Examining the Department of Health’s “National Safe Motherhood Program” as a

policy addressing the increasing trend in the Philippine Maternal Mortality Ratio

Karla Camille N. Ruiz, De La Salle University, Philippines

The Asian Conference on the Social Sciences 2016

Official Conference Proceedings

Abstract
The Philippine Government has been actively trying to address issues pertaining to
maternal health since the inception of the MDGs. Yet, despite its efforts to reduce the
MMR in the country, the MMR trend continues to be high and increasing. As such,
the creation of the National Safe Motherhood Program by the Department of Health
aimed to respond on past and present policy issues on Maternal Health. The policy
proposed focuses on creating an environment where it could promote safer pregnancy
and childbirth through fundamental societal dynamics with strong feedback
mechanism coming from affected sectors. Hence, this study aims to analyze the
progress of the said policy through a Normative Approach under a Multiple Streams
Analysis Framework. This is done in order to create a concrete means of
understanding how the DOH’s policy addresses the increasing trend in the Philippine
MMR. Ultimately, the National Safe Motherhood Program still has a lot of aspects
that it needs to improve on given that some of the issues it tries to solve have sub
issues that need to be addressed as well. Particularly, structural and procedural levels
do have inadequacies that hamper the progress needed in combatting the high
Philippine MMR. Yet, the fact that it acknowledges a number of problems from past
experience allows it to have enough room for improvement through better programs
and incentives that would further motivate LGUs and the private sector in adopting
the government’s policy.

Keywords: Development, Maternal Health, Maternal Mortality Ratio, Public Policy

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Introduction

The Philippine Government has been actively trying to address issues pertaining to
maternal health since the inception of the Millennium Development Goals [MDGs]. It
has been consistently augmenting its over-all health expenditure through allocating a
larger amount of its budget towards projects under the supervision of the Department
of Health [DOH] (Legislative Budget Research and Monitoring Office [LBRMO],
2013; DOH, n.d.). These efforts in increasing the health budget were in line with
DOH’s attempt in reducing infant and child mortality rates and the maternal mortality
ratio [MMR].

However, despite DOH’s attempt to improve the country’s MMR status, according to
the United Nations Children’s Fund [UNICEF], in 2011, every day approximately 13
mothers or around 5,000 every year die from pregnancy-related complications in the
Philippines. With the MDGs targeting 52 deaths per 100,000 live births, the
Philippine’s current ratio of 221 per 100,000 live births is relatively high compared to
other ASEAN countries that have a similar funds disbursal pattern.

The current situation is attributed to a couple of factors but, one key aspect that needs
to be examined is the policy side that contains all the projects, objectives and goals
that the public and private health sector needs to accomplish. As such, DOH’s
National Safe Motherhood Program main thrust is collaboration with Local
Government Units [LGUs] in combatting maternal and childcare issues by
implementing programs that improve services catering to mothers and newborns.
Under the said program, the Philippines aims to abide with MDG 5 that promotes the
improvement of maternal health. The policy proposed focuses on creating an
environment where it could promote safer pregnancy and childbirth through
fundamental societal dynamics with strong feedback mechanism coming from the
affected sectors.

Examining recent related maternal health policies instituted under the former Arroyo
and current Aquino administration, they have similar target points such as
collaboration with LGUs, reaching rural and far-flung areas and implementation of
programs and seminars that try to improve the skills of health officers. This just goes
to show that the problem is chronic despite constant efforts to combat it. As a result,
the country is suffering from high MMR.

Literature Review and Problem Discussion

The urgent need to prioritize maternal health comes from the fact that there are two
lives at risk whenever a complication occurs. Moreover, even after giving birth, the
mother still faces certain risks since she is still recovering from the stress imposed on
her body while delivering the baby. On her way to recovery, her baby, as well as other
members of her family, is affected since they have emotional, physical and financial
bonds. Hence, motherhood requires special considerations since their wellbeing not
only affects their own lives but their families as well. As such, it is alarming to know
that despite the presence of programs such as Unang Yakap, Maternal and Child
Health Integrated Program [MCHIP] and Health Sector Reform Agenda: FOURmula
One Program along with certain DOH memoranda such as A.O 2008-0029 that are in
line with the government’s maternal health objective of lowering the Philippine MMR
and reaching MDG5, the country is still struggling to solve the problem.

In 2008, under the Arroyo Administration, DOH created A.O. 2008-0029 or

Implementing Health reforms for rapid reduction of Maternal and Neonatal Mortality.
According to its Manual of Operations [MOP], this policy was developed as a means
of assisting both DOH and LGUs in implementing health programs that target rapid
reduction in maternal and neonatal mortality by improving women and children’s
health (DOH, 2009). By strengthening the Basic Emergency Obstetrics and Newborn
Care or [BEmONC] and Comprehensive Emergency Obstetrics and Newborn Care
[CEmONC] programs in the country, the program aims to combat the current MMR
trend. However, the materialization of the goals forwarded by this program were
challenging since LGU funding for health remains to be the primary source for its
operations on Maternal, Neonatal and Child Health and Nutrition [MNCHN] activities
despite majority of LGUs lacking financial capacity.

Looking at the burden held by LGUs, the operationalization of health facilities

through the Service Delivery Teams is questionable because at the community level,
the Community and Women’s Health Teams are expected to be capacitated while at
the facility level, BEmONC and CEmONC Teams, Itinerant Teams and Social
Hygiene Clinic Teams are aimed to be utilized. At the same time, in sustaining the
service delivery of MNCHN, members such as health and local government leaders
and skilled professionals for birthing are anticipated to be trained towards its optimum
level of competence. Yet, if the LGU does not have sufficient funds then the programs
cannot be translated into reality.

Similarly, in Herrera, Roman and Alarilla’s (2010) work, they pointed out how
majority of DOH’s financial resources are placed in the salaries and maintenance of
the public hospitals, therefore limiting resources available for capacity building. This
is in addition to the general plight of health services in the country being limited
towards the higher income brackets due to high percentage of goods and services
depending on out-of-pocket expenditures. Given such circumstance, in assessing the
Health Sector Reform Agenda: FOURmula One Program, issues on availability and
quality of healthcare still linger. They also point out how the lacks of social insurance
and free services have greatly hampered access for health needs. As such, the
allocation of DOH budget along with the regressive health system has contributed
greatly to the lack of progress in health services in the country (Herrera, Roman, and
Alarilla, 2010).

Additionally, in a World Health Organization [WHO] study conducted in 2011, the

urgency in addressing the MMR issue is magnified through the conditions of mothers
found in the poorest quintiles where their lack of educational background limits their
capacity to comprehend complex administrative requirements that hamper their
utilization of PhilHealth benefits (WHO, 2011). Their exclusion also has implications
in their households considering that they are given the least rates of health assistance
thus restricting health services they could receive in order to perform better their daily
livelihood and domestic tasks.

In these studies, Maternal Health Policies are programs initiated by the executive
branch of the government to address issues on health financing and social protection
that aims to improve the wellbeing of mothers and their children. Yet, inasmuch that
different policies have been initiated, the data presented shows an urgent need in
addressing the problem on Philippine Maternal Health considering that it is still
suffering from a major health setback along with an apparent problem in its
distribution capacity for health budget share. Thus, examining how policies have tried
to address the problem on maternal health would yield fruitful by identifying what
particular problems it tries to solve under the parameters offered by Political, Social
and Economic environment.

The creation of the National Safe Motherhood Program is one of the DOH’s means of
trying to curb the MMR by utilizing collaboration with LGUs in combatting maternal
and childcare issues through implementing specific measures that could improve
services catering mothers and newborns. The shift in responsibility towards regional,
provincial and municipal governments is in accordance with the Decentralization that
happened in the Philippines in 1991 where certain central government responsibilities
were transferred towards LGUs. As such, LGUs became front-runners in providing
goods and services for their constituents.

Under the said program, the Philippines aims to abide with MDG 5 or the
improvement of maternal health. Considering that developing countries have a hard
time lessening its vulnerability against this problem, the policy aims to promote a
safer pregnancy and childbirth environment through strong social relations that
empowers every sector. Doing so allows them to have a voice in decision-making
matters related to this endeavor with the aim of ensuring quality health care is easily
delivered and accessed by citizens under the hands of competent doctors, nurses and
midwives (DOH, 2013).

As such, the potential offered by the National Safe Motherhood Program as a policy
should be reviewed in order to assess better its capability in addressing issues
pertaining to the Philippine MMR. In doing so, the MMR issue could be addressed in
a holistic and comprehensive approach that better exemplifies what appropriate tools
are needed in creating an MMR policy.

Methodology

The analysis for this study was conducted through a Normative Approach as observed
from 2001 up to the current maternal health environment. WHO, UNDP and DOH’s
articles on the Philippine Maternal Health System vis-à-vis the DOH’s National Safe
Motherhood Program under a Multiple Streams Analysis Framework support such
review. This is done in order to create a concrete means of understanding how the
DOH’s policy addresses the increasing trend in the Philippine Maternal Mortality
Ratio.

By tackling the Problem, Politics and Policy Streams, the interaction of these factors
are assessed in the hopes of creating an adequate comparison as to how the Policy
Stream tries to answer the Problem Stream as well as compensate for any conflict
found in the Politics Stream. However, this study would primarily focus on the Policy
Stream in order to assess whether the program has targeted the problems leading to
maternal deaths.
Analysis and Discussion of Results

The problem stream primarily tackles the increasing trend in MMR despite efforts to
curb it. Looking at the current situation, it can be seen that different factors ranging
from economic to socio-political aspects have affected the accessibility and
sustainability of maternal health services. As such, the policy stream aims to address
the problem through the National Safe Motherhood Program where its program
objectives aim to address, first, the shift in responsibility towards regional, provincial
and municipal government offices in performing central government tasks as a result
of the devolution of the Philippine Maternal Health System and second, establishing
core knowledge base and support system.

These two goals aim to address the maternal health needs of Filipino women
especially those mothers forming the poorest quintiles that have the least rates of
health assistance due to their incapacity to comprehend complex administrative
requirements that hampers their utilization of PhilHealth benefits (WHO, 2011). Such
move is in line with the politics stream where the Inclusive Growth Strategy under the
Aquino Administration aims to upgrade facilities designated to provide emergency
obstetrics and newborn care within the Kalusugan Pangkalahatan framework.

Looking at these two primary objectives, its aim to resolve the main problems
associated with maternal health seem promising at it tries to utilize resources that
have a crucial impact on the success of maternal health programs. However, in spite
of its promising start, the political aspects still shows setbacks since LGUs as local
agents still struggle to unite its personal goals with that of the central government. As
such, their own preferences on what to prioritize and how much they would spend for
these projects are ascertained due to the prevalence of asymmetric information
anchored on lack of transparency and accountability that they possess.

As such, the two components of the National Safe Motherhood Program namely,
Local Delivery of the Maternal- Newborn Service Package and National Capacity to
sustain Maternal-Newborn services aim to sufficiently support the program’s main
objectives. The first component was designed to give LGUs the capacity to mobilize
the vast network of public and private service providers for the delivery of the
integrated maternal-newborn service package in each province and city through
Women’s or Community Health Teams, BEmONC Teams and CEmONC Teams
(DOH, 2013). Meanwhile, the second one aims to provide the longevity needed in
creating consistency for the provision of health services.

The Women’s or Community Health Teams, as part of the policy, focus on poor
implementation of programs targeting maternal health issues as observed in
previously conducted studies on Philippine Maternal Health and Community
Participation due to socio-cultural and historical traditions (Ramiro, Castillo, Tan-
Torres, et al., 2001) that hamper the effectiveness of promoting its cause. Such
circumstance led to the community’s lack of understanding on the devolution of the
health system and the roles they play in health decision-making hence, limiting their
empowerment to provide change in the provision of health amenities (Ramiro,
Castillo, Tan-Torres, et al., 2001).
The second one focuses on the creation of BEmONC Teams for the delivery of basic
maternal health services that are needed in delivering preventive and curative services
that lower any potential threat for the mother and child’ life considering that these
services are offered near their home’s vicinity. Moreover, the presence of the
CEmONC Teams were utilized to perform emergency obstetric functions similar to
BEmONC provider facilities with the additional task of providing surgical delivery,
blood bank transfusion services, and other highly specialized obstetric interventions
(DOH, 2009) needed in assuring that mothers and their children are given required
attention for their survival.

Given the justification for creating these teams, the effectiveness of projects carried
out by these groups cannot be easily surmised, as it has only been three years since
they have been delegated with their tasks. However, in relation to the political aspect
for this program, inequities are still apparent where public health workers that have
been commissioned to serve in communities are still concentrated in NCR and Luzon
(WHO, 2011).

Likewise, the capability to sustain Maternal-newborn services is anchored on the

establishment of Reliable Sustainable Support Systems for Maternal-Newborn Service
Delivery. By offering adequate medical attention and support system crucial for the
well-being of the mother and child, programs are geared towards lowering any
potential risks and complications associated with the pregnancy. Yet, such goal has
been dampened by its limited accessibility. It has been shown that access towards
trained prenatal care providers that could lessen these problems is associated with a
woman’s educational attainment. It has been proven through studies that access for
health services is higher as women’s educational attainment is higher (Rogan and
Olveña, 2004) thus, government efforts are meant to equitably distribute the services
especially for those who have lower level educational backgrounds.

Moreover, looking at current data, we see that the distribution of health goods is still
focused in certain areas. This has resulted in limited access for these drugs where
some areas have been forced to dispensing medicine without pharmacists in remote
clinics, RHUs, and government hospitals even though there is a law that prohibits
such practice (WHO, 2011). Thus, inasmuch that there is a drive to increase
accessibility, the fact that majority of the supply for medicines are still privately
controlled means that its availability is still significantly limited.

As such, the Manual of operation together with the Referral manual is meant to
develop and utilize an integrated communication strategy that would entice women to
be more participative and more aware of their health needs. Doing so would
encourage them to properly seek health information and services before, during and
after pregnancy (Asian Development Bank [ADB]. 2007). Also, as part of the policy
aspect, through the Network of Training Providers, Monitoring, Evaluation, Research
and Dissemination, assessing the necessary improvement and issues that need to be
addressed are given priority. This is critical particularly in addressing the fact that
despite an increase in public financing, regional terms for this remain low. Hence,
out-of-pocket spending increases the vulnerability, particularly the poor, towards
illness due to inaccessibility of services that could cure them. As for the utilization of
social health insurance like PhilHealth, its coverage consists only a tenth of the
country´s total health expenditures (WHO, 2011). This shows the regressive condition
of health financing in the country where the upper income quintiles have a larger
share of the benefits offered by public facilities while the two lowest income quintiles
have the least PhilHealth coverage and lowest PhilHealth utilization rates (WHO,
2011).

Furthermore, although BEmONC trainings are being conducted for the RHU or DHC-
based teams, geographical issues pertaining to LGU coverage, Referral Hospital and
other primary level RHUs and Barangay Health Stations [BHSs] concerns have been
addressed. Yet, a post-evaluation of these trainings, particularly in Leyte, shows that
there are issues that need long-term regular follow-up. Problems regarding
administrative jurisdiction such as hospitals being under the Provincial Governments
while RHUs are under Municipal LGUs, inadequacy of resources due to shortage in
trained manpower, transportation and logistics, as well as conflicting schedules
among team members are just some of the obstacles the need to be addressed in fine-
tuning the program (DOH-Regional Office 8, PHO Leyte, Ormoc CHD and Project
for Strengthening Maternal and Child Health Services in Eastern Visayas, 2014). As
for CEmONC related activities, there are still problems regarding the equitability in
access for it. For example, Region XII has a 90% rate of accessibility although some
provinces and municipalities are still below 50% due to problems on allocation of
financial support (United Nations Development Programme [UNDP], 2014).

Given the problems faced in the programs under the National Safe Motherhood
Program, the need for DOH’s guidance and stewardship allows for the incorporation
of transparency and accountability that affects the performance of these entities and
what factors motivate them to pursue a particular path such as effective resource use
and strengthening LGU governance over time (ADB and World Bank [WB], 2005).
As such, support systems for Maternal-Newborn service delivery allows for
diversification of funding and tangible sources principally driven by the development
of a client classification scheme since in Romualdez’ work in 2010 he discussed how
upper income groups consisting 25% of the population rely on privately provided
healthcare that have better equipment and assistance while the remaining 75% have to
use public medical providers ((Herrera, Roman, and Alarilla, 2010).

This pattern is also ostensible as pointed by WHO since health financing in the
Philippines is regressive. Upper income households have a greater share in the
distribution of benefits delivered by public facilities. Given these prior considerations,
DOH having the over-all technical authority on health by providing national policy
direction and developing national plans, technical standards and guidelines on health,
has the power to find alternative means in regulating all health services and products,
and providing special or tertiary health care services and of technical assistance to
other health providers especially to local government units.

Hence, the National Safe Motherhood Program still has a lot of aspects that it needs
to improve on given that some of the issues it tries to solve have sub issues that need
to be addressed as well. Yet, the fact that it acknowledges a number of problems from
past experience, allows it to have enough room for movement it needs in constructing
better programs and incentives that would further motivate LGUs and the private
sector in adopting its programs. Comparatively, in DOH’s assessment of its over-all
performance for the National Safe Motherhood Program, they concluded that in
relation to the program’s 3 indicators namely, antenatal care, facility-based delivery
and post-natal care, as of December 2012, the program accomplishment is
approximately 65%. This is 5% short of its 70% goal where it attributed its
underperformance on low post-natal coverage of 52% as well as technical,
operational, and hierarchical issues such as procurement, differences in priorities and
LGU organizational structures (DOH, 2013). Similarly, both assessment shows that
the structural and procedural levels do have inadequacies that hampers the progress
needed in combatting the high Philippine MMR.

Table 1 Multiple Streams Analysis for the National Safe Motherhood Program

Policy Stream Problem Stream Politics Stream

PROGRAM MAIN PROBLEM BEING EFFECTIVENESS OF
ADDRESSED BY THE THE PROGRAM
POLICY USED IN
ADDRESSING THE
PROBLEM/
POLITICAL
ENVIRONMENT
UNDER WHICH THE
POLICY WAS
IMPLEMENTED
Collaborating with Local Establishing a sustainable, LGUs as local agents
Government Units cost-effective approach in still struggle to unite its
the delivery of health personal goals with that
services that ensures access of the central
to services and facilities for government.
the disadvantaged women in
order for them to enjoy
acceptable and high quality
maternal and newborn
health services.
Establishing core The number of LGUs that Integrating the
knowledge base and have the capacity to address Inclusive Growth
support systems emergency situations are Strategy that draws
still limited since the majority into the
management for this type of economic and social
circumstances are still mainstream and as such
dependent on the political offer potentially
will of the LGU that wants improved services by
to initiate an emergency strengthening the
management system (WHO, foundation for
2011) infrastructure and
services for maternal
health
Creation of: Targeting maternal health In that short span of
issues as observed in time that these public
1.Women’s/ Community previously conducted health workers have
Health Teams studies on Philippine been commissioned to
2.BEmONC Teams Maternal Health and serve in communities,
3.CEmONC Teams Community Participation the inequities are still
due to socio-cultural and apparent since health
historical traditions facilities and human
(Ramiro, Castillo, Tan- resources are still
Torres, et al., 2001) that concentrated in NCR
hamper the effectiveness of and Luzon (WHO,
promoting its cause. 2011).

Problems related to
geographic access is
addressed--given the
premise that women living
in mountains, forests or any
place away from civilization
are generally discouraged to
access health services due to
travel constraints that
increase costs for availing
such necessities (DOH,
2009).
Establishment of: Provide input on maternal BEmONC trainings:
geographic information A post-evaluation of
1.Manual of operation required in providing a more these trainings,
2.Referral manual accurate gauge on the effect particularly in Leyte,
3.BEmONC Protocol of public health facilities on shows that there are
4.CEmONC curriculum maternal health. issues that need long-
and protocol for service term regular follow-up.
delivery BEmONC trainings being
5.Maternal death reporting conducted for the RHU or Problems regarding
and review protocol/ DHC-based teams aimed to administrative
Issuance of relevant address geographical issues jurisdiction such as
policies pertaining to LGU coverage, hospitals being under
referral hospital and other the Provincial
primary level RHUs and Government while
Barangay Health Stations RHUs are under
[BHSs] concerns Municipal LGUs,
inadequacy of resources
due to shortage in
trained manpower,
transportation and
logistics, as well as
conflicting schedules
among team members
are just some of the
obstacles the need to be
addressed in fine-tuning
the program (DOH-
Regional Office 8, PHO
Leyte, Ormoc CHD and
Project for
 Strengthening Maternal
and Child Health
Services in Eastern
Visayas, 2014)

CEmONC related
activities:
There are still problems
regarding the
equitability in access
for it.
Institution of: Aimed to alleviate the As for the utilization of
health condition of the poor social health insurance
1.Monitoring, Evaluation, through accessibility of like PhilHealth, its
Research and services that could cure coverage consists only
Dissemination them. a tenth of the country´s
2. Improved quality of FP total health
counseling and expanded Address the regressive expenditures (WHO,
service availability condition of health 2011)
3. Integration of STI financing in the country
screening into the where the upper income
antenatal care and Family quintiles have a larger share
planning protocols. of the benefits offered by
public facilities while the
two lowest income quintiles
have the least PhilHealth
coverage and lowest
PhilHealth utilization rates
(WHO, 2011).
Creation of: Access towards trained Distribution of health
prenatal care providers that goods is still
1.Reliable Sustainable could lessen these problems concentrated in certain
Support Systems associated with a woman’s areas. This has resulted
2.Support systems for educational attainment. It in limited access for
Maternal-Newborn service has been proven through these drugs where some
delivery studies that access for health areas have been forced
services is higher as to dispensing medicine
women’s educational without pharmacists in
attainment is higher (Rogan remote clinics, RHUs,
and Olveña, 2004) and government
hospitals even though
there is a law that
prohibits such practice
(WHO, 2011).

Majority of the supply

for medicines are still
privately controlled
means that its
accessibility is still
 significantly limited.
DOH provides stewardship Incorporation of 25% of the population
and guidance transparency and rely on privately
accountability that affects provided healthcare that
the performance of these have better equipment
entities and what factors and assistance while the
motivate them to pursue a remaining 75% have to
particular path such as use public medical
effective resource use and providers (Herrera,
strengthening LGU Roman, and Alarilla,
governance over time (ADB 2010)
and World Bank [WB],
2005)

Conclusion

The increasing trend in the Philippine MMR shows how the interaction among the
Politics, Problem and Policy Stream has greatly influenced how the country has
handled the problem. Given such circumstance, the National Safe Motherhood
Program tried to tackle the pertinent problems being faced in combatting maternal
health problems and has slightly succeeded in doing so. Admittedly, they have made
progress towards creating valuable plans, trainings and activities that contributed to
the improvement in the handling of maternal health concerns however, it still lacked
proper coordination and structural cohesiveness for it to function properly.

Reviewing the two primary objectives of the National Safe Motherhood Program
where it aim to foster better partnerships with the LGUs and at the same time create a
strong core base knowledge for maternal health, the process by which its main
objectives were handled has somewhat underperformed. Considering that, in spite its
promising start, LGUs as local agents still struggle to unite its personal goals with that
of the central government. This had led to LGUs prioritizing their own preferences
and particularly spending on projects they want rather than aligning it with the
national objectives.

Furthermore, doubts on the effectiveness of projects carried out continue to persist

despite the program’s presence. Problems regarding capacity and distribution of
health workers posed as a threat on how programs are to be carried out since majority
are found in NCR and urban areas but those who are direly in need for medical
assistance are found in rural areas. Assessing the access for drugs also show the same
scenario where 50% of the 3000 plus drugstores are located in NCR while the rest are
found in urban areas in other regions. Such circumstance shows the unequal
distribution of resources thus, inasmuch that good programs are created in addressing
the MRR issues if there are no means of properly implementing it then such initiative
would go to waste.

In understanding better the plight being faced by the Philippines in addressing the
increasing MRR trend, further research can be done by introspecting other possible
sources of problems that hamper the success of MMR programs. Other perspectives
could be examined such as the difference in class income, geographical attributes and
regional variations in order to see how these may have significant contributions as to
how policies have been undertaken and what possible changes could be done to
improve it.
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