I. Family Planning Dasmariiias has suffered born low CPR coverage rates between 1994 and 1998. The highest recorded CPR was in 1994, with i 3.5 percent for RHU I1 and 10.8 percent in RHU I. This relatively low performance may be due to the insufficient supply of IUD kits and equipment for midwives in the BHSs who were trained for IUD insertion. Hence, clients must go to the RHUs for such KJD insertion procedures. Fw:ucm(Ri figure 5a. RHU I Prrylnm Indicators, 1995 and 1998 Source : Dasmaririas RHU I RCucmm Figure 56. RHU ll Pmgram Indicators, 1995 and 1998 Source : Dasmatfhas RHU /I 2. Tetanus Tariod two plus coverage for women On TT2+ accomplishmcn~ 50 percent in 1994 was the highest recorded in RHU I and the lowest was 21 percent in 1995. RHU I1 showxi a higher coverage rate, ranging from 41 percen! in 1996 to 66 percent in 1994. There are several factors accounttng for the low coverage rates form+. First is the misconception that one dose of TT2i is enough, so mothen did not return for the succeeding doses. Secondly. pregnant mothers consulted the centers for check-up only when they were about to deliver. Thus, they already missed the opportunites fot the first LPP-Matching Grant Prognm Performance and Evaluation Report: hmanfus C.vitc. I I Phllrppies two initial doses. Finally, there is a lack of adequate manpower in the BHSs to provide TTT+ to mothers bringing in their children dlrring the EPI as they are staffed by one midwife. 3. Fully Immunized Childnn It is in child immunization that Dasrnarifias has near universal coverage, even before the MGP started: RHU U has consistently had 100 percent coverage while RHU I did not fall below the 90 percent mark between 1994 and 1998 (see Figures 4 and 5). 4. Yimin A Supplementation Coverage Both RHUs also had good performance in Vitamin A supplementation (refa to Figures 4 and 5). Vitamin A supplementation for 0-to 83-month-old children ranged hm 70 to 90 percent for RHU U while RHU I had 100 percent coverage for the yean 1994 and 1998. However, the lowest Vitamin A coverage - 25 percent - occurred in 19%. 5. Other Problems with Service Delivery There were other client-related factors hindering service delivery to eligible women. First is the failure to capture those women who prefer to go to hospitals or private clinics for their pre-natal check-ups. Second is the difliculty in identifying wown who are part of the transient and mobile population of the municipality. Fiy, with the employment of many eligible women in factories, many are simply unavailable kg the health centers' clinic hours. IV. ACTUAL MGP INTERVENTIONS 1. CBMIS Realizing the need to keep back of their large and mobile population, as well as their health se~ces needs, the Municipal Health Office (MHO) planned to update LPP-Matching Gnot Prognm Paformtoce and Evaluation Repon: D+smuihr. Caviu. 12 PMippims monthly their existing amsterlist (TCL) to determine the Ti?+. FP and VAC status of women and children and to identify those with unmet needs for services. 2. Improving lT Immunirrrtion The BHS EPI Team Approach (Refer to Appendix, Table 8) Before the MGP, midwives administered only child immu-iimtion during EPI days. With the MGP, nurses were also deployed to cover th: BHSs during immunization days to serve mothers bringing their children for rheir sbots, but were themselves also eligible for lT2+. Home Visifs to Follow-up lTDejoulters (Refer to Appeadu. Table S) Reminders (also referred to as pink letters, refening to ~apa color on which the letter is printed to match uith the pink card (or tke Home-based Mother's Record where 'IT?+ and future appointments for pre-nstal care future are recorded) have been sent to pregnant and post-partum women aZIo failed to return for her next appointment. If the woman still failed to come. the midwife pays her a visit at home to give here the next TT dose. This is also an opportunity to correct misconceptions about the sufficiency of one 1etanu.s toxoid immunization shot Indusm.al Site Visitsfor T77+ (Refer to Appendix, Tables 12.13) Letters were sent to factories within the municipality to schedule a nurse to visit the facility. Dltring these visits, the nurse administers lT2+ to eligible women workers. Targeted were companies with a 50-50 male-female employee distribution, except for one or two garments manufacturing sites sixe they have a mostly female employee population. LPP-Matching Grant Rogrrm Pdo~ and Evaluation Repat: Drrmuianr. Guitc. 13 PbiLppioes 3. Improving Fmlly Planning Training of TEih on aseptic techniques and refwal for TF immunization and FP (Refer to Appendix, Table 14) The MHO has been providing training for TBAs on aseptic delivcry techniques. The MGP emphasized referrals of eligible women for Tl2+ and FP services by TBAs to the barangay midwife. Assuming that TBAs are closer to women in the community, they may be better motivators for these smices. This also fosters closer linkage between the barangay wife and m.4~ who may also be BHWs themselves. 0 Provision of IUD equipment to BHSr with trained mihives (Refer to Tabla 15 and 16) Ten midwives who had their training in IUD insertion were given IUD kits to enable them to provide this senice at their BHSs. This makes IUD more accessible to clients. Prior to the MGP, IUDs were provided only a: the RHUs. Escort Services for Potential VSS clients (Refer to Appendix. Table 17) Voluntary surgical sterilization is done only at the municipal hospital, located in Ddas Bagong Bayan (DBB), which is within the area coverage of RHU II. This senrice is not readily accesible to those residing in the town proper. The MGP provided funds for. midwives and BHWs to accompany potential clients to the DBB hospital for BTL. V. IMPLEMENTATION AND RESULTS This section describes the inputs and process involved in the implementation of the MGP in Dasmariiias, Cavite by major intervention activity and for uch RHU when necessary. Specific human, monetary and in-kind resource inputs of each key stakeholder are summarized in Appendix Table 18, with additional details provided in various proceeding tables of the Indices section. The LPP-Matching Grant Progran (MGP) inputs LPP-Matching Grant Program Performance d Evahtion Repon: Daman&& Cavih, 14 Philippines include resources hm the donor agency (USAID), the implementing agency @OH), key stakeholders of the program, as well as MGP policies and guidelines. Interventions and activities are considered inputs of various processes in the course of the program implementation. The PhP400.000 MGP grant giveo to Dasmarifias was divided equally between the two RHUs. Index Table 4 shows how the differences in their pmfereaces were reflected in the distribution of each RHU's budget. For instance, the RHU Il physician wanted to have the steel type of examining table, so she charged two of those to the MGP and found other sources to provide the other three tables. The RHU I physician also wanted her BHWs and midwives to receive vests for the masterlisting survey, while the RHU U physician wanted t-shirts and umbrellas. Since the MGP was introduced in the second quarter 1999, the LGU counterp;ui equivalent to PhP117.900.00 (see Appendix Table 3) was realigned from their budget for the year. For purposes of the evaluation, process documentation for Damariaas was conducted through participant observation and interview of key informants, such as the RHU physician, nurses, midwives and BHWs. Photo documentation was also employed. Outcome measures were obtained from BHS records and collated at the RHU level or at the municipal level when appropriate. There were also occasions when PIT-MGP data on performance on some specific activities were obtained for comparison and hrkr analysis. Sources of some pre-MGP data included the PHO for the FHSIS data, the RHUs for accomplishment of previous periods and the Municipal Treasllry andlor Accotmting Office for the budget information and fund utilization. The process documentation covered a six-month period starting with the implementation of its first key activity in August 1999 and ending in January 2000. LPP-Matching Grant Rogram Perfo- and Evaluation Report: Dammi&, Gvin. IS Philjppi MasterlistinglCase Finding and hvision of Services Being host to a mobile and transient population, service providers in Dasnariaas decided there was an urgent need for a mastalist of potential health sexice clients in their catchment areas. This was considered necessary because of the lack of monitoring data to show who already availed of key health services and how many doses were already administered, e.g., TM+ among those who were already served. (Refa to &cdx Table LO) Masterlisting was also considered as a case-finding activity so that appropriate services could be delivered to an expanded list of identified clients. This was the most expensive MGP interventions, considering the labor and time needed for its implementation. An advantage, though, is its wide range of applicability because its also addresses other MGP program goals and provides o~portunities for delivering other health senices 1. Development of CBMZS Standard Fonn (See Appdix. Table 1 I) The first step in the process involved the development of a Mard instrument and training of midwives and BHWs on how the form nil1 be used. "Writesbops" wae conducted sometime in mid-August by MSH and Population Council with other LGUs in the 6rst batch of MGP enrollees that indicated interest in including this acivity as part of MGP. The purpose of the writeshops was to construct a tool for masterlisting, oow termed as the CBMIS. A core group of docton, nurses. midwives, and some BHWs 6rom both RHUs attended the writeshop on August 30-3 1. 1999. The writeshop atteodees included the MSH Provincial Management and Technical Advisory Team (PMTAT) and the Population Council MGP Evaluation Team. The writeshop was joiltly funded by MSH and the LGU. The former provided the supplies used while the latter was responsible for cost of food during the writeshop. The Legaspi City CBMIS instrument was adopted as a model in Dasnariilas with data on Hepatitis B vaccination included in the immunization record. Other modifications of the Legaspi model instrument are listed below: LPP-Matclung Grant Fmgram Performmcc md Evaluation Report Dasmik, Chite, 16 Phi~ppiocr, 1) Another column was added in the WRA table to accommodate the woman's place of work, if she is working. This was to identify potential workplace areas for site visits form+. 2) The high-risk columns were removed and replaced with a single column for Medical Condition. 3) Labeling of the actions taken were changed so that Al, A2, etc., which means Action 1, Action 2, etc.. were changed to Al, A2, etc. for actions to be taken for Immunization (Block A); B1, B2, etc. for actions to be taken for Vitamin A supplementation (Block B); and C1, C2, ew.. for actions to be taken for Family Planning (Block C). In RHU I, problems in developing the standard form in collaboration with DLSU's Angelo King Research Center caused some delays. In October 1999, the final version of the form finalized then translated to Tagalog. As of mid-March 2000. masterlisting in RHU I was more than 75% complete. However, tha? were no Tally Sheets available yet to determine the status of the four target populatons for the first round of the CBMIS survey. For RHU H, the earlier English version of the CBMIS form was used, allhough it was more difficult to follow. The CBMlS instrument was also mdfied and condensed to a two-page questionnaire and printed back-to-back, thus reducing iis paper qukmcmt (see Appendix H). 2. Pilor Thing and Sub~equar Trainings A pilot training on the CBMIS was conducted on September 2, 1999 and facilitated by MSH PMTAT. Twenty four BHWs, six RHMs, and four PHNs from each of the two RHUs participated in the training. The MSH FCs, USAID representative, Population Council MGP Evaluation Team and representatives from tie Regional and Provincial Health Offices observed the first CBMIS lraining in Dasrnaritas. Observations of BHWs during the training were as follows: LPP-Matching Grant Rogram Perfomvm aud Evaluation Rcpon: Mas, Chvitc, 17 Fmppk They had difficulty administering the Engl~sh instrument; They had difficulty referring to the recommended actions because they wae printed on a different page; and 0 They need further clarification of what some of the variables and response alternatives meant. Several levels and versions of CBMlS training were conducted in RHU I (see Table 15). The first two training sessions were on the English version of the CBMIS instrument while the last three sessions were on the standard tools that had been developed by MSH, which was translated to Tagalog. MSH also provided technical assistance for the training. On the other hand, pilot training participant; born RHU U conducted two batches of echo training for the rest of RHU ll midwims prior to the actual data collection. 3. Conduct of CBMIS Data collection using the CBMlS form started in September 1999 in RHU U and January 2000 in RHU I. The cost of supplies for the actual conduct of the CBMIS in RHU I was provided by the MSH. In RHU U, deploying trained BITNs reduced its training cost. Also employed in RHU II was the 'Tiayanihan" approach, particularly for large barangays. A team of six to eight members (i.e., nunes. mid;kives, sanitary inspector, clerical staff and utility-workers) carried out the CBMIS in densely populated barangays. From the MGP budget, both RHUs gave non-monetary incentwes to senice providers who carried out the CBMIS. MGP funds for RHU I under this activity included P34,200 for the purchase of 114 sets of vests, which were worn by th? BHWs while doing the survey. RHU I1 provided T-shirts to their BHWs. The vests and T-shirts served as an incentive for the BHWs. At the same time, it associated the survey with the local health units' official activities. RHU 11 had also included the purchase of 44 vaccine carriers, which were used during the CBMIS and other community projects. LPP-Matching Grant Pmgram Perfaumcc and Evaluation Repon: Dm\ Cavitc. 18 Philippi lT Provision I. Provision of lTlmmunization through the BHS EPI Team Approach Nurses were deployed to 48 BHSs in RHU U from August to Decemba 1999. Midwives and nurses worked 593 out of the possible 960 immunization days within the 5-month period in the health stations to provide IT?+ to pregnant ar.d post-parhun women. RHU I has six nurses covering 24 barangays. Each nurse was in charge of four BHSs, which she visited once a month during the scheduled immunization day. RHU U had eight nurses available for this activity, which covered 49 barangays. Immunization days among BHSs were either on Tuesday, Wednesday or Thursday. This means that at most 24 BHSs were covered in a week. About 67 percent of BHSs wm v~sited less than four times a month or roughly once a week. Only three BHSs had nurses more than eight times a month. BHSs with large populations and heavy client load had mare clinic days adopting the EPI Team Approach. For RHU I, the PhP35,000 allocation for RHU I from the LGU for printing of 7,000 pieces of HBMRs was not utilized since it was the PHO hat supplied the HBMRs. No additional vaccines were provided by the PHO because the usual supply for the LGU was adequate. RHU I also budgeted PhP14.400 out of its MGP funding for the nurscs' transpomrion during deployment, but this was not utilized within the 8 montbpcnod since the initiation of this particular intervention. On the other hand, RHU U has spent PhP40.200 of its MGP fuMis to purchase 134 T-shirts and 134 umbrellas as early as October 1999. These supplies were also used by the nurses, midwives and BHWs during their masterlisting survey. 2. Home follow-up of TT ddaulters This activity was perhaps the earliest MGP activity implemented. IT?+ defaulters were identified by midwives based on their target client list (TCL). LPP-Matching Grant Prognm Performance and Evaluation Report Gvk. 19 Philippines Contoding Defiulters through the Pink Letter System As early as July 1999, pink letters were printed and actively dishiiuted to tetanus toxoid defaulters. Not all BHSs, however, adopted this intenention. In addition, some midwives would send the pink letters only to prirnia or pregnant women with their first child, while some would send them alsc to multiparous women. The BHWs delivered the letters and encouraged women defaulters to come for their follow-up doses. Utilization of existing supplies of pink papers and LGL's assistance in printing facilitated the reproduction of the pink letter forms. The minimal MGP allocation for the purchase of pink mimeographing paper (P 3,980.00 for RHU I and P2.000.00 for RHU II) was not utilized by both RHUs at the end of the evaluation period. Actual Home Visit Follow-Up Home follow-up visits for post-parturn mothers have bm an existing activity of the RHUs. The innovation under the MGP was the reminders or pink letters for Tn+ defaulters for pregnant and post-parturn wonen. hlidwives schedule their home visits once a month in the afternoon of EPI &ys becaw they also provide measles immunization. For larger burangays, the fiquency of home visits is as often as three times a month. Home visits focused on tke 38 pea'cat of defaulters who were either pregnant or post-parturn women. 3. Provision of lTImmunization to Women workers through Indumial Site Vii Planning: Contacting Indurtrial Sites The areas in Dasmariiias where this could be done were limited to baranguys within the industrial zone. Out of 50 factories targeted by RHU I fur this intervention. 30 were approached and 12 agreed to participate. The Oflice of thc Mayor sent letters to these factories for their consent in conducting this partic~lar intervention in their company. The supervising nurse of RHU 1 also coordinated with the personnel manager or the company clinic supenisor. LPP-Matching Grant Prognm Performance and Evaluation Repon: I)lsmPriass. Gwtc. 20 Philippines Aside hm the inputs by the MGP aod LGU, some companies provided inputs as their counterpart in this particular intervention. For example, one company printed its own lT2+ cards. Three companies provided cotton balls, while the other company provided a pmonnel masterlist for recording of Tl2+ dose given to their female employees. Two companies provided mobility support for the MGP team in conducting the industrial site visits, and one company required its casual employees to bring their own syringes and needles while supplies for regular/permanent employees were covered by the company. l77+ Services A team composed of a nurse and four to five midwives rn neighboring barungoys of RHU I provided TM+ to women industrial workas. The RHU staff conducted 24 visits to 12 factories. None of the PhP24,000.00 hansportation budget for the nurses was utilized. No problems with the procurement of vaccines and supplies were encountered. 4. Training TBAs to include mothwing women for nand FP The RHUs were already training their traditional birth attendants (TBAs) on aseptic delivery. For this intervention, midwives identified hilots who were not previously trained in their respective barangoys. Training for hilots in RHU I aod RHU Il were conducted on August 24,1999, and September 7-9, 1999, respective:y. Generally, no difficulties were encountered in obtaining the PhP62.400.00 fimds for the training, which included expenses for meals and snacks. Based on the Fund Utilization Report submitted to the DRFO in March 2000. all equipment aod supplies specified in this activity were obtained between September to October 1% @lease see Appendix M). The LGU allocated a PhP2.500.00 budget for training materials. Based on the MGP plan, the Provincial Health Office was supposed to provide training assistance. However, the RHU staff were the lecturers and at the same time facilitators of the TBA training. LPP-Matching Grant Rognm Pcrfonnmcc and Evaluation Report -. Clvitc. 2 1 Philippines The MGP intervention training also included baining for motivating worn to come for ll2+ and family planning services. Basically, the topics of the kaining were almost similar between the two RHUs. However, it should be noted thal RHU II included in their module sessions on breastfeeding, nutrition, infections and fanily planoing. which were not in the RHU haining module. In addition, RHU II touched on matcmal immunization as part of preparation to delivery. It appears that RHU Il emphasized more preventive aspects (Refer to Appendix Table 12). The hvo training modules were intended to suggest that -IT+, Lunily planning and LAM may be more emphasized among the RHU ll hilots lhan the RHU I hilots. RHU II also held monthly meetings with their hilots for feedback and reinforcement. On the other hand, RHU I hilots adopted a strategy, requiring the pink card of the client before attending her delivery. The pink card would indicate that the woman had been to the BHS for her 'lT2+. Family Planning I. Provision of IUD Kits to I0 BHSs Fund utilization report of Damariaas showed that procurement cf supplies ad equipment for this intervention charged to the MGP was accomplished tao months later than the time 6ame indicated in the plan. Ten BHSs (5 from each RHU) with midaives who had Comprehensive Training on Family Planning were provided with IUD kits. This intervention made IUD insertion services available every afternoon at each facility. This is perhaps one of the more expensive MGP intervention activities, i.e., accounting for about 35% of Dasmariiias' the total MGP grant. Generally, the equipment purchased satisfied the specifications raquired by the RHUs except for the examining tables requested by RHU 11. i.e., metal-type tables that cost higher. This was resolved by charging two of five needed tables aginst the MGP funds available for this intervention and the other three to PHO-LPP funds. LPP-Matching Gnot Rognm Performance and Evaluation Report: hmudas &vie, 22 Phhppincs 2. Escort Services for VSS clients Voluntary surgical sterilization (VSS) services are ke at the muricipal hospital, which is right in DBB. It is about two rides away from any point in tom. During the planning, escort services wexe envisioned to encourage more clients to avail of this service. Identification of clients for VSS, particularly bilateral tuba1 ligacon (BTL), had been done by midwives through family planning counseling at the BHSs. A refenal slip was given to the potential VSS client right after FP counseling. VSS senices were free, and scheduled every Tuesday and Thursday at the DBB Municipal Hospital. Potential VSS clients were accompanied by their BHWs. Recentl), trained hilots were helping the BHWs in accompanying potential VSS clients. In this particular intervention, the MGP has budgeted transportation allowance for the client and the accompanying BHW to the DBB Municipal Hospital. The client and BHW are entitled to PSO.00 each for transportation allowance. Based on the MGP plan, the two RHUs are targeting 60 clients for VSS. Financial inputs are minimal (PhP12.000.OC for the able LGU), but the health providers need to spend more time in motivating 'be women, as well as men for vasectomies. Additional Activities Dasmariaas conducted a number of activities that were not included in their original plan. This flexibility is apparently allowed by the DOH, although additional activities were no longer subjected to the review process. 1. Mars Immunizaah for IT The mayor, or the LGU's local executive, was cornmined to a mass immunization campaign for TT2+ as the launching activity of the town's MGP, aiming for universal M+ coverage of all women of reproductive age. Streamers announced the campaign and all health personnel were mobilized to man the BHSs and Ms. The BHWs encouraged women to go to their health centers. In FWJ II, health personntl went house￾LPP-Matching Gnot Rognm Performance and Evaluation Report D ' . Casitc. 23 Phhppines to-house in the aft- This activity was not part of the MGP plan and it was not clear whether resow were obtained 6om the MGP or hm other sources. Recording of women vaccinated was done. but ?n+ accomplishment attributable to thls activity could not be clearly extracted hm the existing reports. 2. TTimmunizaiior in schools and business establishments Midwives who did not have an industrial site in their catchment areas sought to increase their lT2+ coverage by going to schools and business establishn~ents. However. accomplishments were not clearly reported, making it dificult to assess the effectiveness of this intervention. RHU I implemented a house-to-house or 'bopup" operation to reach other women of reproductive age for tetanus toxoid immunization. It was expected that clients missed during the mass immunization at the health facilities would be covered by the mop-up operation. VI. THE OUTPUTS AND OUTCOMES The CBMIS At the end of the evaluation period, masterlisting of 45 barangays in RHU 11 revealed that 27,562 households were covered in six months with 148,006 people identified. Appendix Table 8 shows the data collected from the CBMlS of RHU 11. Important indicators from their collected information show that: Ies than 10.h of children 12-59 months need immunization andlor Vitamin A supplementaion and almost 40% of MWRA had unmet need for FP. LPP-Matching Grant Pmgnm Performance and Evaluation Repon: Drrmuihx Caviu. 24 Philippines The CBMIS was quite useful for Dasnariaas as an interactive mechanism for directing health service provision schemes. Once potential clients and theu health savice needs were identified, the RHU II health personnel focused on sming them. The outcome indicators of RHU II's CBMIS initiative are underxored in Table 1, which shows marked increases in comparable indicators of 1998 and 1999. First, the number of new FP acceptors for all methods more than doubled when data for the last two quarters of the current and previous years are compared. Second, the number of women given Tl2+ shots nearly tripled when comparable data for the pre- and post-MGP periods are contrasted. The increases for FIC were not as remarkable as the other two services. Table 1. Indicators for TT2+, FP and FIC coverages, RHU 11, 1998-1999, and 4m Quarten I 1. Number of new family planning I I I I 1 1 3. Number of FICs 1 1,305 1 979 1 1.378 / 1,103 1 acceptors (all methods) 2. Number of pregnant mothers given at least lT2+ Manpower constraints afFected the rate of implementing this activity in RHU I. Although BHWs in RHU I were effective in using the standard instrument afle=r going through several levels and versions of training, there were not enough BKWs to complete the CBMIS targets by March 2000. Although midwives were quite successful in referring clients, there was no system for follow-up and recording. They also were more conscious in referring IT clients than referring women with unmet need for family planning. This suggests a need for reiterating the latter during regular meetings to be able to maximize benefits from the CBMIS. 613 681 '1.268 ~~~~~ 1 LPP-Matching Grant Program Performance and Evaluation Report: Dmmrik, Gvir, 25 Philippines 607 I I , 461 1,557 Senice providers were also noted ~o have experienced time constraints for CBMS tasks given their already loaded time schedule for the provision of otha health senices. In addition to this, they were found to have little knowledge in dastanding, processing, analyzing, and utilizing collected CBMIS data One possible option to take is to distribute the responsibility of data prowsing from the current midwifecentered procedure toward involvement of BHWs in the initial processing of data The la&x could abstract information hm the submitted forms for information that may bc useful at their level before submitting them to the midwife for final aggregation at the LGU-level. nere is a need to develop a special fonn for BHWs to be used during the initial processing and to train midwives on how to more systematically aggregate datafrom the basicjonnr and the new fonnfrom rhe BHWs. Provision of TIT immunization through the BHS EPI Team Approach From August to December 1999, nurses were deployed to 48 BHSs in RHU Il. A total of 1,910 TT vaccinations were given within the said period or about three mothers per BHS were immunized with 'IT during those days when the nurses =err deployed to the health stations. It was felt that Iinding clients was not much of a problem since women were already seeking immunization for their babies, which may be taken as an example of integration of services and taking advantage of missed opportunities. Comparing 3" and 4m quarters of 1998 and 1999 reveal that IT2+ coverage more than doubled with 68% of the 2,782 pregnant and post-parturn women given TT during these two quarters in 1999 were vaccinated during the clinic days with the EPI Team Approach. These are considerable given the limited inputs for this intmen~ion. This further exemplifies the value of integrating senices to maximize oppobties for contact. Dasmariiias was also fairly successful in sourcing the inputs needed from the region and province (for example, the HBMR forns), thus they generated some savings, which could be used for other MGP activities LPP-Matchug Grant Program Perfam~na and Evaluabon Report DilsmuirLr Gvitc. 26 Philippines Home follow-up of 'IT defaulters The pink letters were considered effective in bringing mothers to the beaith centers for subsequent prenatal check-ups. Midwives were quite satisfied with the 62% response rate of the 1295 women given pink letters. Some of the babies w% given EPI shots only after their mothers had their IT shots. About 16 percent of babies were immunized during their first EPI visit. Of the 38% women who did not respond to the reminder letters and had to be followed-up during the house-to-house visits of midwives or BHWs, about 8 percent were immunized during the home follow-up campaign. Midwives encountered several problems in conducting home visits. Women due for their TT2 shots refused to be immunized because of pain due to the injection or pains associated with childbii and post-partum recuperation. Another problm refm to the nature and implications of a mobile target population. Midwives have difficulty in tracking down their target population. Women giving birth in the area son~etimespend their post-partum period somewhere else; thus they were not available during the follow￾up home visits or the time for their subsequent IT doses. Interviews with some midwives revealed a particular pattern. Out of five mothew two were likely to be immunized in the BHS when they brought their babies for EPI, one would be immunized at home, om would not be available at the time of the home visit, and one would have transferred residence. The sbategy adopted by health workers to address these problems was to get mothm to agree that they be immunizd fust before their babies using the slogan "nanny muna bag0 6aby" (mother 6rst. baby nea). It appears that our next main concern is how to expand the coverage to the remaining 40% of women. Those who were not available during home visits sbould be recontacted at a later date. If data on previous TT dose are available then a :'om or slip of paper should be left behind to remind the mother when she retums that she should contact the health center for her next IT dose. The same strategy may be applied for temporary or permanent movers. In the case of the laner, responsible members of the left-behind household may be requested to inform the mother of the number of additi~nal TT doses that she still needs to get at her nearest health facility. LPP-Matching GRnr Rognm Performance and Evaluation Report C.viic. 27 PhilippiMs TT Immunization in industrial sites The 24 visits by RHU staff in 12 factories where women workers resulted in the administration of tetanus toxoid immunization to 3,394 women, 61% of which were for lT1 and 3Ph for lT2. On average, 150 women were immunized during each visit. This MGP initiative contriiuted about 24.5% to the overall TT accomplishment in the municipality. In one large factory that was visited twice, 'lT accomplishment was at 700 women vaccinated per visit. This suggests that if all the 50 factories in Dasmariilas would be motivated to participate in this activity, this type of intervention may have a big impact on the health situation of mothen. Training of Hilots for Referrals Training for RHU 1(20 hilots) and RHU U (26 hilots) were conducted on August 2-4, 1999 and September 7-9, 1999, respectively. A total of 447 TBAs were trained during the MGP period. These training were instrumental in getting hilots >r bained birth attendants (TBAs) to contribute to the identified MGP activities in Damadas. In RHU I, hilots were able to contribute 8.9% (n=730) of lT2+ and 35.6% (n=552) of FP accomplishment. In RHU II, 150 deliveries were assisted by hilots during the MGP paiod. Hilots were successful in convince 88% of post-partum women to receive their IT?+ shots. This represents about 4.7% of the TT accomplishment of the RHU. They we-e also able to motivate 72.6% of women to use FP methods, which contributed about 4.1% to the total RHU's FP accomplishment. Apparently, the strategy adopted in RHU II of conducting regular monthly meetings during which they shared experiences on complicated deliveries (which they claimed often resulted hm unwanted pregnancies) and they were reminded that they should anend only to normal deliveries, was an effective way of getting hilots accept their role in the referral system. LPP-Matclung Gnnt Rognm Performance and Evaluation Report L- Chvitc. 28 Philippines Provision of IUD Semces Ten (10) BHSs were equipped with IUD kits for IUD insertion senices. Six of the newly equipped BHSs accounted for 8 of 44 IUD insertions in RHU I, and 12 of I5 IUD insertions in RHU ll. Four of the newly equipped BHSs have yet tc perform IUD insertions. Surprisingly, 16 clients hm the catchment area of one of these four BHSs were still referred to RHU I for IUD insertions, IUD insertion services are available every afternoon during weekdays at the newly equipped BHSs. This is a relatively expensive intervention, which may lead to long-term results rather than short-term outputs as required by the MGP evaluation. Inputs will be used for years even after the completion of MGP so it may not be fair to gauge the effectiveness of this intervention on current output level. This, however, points to a clear discrepancy between MGP goals and LGU-selected MGP activities. Escort Semces for VSS clients This refers to the MGP initiative of providing bansportation allowance to midwives and BHWs to accompany VSS clients to the provincial hospital where this particular senice is provided. Output indicators show that there was an increase in the number of clients ligated during the MGP period (58 clients) compared to the pn-MGP period (45 clients). The province-run hospital is located in RHU Il so thesc are province￾level data and are not reflective of RHU-level accomplishment. Appendix Table 15 summarizes the MGP interventions, their peso inputs, outputs/outcomes and comments on sustainability. Some of the interventions are input￾intensive (such as the CBMIS) and, therefore, may need outsourcing of hds if a&ities are to be continued after MGP. LPP-Matching Grant Rogram Perfomwc and Evaluation Report Damadas Cavill, 29 PMippiines Comparison of MCP Outcomes Among RBnrs This section compares the MGP outcomes in the two RHUs of Dasnariihs. Accomplishments of RHU I and RHU II for selected quarters before and after MGP are shown in Figures 2-5 below. For RHU I, it can be seen that while performance improved damatically for TIT+, it has remained relatively the same for FP. RHU I experienced hstic reductions in its FIC and VAC performance. While RHU U's FIC level has not changed, Tl2+ coverage and proportion of FP users have markedly improved. The decline in RHU U's VAC performance was more dramatic than that for RHU I. Staff hn both RHUs athibuted this to the lack of supply of Vitamin A capsules for distribution. These resuhs need to be considered in assessing the over-all effectiveness of the MGP as efforts to focus on one outcome may displace other programs that are doing relatively well. LPP-Matchmg Gmt Program Performance and Evaluation Repon: Damunk. Gvik. M Philippics RHU II 0Q3 6 04.1998 PRE-MGP Fig. 2. Comparative data on fhe number of women given lT2+ in 2 RHUs. pre-and MGP period. RHU I RHU II 803 & C4.1998 PRE-GP 0036C4. 1999MGP Fig. 4. Compatative data on the number of FTCs in 2 RHUs, prernd MGP period Fig. 3. Comparative data on FP users in 2 RHUs, pre-and MOP perid. I/ Children 12-59 moiths given VI A R#. 5. Comp~tiw &t. on iho number of children given Vi A in 2 RHUs, pmnd JlGP period VI. CONCLUSIONS AND RECOMMENDATIONS I. MGP outcomes for Dasrnarifias show a remarkable improvement in lT2+ coverage. which reflects the local executive's bias for TT immunization over other MGP interventions. Hence, there is a need to reinforce efforts in carqing out other MGP LPP-Matching Grant Pmgnm Performance and Evaluation Report: Dasmariius. Cavttc. 3 1 PhilippbKs interventions, which focus on expanding FP, EPI, VAC, as well as otha health carc programs of the RHUs. 2. Support of the local chief executive is a vey important factor in ensuring smooth implementation of MGP activities. It would be good to sustain the interst of the local executive in health-related programs by providing regu1ar updates on specific MGP and non-MGP activities. 3. It is likewise important to get the health staff familiar with the administrative mechanisms in the LGU to simplifylfacilitate fund utilization and sourcing of additional fund requirements. 4. A monitoring and effective feedback mechanism is needed and perhaps its design should be part of the planning process as well. In the Damariaas experience, early detection of problems in the FIC delivery could have been useful in designing a timely and effective feedback mechanism. Hence, the local health staff could :%we benefited more if the problem had been addressed effectively and on time. 5. Guidance or some form of technical assistance may also be needed after the conduct of the CBMIS survey to illustrate to the health workers the various uses of information in the data system. Further technical assistance hm MSH, DOH, aud PHO is deemed important to help sustain the CBMIS as an effdve and useful intervention. 6. Making the CBMIS huly community-based may be limited by the capabilities of the BHWs who are supposedly responsible for its data soilection and initial data processing. In Dasrnariilas, the BHWs were responsible for data collection only. The midwives took charge of the data processing, which was dread) an additional workload for them. There is a need to train BHWs in initial data pnxessing to summarize some indicators that they may be able to use at their level, in aid of the find summary to be done by the midwives at the BHSs. 7. It was not enough that health facilities are provided equipment. It was learned that in Dasmarifias, utilization did not automatically follow pmision of IUD LPP-Matching Gnu1 Program Performance md Evahiatioo Repat C.vitc. 32 Pluhppines equipment to several BHSs. Some orher strategy should go hand-in-hand with interventions like this. This finding necessitates more efforts of sexvice providers, particularly the midwives and BHWs in information dissemination about Ux availability of the equipment to pertinent health personnel and in motivating clients toward its utilization. 8. The MGP highlights its fast track granting mechanisms but the LGU infrastructure may not be that responsive. In Dasmariiias, the speed in the MGP grant process did not necessan'ly make a difference considering that the LGU health personnel needed more time to plan for innovative interventions, lay down the needed mechanisms, and orient the participating health personnel on the goals, requirements and procedures involved so they can effectively implement the program activities. 9. The local health people should be made to realize the diversity and richness of resources that are available in their community waiting to be tapped. Generating such awareness may also be one of the technical assislance tkat they should be provided. LPP-Matching Grant Program Perforrmncc ad Evaluation Report Dammih, Gvitc. 33 Philippines APPENDICES A) Table 2. Program Goals vis4-vis 1998 NDS modem methods I Fully Immunized Children (FIC) 1 65 i 80 8 80 I ! Tetanus Toxoid 2 plus (Tl2+) 1 38 1 80 6) Definition of Terms I C) 1. Contraceptive Prevalence Rate (CPR): This rate is md as the proportion Vitamin C coverage (VAC) of women 15-49 years of age reporting current use of any contraceptive metbod at the 7 1 85 time of assasmat. The denominator consists of all women 15-49 yean of age (WRA). However, in some DOH service statistics, the denominator is defined as cumtly mamed women 15-49 years of age (MWRA). Whenever possible and if the information is available, a delineation between these two measurements will be made. 2. Fully Immunized Child PC): This is the percent of living children 12-23 months of age who have been vaccinated before their first birthday with three doses of Oral Polio Vaccine (OPV), three doses of Dipbtheria-Pertussis-Tetanus IDPT) vaccine, one dose of Bacillus-Calmene-Guerin (BCG) vaccine and one dose of measles vaccine 3. Vitamin A Coverage (VAC): This refers to the percent of childreo 12-59 months of age who received a Vitamin A supplement in the last six monb LPP-Matcbiog Grant Program Performance and Evaluation Repon: D+smuiaPr. Cavitc. 34 Philippines 4. Tetanus Toxoid two plus m+): This is the percent of pregnant women and mothers of reproductive age (15-49 years) with children under 5 yean of age who have received at least 2 doses of tetanus toxoid. 5. Unrnet need for family planning (FP): This refers to the paceot of currently married women of repmductive age (MWRA) who want to limit or space their next child but are not using any family planning method and those using a method but are not satisfied with their current method. The denominator is all married women of reproductive age 15-49 years of age. C) Table 3. Health facilities and @sources. Hal& worker: Population ratio Physician 1: 97.955 1: 83586 Nune 1:24.489 1: 15,197 Midwife 1:7,535 ; 1:4518 I I Public fachtia. HosprPls 0 I I RHUs 1 I 2 BHSs 25 49 74 Private facilities: Hospitals clinics 5 16 21 Source: RHU records LPP-Matching Grant Program Pnfomnncc and Evaluation Repat Damnfib. Chvitc. 35 Pbilippioes D) Table 4. Health Budget and Expenditures, 1996-1998 Rural Health Unit [I: 1996 App E~P 1997 App Exp LPP-Matching Grant Pmgnm Performance .nd Evaluation Rcpon: Lhsmuiau. C.vicz 36 Phlippies E) Table 5. MGP and LGU Budget Counterparts Transportiltioo BHS EPI Team Ap. 14,400 BHWs-ntrsey 18,720 Factory sik visi 12,000 VSS cscortsmrices 6,000 Tniniog (Hilob) Meals andsucks 8.700 training^ Hilot tin 7,500 Supplies d e I Pink paper 3.980 Vests 34.200 Vaccine cmim ! RID& ~.ooo(5) Urnb~tlas T-rbim HBMRprmtiDg LPP-Matching Groat Program Pcrfotmaoce and Evaluation Report: IhmnrblLr. C.vk 37 Ptultppina 0 Table 6. Pre- and- MGP Service Delivery, Dasmariiias BHS EPI Team Approach Home follow-up of lT defaultm IT immunization (hre a week, provided by midwife Re-natal &ys (once a week) IuDrervices Pmvidcd at the taro Rural Healtb Voluntary surgical Clients dmcd to DBB Municipal Climb rcfd and ncated to tbc sterilization Hacpital DBB Municipal Hmp.14 Services provided by Aseptic &hay Aseptic delivery plus rcfd fa FP 'IBAs Pndrr LPP-Matching Grant Rognm Perfo-e and Evaluation Report Dmmdas Gvin. 38 PhilIwines G) Table 7. Accomplishment of Critical Steps I. Request for Application (RFA) issued md received by LGU Much 2. Letter of Intent (LOI) submitted to the DIRFO 3. Orientation mating done I May 12 I I April 29 9 4. First draft and application dom and received by DIRFO - 22 I I 5. First drafi reviewed by DIRFO 1 May 24 8. Fund relcased and received by LGU Jum 28 IS May 12 8 6. Draft review fed back to LGU for approval; final approval of DIRFO 9. Fint key activity implemented August 6 29 I I I Total working days for the pmces to be completed 95 Average number of working days pn critical step 10.5 I I May 24 LPP-Matchug Grant Program Performance and Evaluation Report D Gvite. 39 Philippines 1 H) Table 8. Matrix of the inputs, process and outputs of the Provision of 'lT Immunization through the BHS EPI Team Approach From LGU Staff time (6 nuncs-RHU I &8nUM-mu) P 35,000 for forms Fmm MGP P 54.600 for T-shirts. ~mbrellas, hauspoktion of nurses during the deployment (P14.400 of the amount) Fmm DIWO & PHO Vaccines, syringes, Needles, HBMR forms Funds for fom not used I. because pH0 provided forms ; T-shim & umbrellas ah wd for CBMiS & 0th . MGP achvihes Schedules followed as planmd as a rule 1910TT~doae (Aug - Der 99) a lbout 3 moths per EPI dry send m+ coveage I￾doubkd compand to umc quanm for 98 Conm~ 685; of '17 accompkhamt for tbew P"= I) Table 9. Matrix of the inputs, process and outputs of the Home follow-up of TT Defaulters From LGU Staff time Pw Fmm MGP P 5980 for printing of PinL lcncn Fmm DlRFO & PHO Vaccines, syringes. Needles sompmt-Pprmmwomcn 6% (n=803) of wmm not available on follow-up rrspwded 10 kuus 8%imnunocdoobomcff￾romWOmeD~fux up subvqucnt dose because of 16% imrmrizcd oa baby's pain fun EPI visit I6%unrnhbk ! LPP-Matching Grant Program Perfomaxe and Evaluation Report: thsmaih, Caviu. 40 Philippines J) Table 10. Matrix of the inputs, process and outputs of the MasterlistinglCase Finding and ~r&iooof services From LGU Staff time Funds for training From MGP TA from MSH (CBMIS) PI 14.520 for BHW vests, Transpowtion & vaccine Camm Forms from MSH From DlRFO & PHO Vaccines, syringa, Needles, logbooks development of mndud form took time initial MGP budget did mi include funds for forms RHU n to save time wd English forms & mobilized its midwives RHU I waited for the translated standard fom & mobilized its BHWs; ah tapped rexarch fuods hm university; data galbering 75% complete as of Mu 00 BHWs capable of conducting CBMIS & fulfilling action needed RHU fl has not updated its CBMIS as of March RHU II cod 27s bouvbolds in 6 months, w/ ff findings (see Tabk bcbw): LU5thnIr)Lof~ 12-59 month nccdmg immmhtim&'orVit.A Almost 40?,0?r of MWRk a.' unmctneedforFP Numberofoca.FPrrrptm doubled conputd w! smc quarten in 1998 Number of m+ rlmrm tripled comd m smc period 199f LPP-Match Grant Program Performance and Evaluatioo Reporr: Damadas. &vie, 4 I Philippines K) Table 11. Summary of CBMlS Tally Sheets of 28 barangays of RHU 11, February 2000 A. Children O- 11 months old 1. ?9 mo with incomplete or no immunization 2. e mo with incomplete or no immuniration; schedule not followed 3. mo with incomplete or no immunization; schedule followed B. Children 12-59 months old I. With incomplete immunization 2. Not given vitamin A in lut 6 months C. Women of reproductive age 1. Pregnant with incornplelc or no IT 2. Non-pregnant MWRA mi& incomplete or no IT 3. Single WRA with incomplete or no IT D. MWRA 1. Practicing FP but not satisfied 2. Not wanting to have a child or wanting to space but not practicing FP 3. Wanting a child mn LPP-Matching Grant Program Performance and Evaluation Repon: Damadas. &Me. 42 Philippines L) Table 12. Matrix of the inputs, process and outputs of 77 immunization to women workers through industrial sites visits From LGU Staff time From MGP P 24,000 traospowtion From DIRFO & PHO Vaccines, syringes, Needles From industrial sites 'IT cards, Conon balls Rquircdprchinary li~hges with in- sites One company nunc did the immunization but encountered a number of side cffeCIs Only lO of factories cooperated Changes in worker shifts make follow-up visit diff~cult 3,394 lTh rdmininerrd; 61% forlT1, 30?h for TI2 0 mpomible for 24.5% of lT accomplishnent looneluge f*. accornpliinmt airr 700 women vac:inaud in we day M) Table 13. Number of women given TT during the industrial sites visits, RHU I Cambridge -ya AGrade NAP1 Sanwa Kolin Dutchboy KLT Showa Luzon Magnetics Ishida LPP-Matching Grant Program Performance md Evaluation Report Dammiks C.vitz 43 Philippines M) Table 14. Matrix of the inputs, process and ou@uts of Training TBAs to include motivating women for TT and FP From LGU Staff lime P 2500 for baking From MGP P 62.400 for overhead From PHO TA for haining I RHUnh+ining included i 47lBAsmincd Bdcediog, Nuhitioll, FP, / . For RHU L bibs coofriihd matd immunization & / 8.W (n=7IO) of 'lR+ & infections 35.6% (n=f 52) of FP RHU n ~ISO conducts monddy meetings with their For RHU 0. of mC 150 hilo( TEXAS for feedback a deliveriesduringm~~~p I additional inpuh pmod88~~w/lT2+& I i SomeTBkrcquircdTT 72.6% uu FP, coomi immunization before they would convnt to assist in a birth LPP-Matching Grant Propam Performance and Evaluation Repon: DamuriaPr. Cavitc. 44 Pluhppk W Table 15. Topics of the Hilot training, RHUs I and I1 A. I) Characteristics of a trained hilot 2) Delivery kit 3) Human reproduction I and II 4) Care during prrg~lncy 5) Changes in tbc body during pK!gMq 6) Pre-natal care B. 1) Guidelines in providing mlicf hrn discomforts associated with pregnancy i J 2) Danger signs and symptoms in prrgr~ocy d 3) Riskconditions d C. 1) Dangers in pre-mature and overdue delivery 4 2) Care during labor and delivery @HU II has taro subtopics: ! Preparation and stages of labor) 4 3) Abnonnahormal labor 4) Immunitation (mother); Preparation for delivery D. 1 ) Post-parturn care d 2) Newborn cam 4 3) Bd&g 4) Nutrition 5) Nature, Caws and Prevention of infection in mother and bby 6) Family planning E. I) BithRgistration 4 2) BP taldng practice 4 LPP-Matching Grant Prognm Perfomarm and Evaluation Report [hrmuihr. Gvin. 45 Philippines 0) Table 16. Matrix of the inputs, process and outputs of the Provision of IUD Kits to 10 BHSs From LGU Staff time P 34,000 for kits & Sterilizm From MGP P 138,500 for kits. Stcrilizen & BP apparatus From pH0 UP) Examining tables & BP APP~~ IUD insdon avdabk doily at the cqulpped BHSs Apparent reluctance of some midwives to perform IUD insenions (may require rcfmher mining) Records of IUD insenions difficult to track back to bmgays I0 BHS aquipped for RID inwrtion 8wtof44RHUIrad12out of 15 RHL'U IUD imawar done at newly alutppcd BHSs 4 cqurppcd BHSs hue yet to perform lo iEdioa mough I6 clicotr Eom utchmnt area of ooe of tbrmhdg~mRHUIfor IUDioxrti~~r. P) Table 17. Matrix of the inputs, process, Services for VSS Clients outputs of Escort From LGU Staff time From MGP Transportation con Some trained midwives can do counseling for BTL at BHS; vasectomy is not actively promoted BHWs & TBAs accompany clients to hospital Rccordc ofBTL accomplishment at RHU. BHS & hospital do noc plly 58 clicntrl~gaddunog MGP compucd to 45 durmg same period pMGP LPP-Matching Grant Program Perfonmce and Evaluation Report: -. Guilt 46 Philippines = .I 9) Table 18. Summary of inputs, effects on outcome and sustainability of the different interventions/innovations II BHS EPI Team Approach Horn follow-up of TT defauitm; scoding of TT immunization in indushial sites Training of hilots for ref& I - P52.920 + i m - IOUM~ smwa llmmt hiplad compybd to j ~odmcc; ~tcdr (PW'JOt same quarter of previous YCK. . effontode~k n-P61.600 FF' (new acceptors) - mcmscd by IOK from i syshm work or for previous quarter, doubled compared to sax : the syann to k qurtcr of previous year 1 .ppmiatcd by i FIC - slight increase in RHU n(9% 6rom 1958 - 1 baW ders 1999 in last 2 quutm) 1 - Pl4.4OO + (P35.400) day with EPI Turn; n - ~40.200 Ovedl TT more than doubkd during quuvr beiagdocwrrpul wim MGP I - P3.980 RHU I - may in- utilization of mhDe n - ~2,000 sew;ces by 61%; RHU 0 - my iocreasc utilintion of mtinc services by 65% I I - P12.000 To& numkr of women nccimakd with TT ; Higb rim 1 iocrnscd by 24.5K continmu -- I-P31,200+ I. Effective rcfemls- (Plf 50) for TT - 8.9" of RHU acmmplirbmnt; arpavidoa by n-P31JOO+ for FP - 35.6% of RHU acc0q-1 (~1.~50) II. EKC~~~VC rc~errpls- I i For TT - 4.7% of RHU rc~~~plidunmt I F~~-~.I%o~RHuxwIIIPL~~~~~~~ I 1 - P79.500 + I - shgbt urncase nuy be aIbht&k to MGP HI& needs more (P 10.000) R - MGP my haw conmbuled ID the mausms 1 effm for n - ~9.m + md mf~mnwo (P34,000) Numbm too small to make comlus~ons ~non I Escort semces I - P6.000 Incrasmg mndi m ma. acceptors obvncd. , High 1 for VSS clients I1 - P6.000 Numbers tw small to make conclustom LPP-Matching Gnnt Rognm Performa~ce and Evaluation Repon: Damu&s, Cavite. 47 Phlhppimes DIRFO IV - Repional Technical Office: Dr. Lcticia Olivar, LPP Coordinator Ms. Remy Bamtto. FP Coordinator Retzjonal Field Extension Office. Tnce Martira City Dr. Nerisa lavier. highest DOH-retained Rural Health Unit I, Dasmariiias Dr. Cynthia Cristobal. Rural Health Physiciaq MHO Dr. Liberty de Jesus, MD, Pali- si& Ti Llacer, Public Health Nune. Langkaan I BHS Lanie Andan Rural Health Midwife. Pali- Site Grace ~a~uhg, Rural Health ~idwif;, ~i&mes BHS Annabelle de la Rea, Rural Health Midwife. Hutnayao BHS Rural Health Unit U. Dasmariiias Bagona Bavan Dr. Minerva Mangubat. Rural Health Physican Marilou Maxima. Public Health Nme Raxcda Ramirez. Public Health Nurse Jennifer Ignacio, Rural Health Midwife. Pag-asa BHS Rosanna Arguel, Rural Health Midwife, Lwiminda [I BHS Teresa Buenaventura. Rural Health Midwife, San Mateo BHS Events Obse~ed/Docamcnted 1. CBMIS hainine for core mum. Susan's Bulalo. 3 1 Aum 1999 2. CBMIS ~~IIUD~ for rmda;;v~Pnd BHWs, ~auhrm BH;, 2 Scptcmba 1999 3 Mahng between RHU physlclms md & la Salle Un~vm~ty k KII~ Rtrarch C mter fa poss~le ~oiiabonti~ 10 ~cptcmba 1999 4. Follow-up on -h pmposab submined by the RHU physicians. IS September 1999 5. &-natal consultation, LangLnan BHS, RHU 1.16 September 1999 6. TT immunization in Nippon Antcmy Phils. Inc., RHU I, 20 September 1999 7. TT immunization in AGrpde Mfg., RHU L 21 September 1999 8. CBMIS survey (masterlisting), Luniminda Il. RHU [I. 23 September 1999 9. TT immunization, Sbowa Company. RHU 1.15 November 1999 10. Monthly meeting of trained hilots, RHU II. 16 November 1999 1 I. CBMIS swey, Paliparan Site, RHU 1, 14 March 2000 12. TT immunization, Nissin-Robina Comp., RHU 1.29 March 2000 LPP-Matching Grant Prognm Performance md Evaluation Report: Lhaurihr. Cavite, 48 Philippiies