Executive Summary
The Provincial Government of Bulacan [PGB], through its public health arm, the Bulacan Provincial Health Office [PHO], in partnership with the different local government units [LGUs] and their health offices shall implement the 2009 Annual Operations Plan [AOP]. The AOP takes off from the mid-term, 5-year 2009-2013 Bulacan Provincial Investment Plan for Health [PIPH], incorporating learned lessons and strategies in improving the delivery of quality public health care. The AOP PIPH shall continue health sector reform initiatives in the province aimed at further improving the way quality health care is delivered, regulated, financed and governed.
Towards this end, the Bulacan 2009 AOP shall continue to achieve better health outcomes, a more responsive health system attune with the changing conditions of the province and needs of its constituents, and proving equitable health care financing, particularly for the marginalized and poor sectors of the provincial population.
General Description of the AOP
1. Health Situation as of end of 2008
1.1. Rabies Elimination Services
For 2008, Bulacan registered a total of 8,584 animal bites and six [6] cases of human rabies. San Jose del Monte City registered 3,854, Malolos City with 944, Hagonoy with 601 and Marilao with 521 animal bite cases. The province of Bulacan has established animal bite centers in the six [6] district hospitals and at the Bulacan Medical Center to initially assess and provide treatment to animal bite cases. If vaccination was needed, the centers provided the initial doses of active immunization vaccine. Human rabies cases are immediately referred to San Lazaro Hospital in Manila City.
Animal bite cases in the province were primarily due to the neglect of owners to vaccinate their pets with anti-rabies. Moreover, stray dogs continue to proliferate in the streets. More than twenty [20] LGUs have no mechanism to register pet dogs. Due to limited funds, LGUs have inadequate free vaccines for anti-rabies. LGUs did not have adequate resources to impound stray dogs, making children, the youth and old alike vulnerable to dog bites.
The PHO is working hand in hand with the Provincial Agriculture Office [PAO] that has the mandate for dog immunization and has the resources for dog vaccines for immunization. Dog immunization is done by the PAO in coordination with the Municipal Agriculture Offices [MAOs]. These offices also handle health promotion in terms of responsible pet ownership at the level of the community.
LGUs lacked the resources and manpower to enforce existing ordinances on the vaccination of pet dogs in their respective areas. Also, most public health personnel were not trained on Animal Bite Treatment and Management. There was also the problem of delayed management of animal bite cases in 19 municipalities/cities where there is no dog bite center. Referral system for animal bites is weak among health facilities.
Due to the lack of knowledge of the public on rabies, poor families resorted to “tawak” for the treatment and management of rabies. The limited supply and/or expensive anti-rabies vaccines for pre- and post-exposure exacerbated this. Only when symptoms become critical that families sent the victims to the bite centers, making treatment difficult.
1.2. Leprosy Elimination Services
In 2008, Bulacan registered 13 patients afflicted with leprosy located in the municipalities of Angat, Balagtas, Baliuag, Bocaue, Guiguinto, Marilao, San Miguel and Santa Maria, with a prevalence rate of 0.04/10,000 population. While the number of cases is considered low compared to the other provinces in Region III, there is a need to conduct active case finding in the 24 municipalities/cities. Training on leprosy detection, treatment and management needs to be provided to health workers and volunteers at the community levels for case finding.
The poor health seeking behavior of leprosy patients and their families, lack of awareness on the signs and symptoms of the disease and mode of transmission, social stigma associated with the disease, individual preferences for consultation and limited financial resources contributed to the prevalence of leprosy in the affected municipalities/cities of Bulacan.
Treatment for leprosy cases is at no expense on the part of the patient. Drugs and medicines for leprosy cases are provided free by the DOH and are available at the health centers for the whole duration of the treatment course.
1.3. Malaria Control Services
For several years, four [4] municipalities and one [1] city of the province are endemic to malaria. Malaria is seen in the 15 barangays in the four [4] municipalities of Doña Remedios Trinidad, San Miguel, Norzagaray, San Ildefonso and San Jose del Monte City, afflicting the poor upland dwellers, settlers and indigenous peoples of Aetas and Dumagats roaming in the hinterlands of Bulacan.
The Annual Parasite Incidence in 2008 is 30.7 per 100,0000 population, with 30 confirmed cases out of the 766 clinically diagnosed patients. Morbidity rate of malaria was 26.2/100,000 population. Only 96 of the confirmed and clinically diagnosed cases were given treatment due to lack of anti-malaria drugs at the RHUs. In addition, malaria control program is not devolved yet to the LGUs.
The occurrence of malaria cases in these areas was primarily due to the lack of information of community residents and health personnel on malaria transmission, prevention and treatment. Also, upland human settlements and indigenous peoples make it difficult for patients with malaria symptoms to seek attention from medical facilities. More often than not, malaria cases are found among the indigenous peoples belonging to the Dumagat and Aeta tribes. Due to the nomadic character of these tribes, health care providers find it difficult to identify suspects, modes of transmission and control of the vector because of their mobility, culture and practices. Adding up to new malaria cases are “imported” cases from neighboring endemic provinces of Neva Ecija and Zambales. Many cases came from shipyard workers in Zambales.
There is only one [1] medical technologist, out of the five [5] endemic areas, was trained in malaria microscopy. There is a need therefore to identify, train and deploy community health workers to far–flung areas, carrying with them rapid diagnostic test [RDT] kits, collecting smear samples from asymptomatic patients. Vector control materials, e.g., mosquito bed nets and insecticides, are far from the reach of the affected communities. Most often, malaria patients are poor and rarely can afford to purchase untreated mosquito nets, much more treat these with insecticides. Malaria control to be successful in the province must implement the twin strategy of vector control and active case detection and treatment at the local level.
Malaria drugs are provided for by the DOH through the CHD 3. Led by the Bulacan provincial government in partnership with the concerned LGUs, steps must be taken to ensure the availability of anti-malaria drugs to endemic areas through centralized procurement and distribution; promotional activities on the effective and regular use of insecticide-treated bed nets must be conducted in the endemic areas; and the continuous promotion of early diagnosis, management and referral of malaria cases.
2. Intensified Disease Prevention and Control
2.1. Tuberculosis Control Services
TB ranks 5th as the leading cause of mortality and 8th as the leading cause of morbidity. Since 2000 DOTS have been fully implemented in the province’s 57 RHUs. However, provincial performance on case detection rate [CDR] is 63% against the national target of 70% and cure rate of 80% in 2007 compared to national target of 85%. 2008 data shows that ten [10] out of the 24 municipalities/cities have reached the national standard of CDR of 70%. They are Balagtas, Baliuag, Bocaue, Bulacan, Norzagaray, Obando, Plaridel, San Miguel, Doña Remedios Trinidad and San Jose del Monte City. While six [6] have reached the national standard of TB Cure Rate of 85%. They are Balagtas, Bulacan, Meycauayan City, Pulilan, Santa Maria and San Jose del Monte City. Records from the Provincial Health Office reported that for 2008, there were 2,088 sputum+ cases, an increase of 25% from the previous year.
Aware of the increasing cases of TB in the various municipalities and cities in the province, 21 LGUs have put in place policies for the purchase of anti-TB Category III drugs; 20 LGUs have policies on the procurement of drugs for primary complex affecting children; while 18 LGUs have detailed policy [free and user’s fee] on the distribution of anti-TB drugs.
TB continues to afflict the poor and non-poor alike in Bulacan. Some of the causes were preference of TB symptomatic patients to seek medical help from private doctors instead of the more accessible public health system; patients did not immediately seek medical attention due to the social stigma associated with the disease; and the overall poor health-seeking behavior of affected households and communities.
In the recent TB validation, monitoring and evaluation of the TB Control program, there were still quite a number of municipalities belonging to the low quadrant meaning low CDR and low cure rate, and these has been given priority by the province in terms of prevention and control. The municipality of Paombong has been subjected to a provincial initiative called TB Patrol. The implementation of the project has garnered 100% local support both from the municipal and barangay officials and the community as well. The impact of the project resulted to active case finding and treatment of positive cases.
While the TB Patrol program has been successful in the identification, organization, training of community members for the anti-TB program, its reach has been limited to only a number of barangays. The project was seen as a “best practice” and is now being targeted for replication to the other LGUs in the province on a staggered basis. There is a need to expand its coverage to 555 barangays of the province.
Health care providers from the public and private health sectors still need to be trained on the WHO/DOH standards for TB detection, treatment and management; more so for newly-hired public health nurses. In Bulacan, some public hospitals still preferred to use chest x-ray in the diagnosis of TB rather than the standard and accurate sputum examination. Also, there was no standard protocol for the treatment and management of children with TB.
Though a number of capacity building activities had been conducted in TB control, much more has to be done to completely reduce the TB morbidity and mortality in the province. With the fast turnover of health workers, particularly doctors and nurses, there is an immediate need to orient and re-orient health workers in the efficient and effective implementation of the program.
A total of 40 microscopy centers are located in the main RHUs throughout the province and a quality control laboratory at the PHO. Validation of sputum slides is done by the program coordinator, in tandem with a medical technologist at the QC Laboratory in the province.
Based on the recent monitoring and validation of the TB program, it was found out that 15% of microscopy services did not comply with established standards of laboratory procedures. This puts into question sputum examination done by these laboratories. On-board medical technologists from Guiguinto, Paombong, Angat, Bocaue and Norzagaray have to undergo refresher course on laboratory procedures and TB sputum examination. Also, sputum collection area at the RHU facilities needs to be upgraded to conform to NTP standards. This is one factor why only twelve [12] out of the 57 rural health units are TB-DOTS-accredited by the PHIC.
The constant exposure to residues by laborers within the pyrotechnics industry in the province contributed also to TB morbidity and mortality. Around 100,000 individuals are dependent on this industry. These are located in Bocaue, Santa Maria, Baliuag and neighboring municipalities; while the marble industry is located in San Ildefonso, Doña Remedios Trinidad, San Rafael, San Miguel and Norzagaray. Due to the nature of these industries, workers and communities alike are vulnerable to lung-related diseases. Government must encourage companies to provide healthy work environments for its workers.
The role and practice of private physicians in the province as to TB treatment protocol need to be addressed. The incomplete [indigents/poor] and unsupervised treatment practice of TB patients by private physicians have added up to the increase in multi-drug resistance (MDR) among TB patients in the province. Thus, one strategy to resolve this problem is a collaborative effort among private practitioners is through the Public-Private Mixed DOTS (PPMD). The municipalities of San Miguel and Hagonoy had established a PPMD referral system. The TB Diagnostics Committee [TBDC] will have to review referrals and recommend appropriate treatment management for the projected increase in the number of sputum+ patients.
2.2. HIV/AIDS/STD/STI Control Services
With the highly urbanizing character of Bulacan and its proximity to a former military American base [Clark Air Field in Angeles City, Pampanga] and the National Capital Region, there is a strong trend for the commercial sex industry to proliferate in the province, particularly in Bocaue, Marilao, Pulilan, Malolos City, Baliuag, Bustos, Meycauayan City and San Jose del Monte City. These areas are host to a large number of karaoke bars, watering holes, and assorted commercial establishments suspected of employing commercial sex workers [CSWs]. Aware of this situation and as an interim measure, the National STD Program is being vigorously implemented by the different RHUs. The STD program includes regular smearing and treatment of registered and unregistered CSWs. For 2008, total smear examined was 5,485 and 375 cases were treated for gonorrhea and other STDs/STIs. However, a more comprehensive strategy and appropriate approaches need to be developed to respond to the threats posed by HIV/AIDS/STD/STI.
Target municipalities need to conduct rapid risk assessment to map out high-risk groups in their localities. There is a need to establish social hygiene clinics in strategic areas to cater to high-risk groups such as CSWs, men having sex with men [MSM], and the growing number of drug dependents using needles, among others. Regulation in the operation of establishments catering such kind of businesses needs to reach the attention of local officials.
Also, health care providers need to be trained on HIV/AIDS/STD/STI detection, treatment and management protocols. At the provincial level, there is a need to establish a reporting and monitoring mechanism to immediately identify potential HIV/AIDS/STD/STI breakout areas. A technical assistance package on HIV/AIDS/STD/STI prevention program is currently being supported by the national government and implemented in the province of Bulacan. One mechanism being discussed is the formation of the Bulacan HIV/AIDS Council to serve as an advisory board to the province to respond to the growing threat of HIV/AIDS/STD/STI.