Integrating Immunization and
Family Planning Services:
the Polomolok Experience in the
Philippines
Strengthening Governance for Health Project
(HealthGov)
June 2011
1
Acronyms
•
•
•
•
•
•
LGU: Local Government Unit
FP: Family Planning
EPI: Expanded Program on Immunization
MCH: Maternal and Child Health
RHU: Rural Health Unit
BHS: Barangay Health Stations
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•
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DMPA: Depo medroxyprogesterone acetate injection
IUD: Intrauterine Device
BTL: Bilateral Tubal Ligation
LAM: Lactational Amenorrhea Method
2
Millennium Development Goals
• Goal 4: Reduce child mortality rates
– Target: Reduce by two-thirds, between 1990 and 2015, the
under-five mortality rate
• Children’s immunization
• Goal 5: Improve maternal health
– Target: Achieve, by 2015, universal access to reproductive
health
• Contraceptive prevalence rate
• Adolescent birth rate
• Unmet need for family planning
3
Why integrate Immunization and
Family Planning in Philippines?
• 90% of women within first year after delivery want to
space or limit pregnancy, high unmet need for FP
• Multiple contacts with mothers at service delivery point:
4-5 visits over newborn’s first 11 months
• High access and awareness of EPI services - at least
85% children fully immunized
• Immunizations and FP provided by trained midwives: on
different days and times (referrals made)
4
To Tacurong
To Isulan
Noralla
Tantangan
Koronadal
Sto. Nino
Tampakan
Banga
Tupi
Surralah
k
Polomolo
Lake Sebu
Tiboli
SOUTH
COTABATO
Philippines Map
To General
Santos City
Polomolok Municipality, Province of South
Cotabato (Mindanao)
5
Implementation
• 10 month pilot test in one local government unit (LGU):
Polomolok Municipality
• 1 Rural Health Unit (RHU -- municipal health center) &
28 Barangay Health Stations (BHS) involved
• Began integration with 1-day orientation of all medical
personnel – explained purpose, approach & key
messages
• Developed map of facilities and FP and MCH service
providers
• Pre-tested 3 verbal messages (translated in local dialect)
6
• Messages:
– “Your child is young & you should be concerned about having
another pregnancy”
– “Your health facility provides FP services that can help you”
– “You should visit our FP services after your immunization today
for more information”
• Trained 25 rural health midwives (RHMs-based in BHS),
56 barangay health workers (BHWs), 2 RHU nurses and
1 doctor in FP messages
• Study did not collect special immunization data but data
available from routine reporting to government
7
• Baseline & end-line survey questionnaire was developed
to measure changes in women’s knowledge, attitudes &
practices (KAP)
• Data collected on new FP acceptors, method mix & CPR
(from same monthly period during 2008 and 2009)
• KAP survey administered in 28 BHS – randomly selected
mothers bringing children in for immunizations were
surveyed (baseline: n=269; end-line: n=183)
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• BHW—administered survey, registered children for
immunization & delivered messages
• RHM – administered immunization & delivered same
messages
• “Innovations” in Poblacion-4 BHS: Stapled 3 FP
messages to immunization records & posted messages
in entry way
9
Key Findings
38% increase in New FP acceptors after 10 months,
Polomolok Municipality
(March-December, 2008 vs 2009)
YEAR
MAR APR MAY JUN
JUL AUG
SEP
OCT NOV DEC
TOTAL
2008
151
136
164
149
123
113
151
136
164
149
1,405
2009
176
205
235
178
191
164
176
205
235
178
1,943
43.3 19.5
38.3
%
16.6 50.7 43.3
19.5 55.3 45.1
16.6 50.7
increase
10
CPR Increased by 6 percentage points
Contraceptive Prevalence Rate, Municipality of
Polomolok, South Cotabato
55%
50%
55%
Percent
45%
49%
CPR
46%
40%
2007
Source: FHSIS
2008
CPR by Year
2009
11
Shift in Method Preference
Higher preference for modern methods, lower preference for
traditional methods after six months (June 2009 vs Dec. 2009,
Polomolok)
30
20
Jun-09
15
Dec-09
10
5
FP Methods
W
it h
dr
aw
al
en
da
r
Ca
l
Co
nd
om
LA
M
L
BT
IU
D
PA
DM
lls
0
Pi
Percent
25
12
Percent
Health centers are increasingly important
as primary source of FP information
100
90
80
70
60
50
40
30
20
10
0
87
Jun-09
47
Dec-09
19
12
5
4
Health Center
Family / Relative
10
Friend / neighbor
None
Source of Information
(among FP users)
(June 2009 vs December 2009, Polomolok)
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126% increase in new FP acceptors over 3
months in Poblacion-4 BHS
(written FP messages & posters provided in addition to
oral messages)
YEAR
MAR
APR
MAY
JUN
TOTAL
2008
8
7
12
16
43
2009
40
20
14
23
97
400.0
185.7
16.7
43.7
125.6
%
(March-June, 2008 vs 2009)
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Immunization Data
(Polomolok Municipality—source: FHSIS)
• No adverse impact on children’s immunization
• Fully Immunized Child (FIC) coverage rates
– 2008: 96%
– 2009: 99%
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Potential Best Practices & Processes
Needed for Effective Integration
• Local ownership and support (from local government and
health officials)
• Posted and take-home written messages along with
verbal messages
• Client follow-up to prevent FP drop outs
• Assuring the availability of FP commodities to meet
increased demand
• Ongoing performance monitoring (at facility & LGU
levels)
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Potential Barriers to Integration
• Lack of local political (elected) & technical (health
officials) support
• Lack of contraceptive and immunization supplies
• Lack of trained providers (in both services)
• Social, linguistic norms that pose barriers in some
communities to accessing services (e.g. indigenous
populations)
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Priority Next Steps
• Measure impact of FP integration with other MCH
services: postpartum care, vit A supplem.
• Tracking availability of FP commodities and services
(since creating demand)
• Implementing Data Quality Control trainings for project
staff to assure data reliability
• Study outcomes will determine methodologies to scale
up integration interventions
18