Chapter 1 The Provincial Health Situation introduction




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Table 21: Health Performance Indicators, 2007

Outcome

Benchmark

(DOH)

Performance

(Gaps)/Gains

Rabies Cases
Filariasis
TB Cure Rate(%)
TB Case Detection Rate
STI Cases
Dengue Cases (50% reduction of cases)
Pregnant women with 4 ante-natal visit (%)
Deliveries attended by trained personnel (%)
Pregnant women given at least 2 doses of tetanus toxoid (%)
Pregnant women given iron (%)
Couples practicing family planning (%)
Lactating women given iron (%)
Post Partum Visit
Fully immunized children (FIC) (%)
Infant exclusively breastfed for at least 6 months (%)
Sick children given Vitamin A (%)
Households with access to potable water (%)
Households with access to sanitary toilets (%)


0
85%


70%
80% of cases
Actual
80%
70%
80%

80%
80%


80%
85%
95%
3%=100%

Actual
100%


100%

17 cases; 17 deaths
0
87%
65%
24
921 cases
58%
73%
86%(actual)

58.16%
49.98%


57.85%
63%
83.28%
80.88%

-
89.88%


90%

-
2%


5%
-
(12 deaths)
(22%)
3%

(22%)
(30%)


(22.15%)
(22%)
(11.22%)

-

(11%)


10%

SERVICE DELIVERY

Disease Free Zone Initiatives

Filariasis: For the past years, there have been no known cases of Filariasis in the Province of Cagayan. The health personnel should continue to be vigilant in their surveillance of the disease.

Schistosomiasis: Schistosomiasis is present in Gonzaga, one of the municipalities of the Province of Cagayan. The first case was diagnosed in 2004 whereby the patient eventually died. An epidemiologic study conducted by a team from the University of the Philippines. They noted the presence of the snail host Oncomelania quadrasi in three barangays. There have been ten positive cases of schistosomiasis identified. Lack of information regarding schistosomiasis coupled with the unhygienic practices of the community has contributed to the spread of the disease. The three affected barangays have not been adequately provided with toilet bowls so as to stop the unhygienic practice of moving their bowels anywhere. At present, there is only one personnel trained in microscopy. There is also the perceived need to train BHWs in snail hunting and the conduct of a snail survey. LGU Gonzaga has an inadequate budget allocated for schistosomiasis program. Thus, it cannot afford to provide the populace with IEC materials in the local dialect.

Rabies: Rabies has now become a major problem because of the alarming number of reported cases of dog bites and deaths due to rabies. In 2007, there have been 4,744 reported dog bite cases and 17 deaths due to rabies. As a consequence, the province ranked second nationwide in having the most total number of rabies deaths. There is only one Animal Bite Center located at the Provincial Capitol catering to the whole province. Patients from nearby municipalities of Isabela and Apayao also come to the Animal Bite Center for treatment. The Provincial Government of Cagayan can only subsidize one free dose of vaccination for all patients coming from Cagayan because of the prohibitive cost of the vaccine. The cost of the other doses has to be shouldered by the patients. Because of the high cost of anti-rabies vaccine, most people opt to go to the traditional “tandok” which is really not a cure for rabies. This is quite risky as the patient may die either of rabies or tetanus. While the Province has been pursuing a vigorous information and education campaign regarding rabies, still there are still quite a number of people including some health personnel who are misinformed regarding rabies. Concomitant with the IEC for rabies is the campaign for pet owners to have their pets vaccinated. However, only very few pet owners have had their pets vaccinated despite the free vaccination for dogs.

Leprosy: In 2007, the province had 19 leprosy cases with a prevalence rate of .20/100,000 population. This is way below the goal of the Department of Health which is to reduce the prevalence rate of leprosy to less than 1/10,000 population. However, we should not be complacent with the prevalence rate and the Province should work hard for the eradication of leprosy as a public health problem. Factors influencing gaps in terms of clients are: stigma of the disease on the patient, lack of information on the disease, poor compliance to medication, unawareness of the signs and symptoms and the mode of transmission of the disease, and late consultation of the patient. On the part of the provider, there are inadequate funds to support the Leprosy Control Program and inadequate technical assistance to LGUs on the Leprosy Program.

Malaria: For the period 2002 to 2007 the number of positive cases decreased by 35% from 1,388 to 898. Despite the decline, 898 cases is still considered a considerable number with an Annual Parasite Incidence of 0.837/1,000. The factors influencing the gaps in terms of clients are: lack of knowledge of the disease, migration to malaria prone areas, poor compliance to medication, delay in seeking medical consultation, exposure to the disease due to occupation, slow turn-over of bed nets for retreatment and non-utilization of mosquito nets. In the case of the provider, inadequate number of training of health staff, lack of training on malaria prevention and control and lack of training on severe malaria management. In the case of MLGU/PLGU are: inadequate funds for the purchase of malarial drugs and medicines, insecticides and laboratory and reagents, no locally hired spray men and lack of trained spray men and inadequate technical assistance.

INTENSIFIED DISEASE PREVENTION AND CONTROL
Tuberculosis: Despite the implementation of DOTS, the province has attained only 65% Case Detection Rate which is below the national benchmark of 70%. The province’s TB cure rate is 86% and is within the national benchmark. Factors attributed to the gaps were noted as follows: lack of awareness of the disease process and treatment protocols, delayed consultation of TB symptomatic due to financial problem and social stigma attached to the diseases, preference for private doctors and private drugs and non compliance to sputum follow-up schedules. On the part of Health Providers: no regular medical technologists hired in 5 municipalities (Amulung, Ballesteros, Buguey, Pamplona, Sta Teresita, Tuao), newly hired health workers have inadequate or no trainings on theta DOTS program, there is no instituted referral system between the hospitals and RHUs. Other factors noted are the following: not active TB Task Force, lack of pulmonologists and radiologists, inadequate funds to purchase anti-TB drugs, supplies, equipment and reagents, and inadequate technical assistance from the DOH in NTP due to insufficient funds.

STI, HIV/AIDS: The municipality of Aparri in northern Cagayan and Tuguegarao City are in the forefront of the fight against STI, HIV/AIDS understandably because these two localities are commercial centers and as such they have a very active night life. Although available figures for STI cases show that cases of gonorrhea and cervicitis have been dropping, still the specter of an HIV/AIDS outbreak continues to loom. The problem of STIs is exacerbated by the presence of free lancers. These are sex workers that are not connected with any of the nightspots and videokes. They are therefore not part of those who regularly submit themselves for check-up. Other factors influencing the gaps are: the practice of pre-marital sex by teen-agers and their lack of awareness of safe sex practices. For the provider, the factors are: lack of logistics like reagents and medicines, lack of IEC materials and equipment and lack of trained staff on diagnostic and treatment management on STI, HIV/AIDS.

Dengue: Dengue has become a perennial problem of the province not only during the rainy season but throughout the year. The factors influencing gaps in terms of consumers are poor environmental sanitation practices, late consultation due to lack on information on the danger signs and symptoms of dengue and its prevention and control and the presence of breeding sites of mosquitoes.

On the part of the providers there is lack of IEC materials, lack of trainings of health personnel, inadequate logistics for dengue prevention and control, and inadequate stocks of blood for dengue cases.



Child Health Immunization Program
For the year 2007, the FIC program of the whole province was 83% using projected targets. This is below the DOH benchmark which is 95%. Some of the perceived reasons for the gaps on the side of the consumer are: fear of side effects, low knowledge insofar as effect of the vaccine is concerned and migration or relocation of families. On the side of the provider: inadequate manpower, lack of training of some personnel, inaccuracies in reports, irregular supervision of PHNs, absence of cold chain equipments in the BHS, insufficient supplies for immunization like vaccines and syringes, insufficient IEC materials and no technical assistance to newly hired health workers.

Breastfeeding and Compliance to “Milk Code”
The breast feeding coverage of postpartum women who initiated breastfeeding was 63% which is perceived to be too low. The factors influencing gaps in terms of consumer are: media influence, mothers not aware of the importance and benefits of pure breastfeeding up to 6 months, misconceptions regarding breastfeeding and the mother’s preference for milk formula brought about by the aggressive advertising of milk companies. On the part of the provider, the following are perceived to be contributory to the gaps: lack of trainings, lack of efforts to motivate mothers to breastfeed, lack of enforcement of the Milk Code by the LGU because of the absence of enabling policies and lax implementation.

Integrated Management of Childhood Diseases – It is lamentable to note that many of childhood diseases like measles and diarrhea can be prevented. However, many mothers lack the knowledge on these preventable diseases. Mothers also tend to self-medicate and then they bring the child to the health facility only as a last resort. This is because of financial constraint or the difficult terrain. They also lack awareness on the use of reformulated ORS and Zinc supplementation. On the side of the provider, the following reasons contributed to the gap: lack of training of personnel, both on the municipal and provincial level, insufficient medicines, insufficient supplies, insufficient IEC materials and insufficient funds for training.



Micronutrient Supplementation/Protein Energy Malnutrition:
As of 2007, there has been a decreasing trend in the prevalence rate of malnutrition among pre-schoolers from 8.79% in 2006 to 5.88%. There is also a decreasing trend in the prevalence of above normal children. This is despite deficiencies in terms of supplies, materials and equipment. Micronutrient supplementation especially Vitamin A among 6-71 months old showed an accomplishment of 78% in 2007 which is far below the national benchmark of 95%. Factors contributory to the gaps on the consumer side are: poor family income, negative attitude due to the aftertaste of iron and lack of information regarding proper nutrition. On the side of the provider, the following factors contributed to the gaps: lack of training of health service providers on Nutrition Program management, fast turnover of BNS and therefore are untrained, lack of training materials for nutrition education. On the side of the MLGU/PLGU, the following factors contributed to the gaps: inadequate supply of Vitamin A, inadequate supply of iron supplementation, inadequate supplemental feeding, and lack of prescribed weighing scales, lack of iodized salt testing kit and lack of funds for training.

Newborn Care/Screening – Data shows that only fifteen (15) government hospitals, eight (8) private hospitals and one (1) RHU provide newborn screening services for a percentage accomplishment of 19%. This may be due to the prohibitive cost of the newborn screening kit.



Maternal Health/Safe Motherhood

The Province’s MMR is noted to be increasing from 6 maternal deaths in 2002 to 12 in 2007. Program interventions to reduce maternal deaths and improve women’s health did not perform very well in the following areas: Prenatal care coverage of 57% , TT+ coverage of 62% , hospital deliveries of 21% , vitamin A for pregnant with only 10%, iron supplementation for pregnant women of 56% and 57% for post partum visit. CPR was decreasing from 56% in 2003 to 49% in 2007. Births attended by skilled health personnel was 74% which was mostly attended by midwives during home deliveries.

The increasing trend of maternal deaths is perceived to be due to the following common reasons:


  1. Delay in deciding to seek care for failure to recognize the danger signs of pregnancy and its complications;

  2. Delay in reaching health facility due to poor referral system, lack of emergency transportation and financial problem; and

  3. Delay in receiving appropriate and adequate care at the facility for some reasons like unprofessional attitudes of health care providers, inadequate health care personnel and shortage of supplies/medicines and lack of basic equipments and also poor skills of health care providers.

The low demand in prenatal care may be attributable due to the lack of awareness on the importance of early and complete prenatal care, lack of appropriate information materials and inadequate training among health personnel. On Maternal and Child Health, the low performance is attributed to the lack of awareness of pregnant women on the importance of iron in pregnancy and inadequate supply of Ferrous Sulfate in most of the health facilities. Only few LGUs procured micronutrient supplements.

The low Contraceptive Prevalence Rate was attributed to the following: inadequate FP supplies due to pulling out of donor agencies like USAID; difficulty in recording (no records of usage from personally bought contraceptive by clients); and the LGU’s inability to purchase FP supplies due to inadequate funds.



Adolescent Health & Reproductive Health Initiatives –The results of the YAFFS 1 and 2 were very disturbing. For example it was found out that 18% of young people indulged in casual premarital sex with multiple partners. The findings have implications on teen-age pregnancies, spread of sexually transmitted diseases, abortion and its complications, etc. The results of the survey were not segregated per province and so we do not have figures for Cagayan Province. To conduct a similar sexuality and fertility survey is not possible at the moment. However, we can appreciate the magnitude of the problem through reports of hospitals whereby there are many teen-age patients admitted due to complications of abortions. There is a need to strengthen the Adolescent Reproductive Health Program to include more activities relating to youth. These activities would be aside from the regular activities of training of peer counselors, orientation on sexuality and the conduct of a Youth Congress. There is a need to intensify the IEC/Advocacy efforts to include more high schools in the province.

Healthy Lifestyle and Management of Health Risks
Advocacy for Risk Behaviors – Because of the emergence of the so-called lifestyle diseases of hypertension, diabetes and cancer brought about by unhealthy lifestyle practices like smoking, drinking, stress and lack of exercise, the Province is now in the forefront of the healthy lifestyle advocacy. It has launched the HATAW program of the DOH. However, there is a need for the institutionalization of the Healthy Lifestyle Program in all the LGUs of the province. There is also a need to train lifestyle advocates and to come up with relevant IEC materials like flyers and tarpaulin.

Water and Sanitation Program
Access to potable water – For the year 2007, water accessibility in Cagayan is 80%. This is below the national benchmark of 94%. The remaining 20% of households still have problems on access to potable water. Most of these are located in far-flung and inaccessible and often mountainous terrain. Many households still maintain the open dug well type which is a potential source of diarrhea and other gastro intestinal diseases unless they are regularly chlorinated. LGUs need to invest in the installation of

more pump wells, as well as purchase chlorine granules for disinfection. Training of RSIs on the EVS programs is likewise desirable.


Access to Sanitary Toilets – 9 out of 10 households have access to sanitary toilet in the Province. The remaining 10% of the household without sanitary toilets cites financing capacity as the main reason. The Province should invest in toilet bowl molders for distribution to LGUs so that they in turn can provide the poor residents with free toilet bowls. A training for toilet bowl fabrication is also in order.
Waste Management System – Only a handful of municipalities in the Province have controlled dumpsites thus, the Solid Waste Management Law is not fully implemented. Majority of the people do not see the importance of proper waste disposal and waste segregation. Burning is still the preferred choice for garbage disposal. Intensive IEC on proper waste disposal and composting should be undertaken by the LGUs. They should also invest in the publication of IEC materials.

Surveillance and Epidemic Management System
The Cagayan Provincial Epidemiology Surveillance Unit (PESU) had been in existence since 2002 and had been actively monitoring and doing surveillance in the occurrence of diseases with epidemic potential like Malaria, Dengue, typhoid fever, etc. On the same year, the Municipal Epidemiologic surveillance unit of every municipality was established and manned by the Rural Sanitary Inspectors (RSI). The PESU and MESU’s not only do surveillance and monitoring but also give immediate information in the prevention and control measure to avoid occurrence of new cases. However, the following gaps have been observed. On the part of the consumer, they lack knowledge on emerging and re-emerging diseases. On the part of the provider are the following gaps: they lack training on emerging and re-emerging diseases which should be provided by the LGU. The LGU should also organize the Barangay Emergency and Response Team (BHERT), and be responsible for the training of the members. It should also provide funds for supplies and materials and stocks of emergency drugs and personal and protective equipments (PPE).

Disaster Preparedness and Response System
Currently, every local government unit has an established disaster coordinating council (DCC), a mandated body tasked with the responsibility of overseeing rescue and relief operations during disasters. Being ad hoc, it is not clothed with the appropriate legal authority to act accordingly; hence many of such councils have failed to live up to expectations. In the health sector, the MESU and the PESU serve as the basic units that are charged with these tasks. It has been found out that majority of LGUs do not have appropriate planning on disaster preparedness and if ever there are existing plans, these plans are not widely disseminated to the grassroots level. Moreover, there are not enough funds set aside for emergencies and communication equipment. There is also no proper networking of NGAs and NGOs and consequently, during calamities, funds do not reach the intended recipients.

Health Promotion and Advocacy
Dental Health – Dental health seems to be a low priority among the majority of Cagayanos. They only see the dentist if they are in pain and most of the time the dentist can no longer safe the tooth. This can be attributed to their inadequate knowledge on the importance of oral health. The delayed health seeking behavior of clients is mainly due to lack of financial resources as well as uncooperative and inadequate support of parents and guardians.

Mental Health – There is still a pervading stigma on people having mental health illnesses. On the part of the consumers, this can be attributed to their lack of knowledge on the causes of mental health illnesses. The presence of drug users and drug dependents who later on become psychotics due to the effects of drugs on their brain also complicates the problem. On the part of the provider, the following are the perceived gaps: lack of training on the detection, diagnosis and management of mental health illnesses, no trained health workers, no IEC materials and not enough institutions and doctors to provide treatment and management of mental health patients. On the part of the LGUs, there is no fund allocation for mental health program because this is not a priority program.

Occupational Health –The number of work-related diseases is on the upswing and the LGUs seem to be unequipped to deal with the problem. The perceived gap on the part of the consumer is their seeming lack of awareness on the causes of work-related diseases. On the part of the provider, the health personnel lack the necessary training on occupational health. On the other hand, the LGUs lack coordination with other concerned government agencies like the DOLE regarding the implementation of labor laws and policies.

Health Facilities Development Program
Rationalizing Services in Facilities & Human Resource Capability Building – The preference of mothers to deliver at home is often due to the inaccessibility of health facilities due to distance and terrain. The cost of delivery in health facilities is also not within the reach of most families. The RHUs and BHSs are not fully equipped to deliver services especially for high risk or difficult pregnancies. Oftentimes, they are dilapidated or in run down conditions. In 14 municipalities of the province, there is no BEMOC available. It seems that LGUs cannot meet and shoulder the cost of devolution, thus, RHUs have inadequate supplies, equipment and instruments. It seems that health problems are not a priority of LCEs who are into infrastructure projects.
In the case of hospitals, many are in poor conditions. Aside from the inadequate space, they are not well-ventilated and there is a lack of toilets in most of the rooms. They also do not have a water system so that patients do not have a source of potable water. Most hospitals have poor facilities and the hospital beds are in poor condition. They also lack basic hospital equipments, medical supplies and instruments. The laboratory facility is only primary level and most hospitals have inadequate laboratory supplies. Thus, diagnostic error is a common occurrence. There is a limited budget/allocation for patients’ meals. Most of the hospitals are fire hazards and they need new electrical wirings. Not all hospitals have available and working ambulances because most ambulances have reached their obsolescence and are beyond repair.

HEALTH FINANCING
PHIC Expansion Program – The low enrollment to the PHIC Program is due to the following reasons: on the part of the consumer, low level of awareness of the benefits of PHIC, non-continuity/sustainability of enrollment. Moreover, the list of indigents has been politicized because of the interference of local officials such that true indigents have been excluded in the list of enrollees. LCEs need to have a lot of convincing for them to enroll the indigents in their localities.
PHIC Accreditation –Some health facilities are not PHIC accredited because they are not fully equipped and are not up to the accreditation standards. Rehabilitating 15 district hospitals and providing them with the necessary supplies and equipment is a daunting task that the Provincial Government of Cagayan is bravely facing.
Increase in LGU Investment for Health – While most LGUs really spend for their health program, it is not enough. This is understandable since Cagayan and its municipalities is IRA dependent for majority of its projects. Seemingly health is not a top priority among LCEs but infrastructure projects like roads, bridges and SWIPs are.
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