Integrating Family Planning Services into EPI: the Polomolok Experience in the Philippines Strengthening Governance for Health Project (HealthGov) June

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) 2

Polomolok Municipality, Province of South Cotabato (Mindanao) 3 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 4

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 5

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) 6

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 7

8 Key Findings 38% increase in New FP acceptors after 10 months, Polomolok Municipality YEARMARAPRMAYJUNJULAUGSEPOCTNOVDEC TO- TAL , ,943 % increase (March-December, 2008 vs 2009)

9 CPR Increased by 6 percentage points Source: FHSIS

10 Shift in Method Preference Higher preference for modern methods, lower preference for traditional methods after six months (June 2009 vs Dec. 2009, Polomolok)

11 Health centers as primary source of FP information increased from 47% to 87% (among FP users) (June 2009 vs December 2009, Polomolok)

12 126% increase in new FP acceptors over 3 months in Poblacion-4 BHS (written FP messages & posters in addition to oral messages) YEARMARAPRMAYJUNTOTAL % (March-June, 2008 vs 2009)

Immunization Data Polomolok Municipality—source: FHSIS) Does not appear to be negative Fully Immunized Child (FIC) coverage rates –2008: 96% –2009: 99% 13

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 14

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) 15

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 16

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 17