Integrating Family Planning Services into EPI: the

Polomolok Experience in the Philippines

Strengthening Governance for Health Project (HealthGov)

June 2011

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Facilitating factors

• Multiple contacts with mothers at service delivery point: 4-5 visits over newborn’s first 11 months

• 90% of women within first year after delivery want to space or limit pregnancy, high unmet need for FP

• High access and awareness of EPI services - at least 85% fully immunized child (FIC) coverage present at service delivery point

• Immunizations and FP provided by same (trained) midwives, on different days and times (referrals made)

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Polomolok Municipality, Province of South Cotabato (Mindanao)

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Lake Sebu

SOUTH COTABATO

Tiboli

Surralah

TupiBanga

Sto. NinoKoronadal

TantanganNoralla

Tampakan

To Isulan

To Tacurong

To GeneralSantos City

Philippines Map

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 study 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) in two locales

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• 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 (RHWs-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 FHSIS

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• Baseline & end-line survey questionnaire developed to measure client changes in 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 of reproductive age (MRA) bringing children in for immunizations were surveyed (baseline: n=269; end-line: n=183)

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• BHW—administered survey, registered child for immunization & delivered messages

• RHM – administered immunization & delivered same messages

• 2 “Innovations” in Poblacion-4 BHS – Distributed 3 FP messages in written format (found

mothers to be distracted during verbal delivery) & posted messages in entry way

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Key Findings

38% increase in New FP acceptors after 10 months, Polomolok Municipality

YEAR

MAR

APRMAY

JUN JULAUG

SEP OCTNOV

DEC

TO-TAL

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

%increas

e

16.6 50.7 43.3

19.5 55.3 45.1

16.6 50.7 43.3 19.5

38.3

(March-December, 2008 vs 2009)

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CPR Increased by 6 percentage points

46%49%

55%

40%

45%

50%

55%

Percent

2007 2008 2009

CPR by Year

Contraceptive Prevalence Rate, Municipality of Polomolok, South Cotabato

CPR

Source: FHSIS

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Shift in Method PreferenceHigher preference for modern methods, lower preference

for traditional methods after six months (June 2009 vs Dec. 2009, Polomolok)

0

5

10

15

20

25

30

Per

cen

t

FP Methods

Jun-09

Dec-09

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Health centers as primary source of FP information increased from 47% to 87%

(among FP users)

47

1912 10

87

4 5

010

2030

4050

6070

8090

100

Health Center Family / Relative Friend / neighbor None

Source of Information

Perc

ent Jun-09

Dec-09

(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 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)

Immunization DataPolomolok Municipality—source: FHSIS)

• Does not appear to be negative

• 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 --written FP messages stapled to immunization records to prevent loss -- 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)

– nurse monitors FP referral message delivery; local Department of Health reps monitor LGU

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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)

• Overcoming social norms that pose barriers in some communities to accessing services (e.g. Muslim and indigenous populations)

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Current Gaps and Priority Next Steps

• Study limitations:– Results from only 1 municipality – do not yet know if these can

be replicated elsewhere– This study included monitoring component, but program impact

was not measured (no control group)– Caution about data quality – data cleaning going on now, may

change CPR, # of FP acceptors

• Steps to Strengthen study: – Examining FP data in comparable municipalities in province,

with no FP-EPI integration over same period

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Priority Next Steps• Implementing quasi-experimental program impact study in

2 provinces (with intervention & control groups)• Besides FP-EPI, measuring impact of FP integration with

other MNCHN services: postpartum care, vit A supplem.• Immunization data (FIC) being collected in addition to FP

data • Tracking availability of FP commodities and services (since

creating demand)• Implementing Data Quality Control (DQC) trainings for

midwives, nurses, project staff to assure reliability• Study outcomes will determine methodologies to scale up

integration interventions

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