The management of community-based initiatives in reproductive health in three provinces in Western Visayas: A comparative analysis

Abstract

This study aimed to describe and compare the management of community-based initiatives in terms of inputs, processes used in implementation, actual project performance, facilitators and constraints in project planning and implementation in Reproductive Health in the three provinces in Western Visayas namely Aklan, Antique, Capiz.

This study is descriptive in nature and utilized both quantitative and qualitative approaches using mostly secondary data. A meta-analysis on the management processes and intervention was employed, utilizing the results of the Evaluation of Community Based Initiatives and NGO Subcontracts conducted by David (2004), a project supported by the United Nations Population Fund or UNFPA. The result of documents analysis, focus group discussions and key informant interviews were reviewed and utilized in the present study. Additional interviews and document analysis were conducted to fill-in data gaps needed in the analysis of the present study.

Findings show that in terms of inputs, Aklan and Capiz had bigger funds of more than twelve million than Antique having almost half less of seven million pesos. Capiz had the biggest allocation for CBI areas, followed by Antique during the last two years followed by Antique based on the last two years. Aklan had expended the least during the last two years of operation but spent more during earlier years. As to funds expended for NGO subcontracts, Aklan registered the highest, followed by Antique while Capiz had the least expenditure.

Capiz had the biggest inputs in IEC activities and then by Aklan followed by Antique having the least expenditure on this particular component. Capiz had registered the biggest expenditure in all activities during the last two years of operation, followed by Antique. However, Aklan had registered the biggest expense on Special Courses to which ARH activities were incorporated, followed by Capiz and then by Antique. Capiz had more inputs related to management and protection of violence against women and children, than Aklan and Antique.

Capiz had introduced the most number of activities to assist the CBI areas like proposal making, bookkeeping, conducting meetings, financial management. Aklan and Capiz had conducted more trainings on RH than Antique. Trainings for service providers primarily on Integrated Reproductive Health were conducted in the three provinces, but Aklan had trained the most number of service providers followed by Capiz and then by Antique.

As to community-based initiatives, Capiz focused more on safe motherhood through the establishment of functional birthing clinics followed by Aklan which focused more on blood typing and blood mapping. Capiz also had many Teen Centers giving ARH services. In fact, the positive impact of these Teen Zones or Teen Centers encouraged the provincial government to establish nineteen teen centers (piloted in the 16 municipalities and 3 cities) with funds coming from the provincial government. Aklan had also established four Teen centers. It was also worth noting that Aklan had more number of active peer educators especially on ARH compared with the other two provinces.

As to processes involved in CBI management, the involvement of the stakeholders were apparent in the three provinces. However, it was in Aklan where the church and the NGOs involvement in planning is prominent.

Although in two CBI areas in Antique, there were involvement of a church and an NGO in one of their planning or launching meetings, NGOs participated in some activities of the RH Subprogram but not necessarily in the CBI areas of the province.

NGOs involvement in the present study mirrors one of the findings of the case study on irrigation sector reforms in Gujarat, India by Apoorva Oza which revealed that the way ahead is through involving the farmers and also acceptance that NGOs are equal partners in the reform process and the community organization is an essential for any government subsidies, the cost of community organizing process by NGOs. NGOs involvement in the present study however is not sustainable since their activities were not necessarily in most CBI areas. Based on documents, there were NGO Subcontracts whereby funds were released to these NGOs, however, it was not clearly stressed that RH interventions must be done in the CBI areas. In effect, CBI funds were spread too thinly for both CBI and non CBI areas of the three provinces. Thus, efforts were fragmented that did not create greater impact to pilot areas.

Planning steps for the CBI areas as prescribed by UNFPA and DOH in collaboration with PHO, RHU, and LGUs were observed in the three provinces. All stakeholders did the initial planning especially at the barangay level, spearheaded by the Municipal Health Officer of respective RHUs with close coordination with the barangay council, Barangay Health Workers and community volunteers. The rural health midwives were the key persons behind program implementation who acted as facilitators and at the same time community organizers. However, Aklan had involved the most number of NGOs or private organizations in the planning and implementation of RH in most CBI areas other than the LGUs.

Organizing in the CBI areas was weak since there was no formalization of organizations based on organizing principles among target beneficiaries in the three provinces. A short-cut was done in the planning and implementation process. Community organizing process was not fully understood which could have been a big help in project implementation.

Moreover, leadership development in the CBI areas did not come directly from the ranks of community residents, which posed a danger of interpreting the situation to be not promoting genuine participation. Since activities were usually planned by outsiders starting from the nurse, midwife and even the doctor concerned, it could be interpreted as top-bottom approach. The community residents participated in all RH activities in the community but did not have the real stake in decision making considering the role of the RHU personnel especially the RHM and RHN. Thus, it would be suffice to say that the objective of empowering that real stakeholders and beneficiaries in RH in CBI areas is not met. Considering the Community-Based Initiative as a strategy to implement Reproductive Health did not really work. It could be interpreted as a good start for barangay council to lead members in activities with assistance from the midwives, however, transition of leadership to the ranks of volunteers in the community is vital to achieve desired outcomes.

Controlling in the form of monitoring and evaluation of CBI areas were only in the areas of RH delivery of services. Monitoring conducted quarterly by barangay health workers focused only on Reproductive Health Services for the three provinces. Obviously, this did not capture the monitoring and evaluation of projects and activities initiated in the CBI areas. In Antique however, with their focus on income generating projects, the women RH members also monitor and evaluate status of their income generating projects. The treasurer, auditor or collector or storekeeper were the ones monitoring loan repayments. Regular meetings serve as a venue to monitor the status of the projects and the borrowers and their repayments. The meetings were conducted regularly which require officers to report project status and address problems that were fleshed out of this activities.

Performance based on the Objectively Verifiable Indicators (OVIs) revealed that there was an increase in the number of clients going to the barangay health stations to avail of RH services when compared in the past. In terms of providing technical assistance to service providers, Aklan and Capiz invested much for trainings. Aklan had trained many service providers compared with the other two provinces, which affirmed the study of David that Aklan had trained the most number of community volunteer health workers and also with the Midterm Evaluation (2002) report. Capiz however, had trained many service providers after 2002 evaluation.

The factors that facilitated program implementation were: the commitment of the LGUs to the program; supportive Rural Health Unit Personnel especially the Rural Health Midwives, Rural Health Nurse and the support of Municipal Health Officer; support of LGUs or UNFPA during program reviews, meeting or backstopping sessions xvii on RH which means that their efforts have relevance. The activities or projects were implemented as planned based on the proposals and according to budget.

Aklan had recognized the strength of active peer facilitators and the strong linkage with the LGUs and the NGOs as plus factors in the CBI implementation. The final report in Antique also revealed that infusing income generating projects for CBI as a strategy in community organizing or group mobilization facilitated the CBI planning and implementation. Capiz recognized that the strong support of community health volunteer workers like health workers or barangay nutrition scholars or hilots were vital considering the fact that they had focused on safe motherhood related activities.

Service providers in Aklan had heavy workloads, as they were not only given RH related tasks but other health related assignments as well which affected the program implementation. The task forces which were ad hoc in status affects project and political situation and in the long run affected the program implementation.

In Antique, the small number of barangay health workers affected program planning implementation considering the ratio of midwives to the number of assigned barangays which implies the need for community volunteer health workers. The budget given to CBI areas were spread too thinly to both CBI and non CBI areas. The lack of health facilities like barangay health stations in the choice of CBI barangays affected the easy access to RH services. Also, the inability to document or lack of documentation skills related to planning and implementation of projects and activities and best practices is a minus factor and inadequate training of service providers especially follow-up learning sessions on integrated reproductive health.

Capiz considered lack of barangay counterpart until 2003 affected program implementation, funds for IGPs were inadequate, skills development not available in bookkeeping and project management for both implementers and those who were involved in the project. Overlapping or conflicting training schedules for RH and other health related programs affected project implementation. Also the limited health facilities pose a challenge to the dwindling funds of local government units. Lastly, mentoring and supervision skills at the provincial level were yet inadequate to respond to evolving needs of the field level implementers.

In conclusion, of the three provinces, Aklan had registered the biggest expenditure with Antique having the least. Indeed, the performance to any initiative could be determined by the inputs available for a certain area. In the case of Aklan and Capiz, it is inferred that given that funds is enough and available, many activities were conducted in these provinces especially trainings related to RH. In effect, therefore, there were more service providers trained on RH not only for health but also to non-health sectors who were involved in the RH implementation. Thus, the 2002 Midterm Evaluation is affirmed that Aklan had trained many service providers compared to the other two provinces with RH program implementation. As to planning, Aklan had involved many NGOs and the Church sector other than LGUs. Antique had involved many LGUs such as Department of Education, Municipal Planning and Development Office and the like.

The management of RH Subprogram in the three provinces were relatively been effective. Members’ participation in the entire project management cycle was moderately active. As to the provision of resources, CBI areas were also moderately active since the projects were funded by both UNFPA and the local government especially at the barangay level. The personnel involved in the implementation were both internal and external, the BHWs and the RHU personnel had collaborated well in the entire program implementation. As to extent of integration, LGUs were involved in the three provinces from the provincial, municipal and the barangay level, however, Aklan was the most integrated in terms of project implementation because of the involvement of different agencies especially the NGOs, followed by Antique and the least by Capiz. In the case of Antique, NGO intervention does not only focus on the CBI areas but also to non CBI areas for as long as activities promoted reproductive health.

In leading, the barangay captain chaired the task forces or committees on RH in the three provinces as prescribed in the CBI planning and implementation guidelines. During annual reviews or regular meetings usually attended by MHOs, RHMs or RHNs where reporting or sharing of the status of implementation happened, the assistance of the UNFPA representatives, PPMU staff, and PHO personnel served well to encourage persons involved in each province or each municipality to perform well and even employ corrective measures in their implementation.

Barangay level monitoring was conducted quarterly for RH services and other health related status and these were presented in data boards in barangay health stations. In Antique, the regular meetings served as a way to monitor the status of the program implementation of their income generating projects. The storekeeper or collectors reported the status of loan repayments.

In terms of community-based initiatives, Antique had focused on income generating projects for RH beneficiaries. Capiz also had started having IGPs but none in Aklan. Capiz had focused on safe motherhood through birthing clinics and planned to have a user’s fee.

The actual performance in the CBI areas for the three provinces were varied. However, Aklan had delivered varied services, and activities since they had enough funds. They were able to train more peer educators who were generally active and functional. Capiz however, had been doing well in terms of promoting safe motherhood through establishment of many birthing clinics. They also had been doing well in establishing Teen Centers. Antique however, worked well with their income generating projects. Hence, it was wise to conclude that funding has an important bearing to actual performance.

The beneficiaries had perceived CBI management to be effective, efficient and relevant when they had rated performance their performance to be 75-80 percent. In terms of sustainability, there were efforts to make way for the inclusion of the RH projects and activities in the Barangay Development Plan. To this, perception of the beneficiaries and stakeholders of the project performance reveal that performance is very good.

There were many lessons or insights in the RH planning and implementation especially in the CBI areas. It was believed that participation is important in the program planning and implementation by all stakeholders. The counterpart given by local or barangay government facilitated many activities in Antique for CBI areas. The support of barangay captain was important considering his role in the community. It was a good start for them to take care of the program but there must be a transition of the leadership role which must be played by other members of the community who could become committed to the program other than the barangay captain.

Based on the findings and conclusions it is recommended that projects and activities in the CBI areas must be so designed in such a way that efforts are sustained. The counter parting or putting-up of projects through local government initiative at all levels was good and thus, must be sustained. In giving funds to NGOs, or municipalities, it must be stressed that their focus of intervention must be the CBI areas in order to create greater impact. Furthermore, there must be proper appropriation and careful scrutiny of the kind of trainings to be conducted and with proper focus based on training needs assessment.

Community organizing principles in the RH Subprogram must be incorporated in the planning and implementation. The midwife must not act as community organizer but instead a project community organizer to build a strong RH organization must be hired to work closely with people and the midwives. With this leadership development among beneficiaries could be done leading to people empowerment in the long run. Regular meetings and program reviews could be pursued. Documentation skills must be developed or encourage among stakeholders in order to monitor and evaluate performance so easily aside from direct observation.

Monitoring and evaluation tools from provincial and municipal level must be designed together with representatives from all CBI communities. This monitoring and evaluation plan should have been done regularly like once a month so that corrective measures are to be made whenever necessary. This must not only be done by provincial managers and the RHU staff but also by those who had the direct stake like beneficiaries in the community.

The guidelines in the CBI planning and implementation must be critically analyzed and revised since it does not consider empowerment principles as a long term goal. The need to maximize NGO involvement in the CBI areas not only in planning but also all throughout the project management cycle is imperative.

Lastly, the log frames or the objectively verifiable indicators (OVIs) set by UNFPA was too broad to be used for CBI areas, considering that CBI is just a strategy to effect RH Sub Programme. The evaluation must have to be designed based on the specific guidelines made for CBI planning and implementation.