Empowering Women and Strengthening Health Systems and Services Through Investing in Nursing and Midwifery Enterprise: Lessons from Lower-Income Countries: Workshop Summary (2015)

Appendix D

Innovations in the Provision of Health Services Using Empowered Nurses and Midwives in the Philippines¹

Oscar F. Picazo,² Valerie Gilbert T. Ulep, Ida Pantig, Danica Ortiz,
Melanie Aldeon, and Nina Ashley de la Cruz³
September 9–11, 2014

INTRODUCTION

The Philippines is a large-scale producer of nurses and midwives for both domestic employment and export. However, as advanced countries (e.g., the United States) decided to expand domestic nursing education, Filipino graduates increasingly found it difficult to find overseas employment especially in lucrative destinations like Australia, Canada, the United States, and Western Europe.

Interestingly, although there has been a domestic glut of Filipino nurses for some time, many rural and peri-urban areas in the country remained unserved or underserved with health personnel, resulting in weak improvement in national child health status and a setback in the reduction of maternal mortality ratio. This has been mainly because of the low pay of health personnel in poorer areas, which also stems from the inadequate

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¹ Paper prepared for the Institute of Medicine’s Workshop on “Empowering Women and Strengthening Health Systems and Services Through Investing in Nursing and Midwifery Enterprise: Lessons from Lower-Income Countries,” The Rockefeller Bellagio Center, Bellagio, Italy, September 9–11, 2014. This paper relies on the findings of the nationwide search for Health Market Innovations (HMI) in the Philippines that was given a grant by The Rockefeller Foundation through the Center for Health Market Innovations (CHMI) of the Results for Development (R4D) in Washington, DC.

² Senior research consultant, the Philippine Institute for Development Studies (PIDS). More information at www.pids.gov.

³ PIDS staff involved in documenting case studies in the Health Market Innovations (HMI) Project in the Philippines.

third-party payment system that should make the employment of nurses and midwives in these areas more attractive on a personal level, and more sustainable on a health system perspective.

In recent years, several private-sector initiatives have emerged focusing on the deployment of nurses and midwives to underserved areas, and employing more sustainable business models. This paper profiles four major innovations using nurse or midwife empowerment as a basis, and focusing on the health needs of the poor and near-poor. These health market innovations are:

• the Well-Family Midwife Franchise Clinics;
• the Mother Bles Birthing Clinics, a public–private partnership;
• the Blue Star Pilipinas Clinics; and
• the EntrepreNurse Cooperatives.

WELL-FAMILY MIDWIFE FRANCHISE CLINICS

Improved quality of maternal and reproductive health care is necessary to decrease the high level of maternal and infant mortality. Given the vibrant role of the private providers in the health care system, they can serve as an instrument in delivering quality and standardized maternal and child care services. The Well-Family Midwife Clinic (WFMC) was put up in 1997 by the John Snow Institute Research and Training Institute, which specializes in providing technical assistance to public health programs around the world.

WFMC was initiated under the Technical Assistance for the Conduct of Integrated Family Planning and Maternal Health Services by Philippine Nongovernmental Organization (NGO), or TANGO for short. The U.S. Agency for International Development (USAID) provided support for piloting this franchise. The Philippines was deemed appropriate for this type of business model because of (a) the surplus of available and trainable health service providers (midwives), (b) the existence of a segment of the population willing and able to pay for services, and (c) popular demand for quality health services, as revealed in demographic and health surveys.

WFMC envisions affordable and accessible quality health care for every Filipino by providing entrepreneurial opportunities to midwives who have established linkages with their respective communities. It operates as a social franchise that offers a “one-stop” shop for family planning and maternal and child health services targeting lower- and middle-income families. Social franchising works in much the same way as commercial franchising by applying the latter’s strategies to the health sector to efficiently expand access to quality health care to underserved communities; the only difference is the initial subsidy (in development costs, training, and information

campaign) that a social franchise gets from a sponsor (external or local donor or government), which a business franchise does not get.

The WFMC clinics are equipped with birthing facilities and private examination rooms for pregnancy tests, minor gynecological services such as Pap smear, basic health services of a midwife such as normal spontaneous delivery, pre- and post-natal care, and immunization services. At present, there are 120 WFMCs located in Metro Manila and in 28 provinces all over the country.

The franchise network of WFMC has translated to effective delivery of services because of the quality standards set. These standards were provided under the technical assistance and business training given to the midwives initially by the TANGO project and thereafter by the successive franchisor-NGO that was put up for the purpose after the TANGO project ended. By being part of the WFMC network, midwife-franchisees are also assured to receive technical updates which contribute to the effective service delivery in the clinics.

The benefits have translated not only to a significant number of mothers and children who receive quality health services, but also to the midwife-turned-entrepreneurs who have modestly increased their income by running the clinics instead of only being on-call. Thus, the WFMC has successfully evolved to become an autonomous, self-sustaining franchise system, revolving around the midwife-entrepreneurs.

The social franchise scheme of WFMC has scaled up access to quality health care especially for the people in rural areas. Social franchising is indeed one of the innovative ways in which the need for family planning and maternal and child services of the underserved population can be met.

MOTHER BLES BIRTHING CLINICS

Maternal mortality ratio in the Philippines is targeted to be reduced by three-quarters by 2015; this is equivalent to 52 maternal deaths per 100,000 live births. However, the country is not on track to meet this target. Indeed, in 2009, maternal mortality ratio was recorded to be 169 per 100,000 live births, and there was even a significant increase in the ratio in 2011 to 221/100,000). Aside from maternal deaths in married women, teenage pregnancy has also increased.

The problem of maternal deaths in the Philippines is mainly due to poor access to affordable and high-quality facility-based maternity care services. Many pregnant mothers live too far from a health facility with basic maternal and obstetric care. This situation leaves no option for many poor mothers but to rely on traditional attendants for giving birth.

To address this severe lack of birthing facilities, Sister Eloisa David of Kakak Foundation Inc. (a local NGO) and Governor Carlos Jericho

Petilla launched the Mother Bles Birthing Clinics (MBBCs) in Leyte Province, one of the highly underserved local government units in the country. MBBC is a public–private partnership (PPP) initiative that provides a solution to the poor maternal health and infant care services among the lower- and middle-income mothers in the province. MBBCs are networks of PhilHealth-accredited birthing facilities that offer affordable and accessible professional obstetric and other medical assistance to clients.

MBBCs systematically select the areas in the province with high maternal mortality ratio. This problem-identification stage is deemed crucial, as the location of a clinic is very critical in maternal mortality reduction programs. The appraisal and the construction of the clinic is followed by negotiation and arrangement with the barangay (village) or the municipality for clinic space. In most cases, the clinic space is the contribution of the local government unit in the PPP. The training of midwives is provided by MBBC in partnership with the Private Practicing Midwives (a local NGO group), while the operation of the clinic is undertaken by Kakak Foundation.

The MBBCs offer a variety of services focusing on maternal, family planning and reproductive health. These include prenatal care, nutrition and family planning, PhilHealth enrollment assistance, postnatal care, guidance counseling and catechism, and registration of live births, baptisms, and even validation of marriage for unwed couples.

With the determination to provide affordable and quality maternal and infant health care services to the poor, Mother Bles has established 50 clinics in 3 years from 2010 to 2013: 4 in Pampanga, 2 in Bataan, 3 in Cebu, 6 in Northern Samar, 2 in Western Samar, 24 in Leyte, 2 in Southern Leyte, 1 in Antique, 2 in Misamis Oriental, and 4 in Bukidnon.

Mother Bles has also constructed the Mother Bles Learning Center as its corporate social responsibility. It also donated a multi-media room to Palo Central Public School and a multicab to a far flung barangay in Lonoy, Maasin, Southern Leyte, so that mothers can be brought to the town center. Mother Bles has also sponsored the training of 43 midwives as scholars to be deployed in these clinics.

BLUE STAR PILIPINAS CLINICS

Blue Star was launched in 2008 as a nonprofit network of clinics providing reproductive health services in the Philippines. The social marketing network is organized as a franchise arrangement with the license and accreditation being provided by the franchisor, Blue Star. Blue Star’s parent organization is Population Services Pilipinas, Inc. (PSPI), a nonprofit company. The clinics provide family planning, reproductive health, HIV/ AIDS prevention, maternal health, and newborn and child health services, targeting the bottom 20 percent of the Philippine population.

The franchises are run by licensed midwives (1 midwife per clinic) in 200 clinics. To ensure quality, Marie Stopes International trains Blue Star providers in state-of-the-art service delivery and then regularly monitors quality to ensure that agreed standards are met. Providers receive training in areas such as family planning knowledge, counseling, clinical skills, marketing, and business management. Existing private facilities are refurbished and rebranded with a Blue Star logo, and are then promoted to clients to assist them in identifying and accessing quality services. Franchises are able to buy family planning contraceptives for their centers at reduced prices, ensuring better profit margins.

To participate in the network, the midwife-franchisees pay an annual membership fee of US$24 and weekly fee of US$7, which covers PSPI’s initial investment for the franchise clinics and midwife-operator, including training and initial supplies and equipment. The fee also covers Blue Star Pilipinas’ management cost in running and enhancing its operations as franchisor.

Accreditation of providers and facilities of PhilHealth’s Maternity Care Package has entitled Blue Star’s franchisee-midwives to claim US$120 in reimbursement for each delivery of a PhilHealth enrolled woman, which helps franchised-midwives cover operating costs.

Quality assurance and performance monitoring methods include (a) site visits (six per year) and internal audits (twice per year); (b) external audits (once per year); (c) client exit interviews (once per year); (d) qualitative reviews with clients (twice per year); and (e) qualitative reviews with providers. The business systems audit verifies client numbers and service statistics that are reported by the franchisees. Blue Star uses these findings to improve the reporting mechanisms.

ENTREPRENURSE COOPERATIVES

The Region XI Office of the Department of Labor and Employment initiated EntrepreNurse in 2010 to address the pressing problem of unemployment among local nurses and to provide adequate public health workforce and services to the people of Davao Region. In the late 2000s, graduate nurses had exceeded more than 150,000 R.N.s/B.S.N.s nationwide, the glut resulting from the narrowing of the market of nurses in the United States and other advanced countries and the inability of local nursing production to adjust accordingly.

In collaboration with the Department of Health and PhilHealth, the EntrepreNurse Project aimed to increase the employment of nursing graduates by training them on entrepreneurial management and organizing them into cooperatives of nurse-run clinics that offer reduced cost of primary and home health care services to indigent or poor rural households.

EntrepreNurse cooperatives were piloted in the communities of Davao City, Davao del Sur (Digos City), Davao del Norte (Tagum City), Davao Oriental (Mati), and Compostella Valley. The capitalization of these cooperatives comes directly from their members while the pieces of clinic equipment are provided for by the Department of Labor and Employment.

The main purpose of the nurse cooperatives is to deliver home and primary health care services. Other services were added later, including medical transcription, emergency medical services, tourism health services, wellness and fitness management for private companies, outsourcing of nursing health services for private establishments, medical mission management for private companies and local government units, and periodic physical examination of workers for private companies.

The strategy is to deploy recruited nurses to barangays (one nurse per barangay per month) with serious public health problems, as identified by the local government units and the regional Department of Health office. During the barangay (village) visit, the nurse-member of the cooperative will do health education and care provision and will be paid PHP1,000 per visit by the sponsoring organization, which can be the local government, PhilHealth, the local Congressman, or a donor. Each cooperative should have at least one experienced head nurse to oversee its operations.

The entrepreneurial training of nurses is given prior to their becoming cooperative members, and it involves orientation on cooperative principles, the salient features of R.A. 9520 (the Act on Cooperatives), membership fees and subscriptions, duties and responsibilities of cooperative members, and benefits of cooperativism. The number of nurse-cooperative members per province in the Davao Region ranges from 30 to 60. There are 65 nurses registered in Davao Oriental, 23 in Davao City, and 30 in both Davao del Norte and Compostela Valley. Five EntrepreNurse cooperatives have been organized, one each in the following areas: Davao Oriental (Mati), Compostela Valley, Davao del Norte (Tagum City), Davao del Sur (Digos City), and Davao City.

CONCLUSIONS:
WHAT MAKES THEM WORK? WHAT ARE THE CONSTRAINTS?

The five cases described in this paper involve innovative ways of deploying health workers (nurses for the most part) to underserved areas. What makes these innovations work?

• Availability of nurses and midwives—The Philippines produces hundreds of thousands of nurses and midwives per year. Thus, there is a ready supply of these health workers. Traditionally, these have worked in government and private hospitals and outpatient

• clinics, or with NGO health programs, but since the 1990s there have been increasing flow forming their own practices.

• Leadership and initial investment support—These innovations were invariably started by individuals with entrepreneurial streak (e.g., Sister Eloisa of Mother Bles Clinics) or by donors or NGOs (USAID, Marie Stopes International) led by strong Filipino leaders. Leadership, of course, is idiosyncratic and hard to replicate.
• PhilHealth reimbursement for facility-based delivery—Although the initial impetus for these innovations was not driven by PhilHealth (the social health insurance program), the expansion of PhilHealth benefits to include safe motherhood and selected reproductive health services gave strong incentives for their growth. The government policy requiring all mothers to deliver in health facilities also helped. With the enactment of the Reproductive Health Law, it is anticipated that many more nurse-led health services will bloom. This will gain traction through the expected approval of wider primary care benefits under PhilHealth.

What have been the constraints for these types of innovations to start or to thrive?

• Regulatory obstacles and bureaucratic delays—It takes nearly 18 months and up to 2 years to get a license to operate a small social health enterprise (pharmacy, clinic) from the regulatory agencies (Food and Drug Administration, Department of Health Center for Health Development) and business permit from local government units. There is little sense of urgency among these regulatory agencies to expedite the processing of a license to operate and a business permit.
• Professional turf issues—Physicians, especially obstetricians and gynecologists (affiliated with the Philippine Obstetrics and Gynecological Society), often lock horns with nursing and midwifery groups (or individuals) over their respective scopes of professional practice as well as patient-clients. Some physicians feel threatened by the increasing role and market share of nurses and midwives in such services as antenatal and post-natal care, safe delivery, and reproductive health.
• Inadequate training of nurses and midwives on management—Some observers have noted that the education of nurses in the Philippines is too oriented at their being caregivers rather than being care-managers. The existing training programs also tend to underplay the importance of professional autonomy among nurses.

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