Case Study of the Women's Health Care Foundation, Quezon City, Philippines
The Women's Health Care Foundation seeks to expand women's health care services "beyond the womb." Established in 1980, the Foundation works to meet the diverse health needs of Philippine women throughout their life cycle, broadening services beyond the traditional maternal-child health programs to include services for adolescents and postmenopausal women; counseling on sexually transmitted diseases and AIDS; information on breast cancer screening and domestic violence; and information for couples seeking contraception as well as couples seeking counseling on infertility. The Foundation operates three health clinics, plus numerous community outreach programs. In addition, the Foundation is involved in advocacy efforts to promote improved reproductive health rights for women. This case study is the third in a three-part series on women-centered health programs.
The idea for the Women's Health Care Foundation was born from a distinct need. Women in the Philippines had few opportunities to obtain modern health care beyond maternal health care or standard public health services offered during their childbearing years.
The founders of the WHCF began the program with a philosophy that health services should address women's needs throughout the life cycle, from infancy through old age, and that gender perspectives should be incorporated into both program design and service delivery. All women should have access to health services and information; services should not be limited to the time before, during and immediately after pregnancy, or to pregnancy prevention.
Affordability and accessibility were the hallmarks of the WHCF when it was founded in 1980, and they continue to be important elements of the service delivery today. Client fees have been kept low, and staff have been trained to perform multiple tasks to make efficient use of limited resources. The WHCF currently operates three fixed-site clinics in the metropolitan Manila area, plus an extensive outreach program designed to provide information, education and services to women and their families in rural and underserved communities near Manila.
One of the greatest strengths of the WHCF is that when designing and delivering services, staff consider gender dynamics -- the roles prescribed for women and men by society -- as well as women's biological needs. Staff recognize the multiple roles of women and also the need to offer health services that are comprehensive and holistic. For example, the WHCF offers counseling for women who want family planning, as well as for couples who need counseling about infertility; it offers education about STD prevention and treatment; and it provides information on cancer screening and domestic violence. In addition, services are offered for men and for children, with the realization that women often put the health needs of their family members before their own needs.
Because women's health is affected by factors other than physiology -- by family relationships, by living conditions in their home and communities, by political activities -- the WHCF has developed strategies to address women's health from vantage points outside the clinic. WHCF has a strong community outreach program, which includes training of local residents to provide health care information to their neighbors; a political advocacy effort, which includes lobbying for health care reforms that affect women; and networking with nongovernmental organizations and grass-roots groups that have similar interests in women's health and rights. The result is that the WHCF has become not only a point for delivery of a wide array of health services, but a source of health care expertise in the Philippines.
As the WHCF looks toward the future, it will face several challenges: the need to publicize and market its services and programs to gain a larger client base; efforts to make WHCF operations sustainable instead of reliant on grants from donors; and decisions about how many services to provide and to whom.
The WHCF views health care as an essential component of quality of life and offers education, information, and services as tools for women's empowerment. At a time when there is much discussion about how to provide integrated reproductive health programs, the WHCF can serve as an example for others hoping to offer a comprehensive program to address women's diverse health needs.
The front yard of Emerlita Domingo, a community health worker (CHW) in the village of Barangay Putatan, resembles a waiting room at a doctor's office.
Low benches line one side of the small dirt yard where women and young children sit patiently beneath a makeshift canopy of cotton blankets and sheets, the better to protect them from the early afternoon heat of a summer day. At the other end of the yard, a low wooden bed and desk serve as a temporary office, where a nurse and her male assistant preside over pre-consultation procedures, such as weight and blood pressure measurement and preliminary interviews with patients. Two women, one of them a medical technologist and the other the head of the training program for community health workers, take charge of collecting the patients' donations and payments for the medicines, which are dispensed from a nylon bag.
The doctor has set up her office in Emerlita's living room. Dr. Myrna Hernandez interviews and examines the patients, then after each consultation, shouts out the name of the next patient. At times, neighbors must rush out of the yard to summon a patient who has gone home.
Once a week, the staff of the Bahay Pangkalusugan para sa Kababaihan at Pamilya (Home of Health for Women and the Family), one of three Women's Health Care Foundation clinics, visit a depressed neighborhood in Emerlita's hometown of Muntinlupa, located at the southern end of Metro Manila. Staff also visit the neighboring town of Alabang, and in both locations, provide medical and health services as part of the WHCF outreach program. Responsibility for preparing the site and informing the residents about the WHCF visit lies with the CHWs, neighborhood women who have undergone training with the Foundation and volunteer their services, receiving no remuneration except transportation and meal allowances.
"These visits are important for the people in the neighborhood," says Emerlita, who, in addition to being a CHW since 1992, also works as a day-care teacher at the town hall. Though they can receive free consultations and medicines at the government-run health center in the town hall, Emerlita says, many residents in this neighborhood of shanties and semi-concrete houses cannot afford even the minimal expense of a jeepney* ride to and from the town center. Besides, with no household help, the mothers, many of whom work in nearby factories or as laundry women, find it difficult to leave home or find child care when they go to government health centers.
At Barangay Putatan, an older woman arrived at Emerlita's house with another woman, who was carrying a one-year-old girl in her arms. The girl, her daughter, had suffered from rashes and a high fever for a week. "I passed by her place because I had heard about her daughter's illness," explains the older woman. "So when I was told the doctor was here, I convinced her to bring the child for a consultation." Dr. Hernandez diagnosed the child's illness as rubella.
Through the outreach clinics, women can obtain medicine -- most of it antibiotics and cough and cold preparations in response to the most common complaints of patients -- at nearly half the price charged by the largest, most popular drug store chain in the country. A nominal donation of 10 pesos (less than U.S. 50 cents) is requested from each patient who visits the outreach clinic, but many times the people who come for consultation are too poor to pay. At the end of the afternoon, after providing consultations to more than 20 patients, the team finds that only one patient has bought medicine from them. The rest said they did not have enough money.
__________________________________ * A jeepney, an elongated jeep, is an inexpensive means of transportation in the philippines metropolitan areas.
To understand the work of the Women's Health Care Foundation, it is first necessary to understand the context of women's health in the Philippines. Until recently, women's health concerns were thought to be adequately served by maternal and child health (MCH) programs. Increasingly, however, women's advocates have emphasized that MCH programs do not meet women's total health needs. Danguilan and Verzosa1 assert that looking at women solely in terms of motherhood tends to ignore the premise that women have a right to good health, no matter what their maternal status, and that health is an important, indispensable value by itself.
The MCH approach does not take into account the health needs of women who are not pregnant, nor does it accommodate women's changing needs throughout their life cycle. Limiting women's health services to maternal and child care means numerous gaps in the provision of comprehensive health care for women and girls. For example:
Health of the girl child. Across cultures, women's health problems begin in infancy. Young girls may be subject to inequities in the distribution of household resources (food, clothing, education, leisure activities) and responsibilities (such as care for siblings).2
Adolescent health. In the Philippines, chastity before marriage is highly valued. On average, the first sexual experience occurs at the age of 18 for both sexes,3 with 23 as the median age of first birth for Filipino women. However, one in every 15 teenagers is a mother or pregnant with her first child.
STDs. Sexually transmitted diseases (STDs), including HIV, are a great threat to women's health, putting them at risk for infertility, AIDS and, possibly, reproductive cancers. However, in the Philippines, men are seen as victims of STDs and women as the carriers. The euphemism for STDs is sakit ng babae, a disease caused by a woman.
HIV and AIDS. In the Philippines, the highest percentage of HIV infections occurs among young women. Twenty-five percent of HIV infections are in the 20 to 29 age group for women and 20 percent in the 30 to 39 group for men.4 The most common mode of transmission is heterosexual intercourse, accounting for 51 percent of all cases of HIV infection. As of September 1996, a total of 821 HIV cases were reported. The Department of Health estimates there are about one hundred infections for each identified case.
Violence. For many women and girls, violence is a routine part of life. According to the national Safe Motherhood Survey (SMS), one in 10 respondents said she had been physically harmed by someone close to her; about one-third also reported being harmed during pregnancy. A survey5 among males in Metro Manila revealed that one in every five married men admitted to beating their wives. Police statistics, widely viewed as conservative, show that while the incidence of all other index crimes has fallen, "crimes against chastity" (mainly rape) have risen. More than 60 percent of SMS respondents who said they were ever raped did not tell anyone or try to seek help to deal with the aftermath of the assault.
Abortion. Induced abortion is illegal in the Philippines, where Roman Catholicism is the dominant religion. However, many women still have abortions, which are usually performed in secret, often under unsanitary conditions and without proper medical care, posing a threat to women's lives and health. A 1993 study of 1,169 women in Metro Manila, conducted by the University of the Philippines Population Institute, found that 4 percent experienced induced abortions and 12 percent reported induced menstruations. Among the reasons women gave for resorting to abortion were economic difficulties; problems with the husband/partner; too many children in the family; not being ready to bear a child; and planned/scheduled travel abroad (for example, to work as an overseas contract worker).
Family planning. "Unmet need" for contraceptive services appears to be a concern in the Philippines. According to the National Demographic Survey (NDS), nearly 63 percent of married Filipino women do not want to have additional children, and 19 percent want to delay their next birth for at least two years. Yet, while more than 90 percent of women knew of at least one modern method of contraception, at the time of the survey only 40 percent were using contraception. One in four used a modern method, while one in six used traditional methods, including withdrawal. Female sterilization and oral contraceptives were the most widely used contraceptive methods, but there were more users of natural family planning (NFP) and withdrawal than users of other modern contraceptives, such as the intrauterine device (IUD), injectables and the condom. Only 3 percent of couples used condoms, and very few men were sterilized. The 40 percent contraceptive prevalence rate (CPR) in the Philippines is lower than that of many of its Southeast Asian neighbors.
Of those who start using a family planning method, one in three discontinued during the first year, NDS data showed. Discontinuation rates were highest for the condom (59 percent), followed by withdrawal (41 percent), and the pill (40 percent). Side effects and health concerns were cited as the main causes for discontinuing the pill. Other reasons were: desire for a more effective method; inaccessibility or inconvenience; the expense involved; and personal attitudes, such as husband's disapproval or the respondent's fatalism. Discontinuation of withdrawal, NFP and condoms can be attributed to high failure rates. One in five withdrawal users and one in seven couples who used condoms and NFP reported a pregnancy within a year of starting the methods.
Aging. The elderly, a group in which there are many more women than men, are more vulnerable to anemia, with rates even higher than those noted among pregnant and lactating women.
Maternal health. Ironically, in spite of the focus on maternal health, the act of bearing children still puts many Filipino women at risk for illness and death. From 1940 to 1990, there was a considerable -- indeed dramatic -- decline in maternal mortality rates, from 6.3 deaths to 0.8 deaths per 1,000 live births.6 But current statistics show even this low rate means that five to six Filipino women die of pregnancy-related causes every day. The leading causes of maternal mortality are postpartum hemorrhage, hypertension during pregnancy and childbirth, and complications from abortion.
A major health concern related to motherhood is anemia, which makes women more vulnerable to pregnancy complications and puts them at higher risk of having low-birth weight babies. Although the incidence of anemia has been decreasing in the Philippines, its prevalence is still high among infants (49.2 percent) and pregnant and lactating women (44 and 43 percent, respectively).7
To mark its sixteenth year, the WHCF planned an unusual event for a health clinic -- a rock concert. The anniversary celebration, which highlighted the needs of adolescents, combined performances by rock bands with games and speeches about health. This rather unorthodox observance was prompted by a comment from the teenage daughter of the WHCF's associate executive director. She warned her mother that "no one would come" if young people thought they would be listening to nothing but lectures. The event, which marked the beginning of a year-long WHCF effort to highlight reproductive health, was billed as Kamalayan (Awareness) and ultimately drew a respectably-sized crowd of college and high school students.
For the WHCF's fifteenth anniversary, the celebration focused on women at the other end of the age spectrum. "The Woman Beyond the Reproductive Years" provided information on the health needs of postmenopausal women.
These anniversary celebrations illustrate not only the diversity of the WHCF clients, but also the WHCF's dedication to its founding principle: the concept that women's health must be expanded to include all aspects of the life cycle, from birth to death. WHCF's programs and activities today remain centered on this principle and aim to provide access to quality health services and information in ways that are affordable, safe, acceptable, comprehensive, and gender-sensitive.
"WHCF and other women's organizations realized that when talking about women's health, the issues go beyond the womb," says Dr. Tadiar. "You have to give women choices at every stage of the life cycle. It should not just be what the provider wants."
The WHCF began in 1980. A group of physicians, lawyers, business people and researchers -- all dissatisfied with existing health services for women that focused heavily on MCH and family planning -- designed their own health care service.
The guiding principle set by the founders of WHCF was that "women, regardless of age, socioeconomic status, political, religious or other inclinations have the right to quality health care which is accessible, affordable, available, comprehensive and appropriate."8 WHCF sought to provide "health services that will enable women to realize this right, and information that will help them to make proper decisions about their health care."
Today, the WHCF defines its primary goals as: (1) improvement of women's health and the provision of quality, comprehensive reproductive health care and other related services; and, (2) promotion of correct and adequate information, education, and training services to the general population, particularly to women.
WHCF founders viewed health care as a right necessary to ensure quality of life. The WHCF's concept of how its clinics would operate and which services they would provide was shaped by founders' vision of an ideal health environment for women. In this ideal world, women would enjoy good health -- physical, mental, emotional, social and spiritual -- from birth to death; would be respected and treated with dignity; and would be able to obtain adequate and correct information on reproductive and sexual health.
With this vision in mind, the WHCF developed a list of objectives that included health service delivery, advocacy and outreach:
to establish and effectively operate quality and affordable clinical and laboratory facilities that respond to reproductive health needs of women -- particularly the disadvantaged -- their partners and their children;
to conduct information and motivational activities among women and men to enable them to understand their reproductive health rights and responsibilities and to enable them to make decisions about their health;
to undertake advocacy efforts to help policy-makers, health professionals and other groups improve the quality of reproductive health care;
to participate in research and evaluation studies on women, their health, and their health problems; and,
to establish working relationships with local and international organizations, agencies and individuals who could help promote WHCF's goals.
With initial funding from the Population Crisis Committee, through the International Women's Health Coalition (IWHC), the WHCF established three clinics in different locations in Metro Manila. The aim was to make services available to people who were not served or were underserved by existing medical facilities.
In the Sampaloc-Quiapo area of Manila, in the heart of what is known locally as the "university belt," a clinic was established to cater to young women, particularly students. A second clinic in the "tourist belt" was established among the nightspots in the Ermita-Malate area and was meant to draw a clientele from the entertainment and sex worker industry. A third clinic was established in Cubao, a busy commercial district in Quezon City. The Cubao clinic provided services to walk-in clients, including office employees, saleswomen, and waitresses working in nearby businesses.
One of the WHCF's primary goals is that health care be affordable and accessible.
Since it began offering services, the WHCF has kept its client fees low, and a fee schedule based on ability to pay has been implemented, so that poor women and students can obtain health services. To minimize costs, the WHCF leased inexpensive office space. Doctors were hired on a part-time basis, while full-time staff were trained to perform multiple tasks. In time, nurses and midwives became competent in taking medical histories; providing prenatal and postnatal care; offering family planning information and methods, including insertion of intrauterine devices; and conducting simple laboratory procedures, such as gram staining and pregnancy tests. Today, each WHCF clinic is staffed by at least one nurse, one midwife, one lab technician, and a consulting physician. Apart from the doctor, all staff continue to share tasks and assume the duties of other staff members when the need arises.
To increase accessibility to services, the WHCF developed several strategies. In the early years, the clinics were open from 8 a.m. to 6 p.m. or later, "long after government health facilities were closed," says Dr. Tadiar, who became WHCF executive director in 1980. The clinics also were open on Saturdays, when government health centers were not, to serve women who worked away from home full-time during the week.
The services initially offered by the WHCF focused narrowly on women's health concerns: obstetrics and gynecological consultations and care, including family planning, for all women, regardless of age or marital status. The clinics also performed laboratory tests and offered premarital and marital counseling, as well as counseling for adolescents. Staff referred patients to medical specialists and to other services, such as legal aid offices, crisis centers, and psychosocial counseling.
WHCF's non-discriminatory policies were an important step in increasing women's access to health care; government health services were biased toward married women of reproductive age (regardless of official policy statements),9 and there were -- and are still -- great cultural constraints on young and single Filipino women seeking family planning advice and services.
In 1986, direct funding for the WHCF clinics ran out, necessitating cost-cutting measures, including the closure of the Sampaloc and Ermita clinics and the retrenchment of some staff. Dr. Tadiar calls this WHCF's "period of crisis," and the Foundation survived by maintaining a lean operation and cutting its hours of service. Later, Dr. Tadiar and the WHCF board managed to raise additional funds from international agencies, but much of this money is targeted to specific projects.
In spite of the financial strains, the WHCF was later able to open two clinics in addition to the Cubao facility: one at the Foundation's headquarters on Quezon Avenue and another in Alabang, in Muntinlupa town.
The Quezon Avenue and Cubao clinics are located in areas where business and commercial establishments abound and where inexpensive night spots operate. The Quezon Avenue clinic serves employees from nearby offices, plus college and university students. Its clients include a number of men seeking physical examinations to work overseas. The Quezon clinic also is a referral point for other NGOs and grass-roots urban community organizations in the surrounding area. Approximately 300 clients visit the clinic each quarter.
The Alabang clinic is located in Muntinlupa, a suburban area on the outskirts Makati City, a business district, where the urban poor and less privileged live in almost rural communities. Established in 1991, this clinic serves as a base for an outreach and information services program funded by the United Nations Population Fund (UNFPA). In the six years the clinic has been open, its outreach programs have served approximately 400 to 500 clients quarterly, while visits to the clinic itself number about 100 per quarter.
The clinic in Cubao draws the most clients. Like the Quezon Avenue and Muntinlupa clinics, the Cubao facility is a modest establishment with a small reception area, an even smaller laboratory, and a screened-off examination room. On the walls are posters on women's health issues and general health information. The clinic is located less than a block down the main avenue of the commercial district, a fact that may explain the large number of walk-in clients.
At the Cubao Clinic, established in 1980, clients are usually employees from surrounding businesses. Most are working, middle-class women. Since this clinic was WHCF's first clinic, its number of clients is larger than the other two clinics. An average of 350 clients visit the Cubao Clinic quarterly.
At present, the WHCF staff consists of four full-time and three part-time physicians, plus 15 full-time paramedical personnel, including nurses, technicians and midwives. Recently, the organization hired two male nurses to better meet the reproductive health needs of men.
All of WHCF's clinics and outreach efforts can provide physical examinations and basic laboratory services, such as pregnancy tests, semen analysis, and blood tests. In addition, the clinics provide information and counseling about family planning methods, including natural methods, hormonal contraceptives, IUDs and barrier methods; menstrual and menopausal problems; and reproductive tract infections and STDs. Clinics provide prenatal and postnatal care. The Quezon Avenue clinic has facilities for births, and clinic staff attend home births as well.
The vision of WHCF founders was that clinics would be staffed by individuals who were sensitive to the specific needs and problems of women and who would respond to these needs from a woman's viewpoint. In addition to training in technical skills, WHCF staff underwent orientation on the goals and philosophy of a women's clinic, including training on women-oriented counseling in reproductive health care and other health issues.
Early in WHCF's existence, the board realized that the clinics alone could not reach a significant number of women. Board members felt "that many women needed to be reached in the places where they lived and worked," Dr. Tadiar says. Working with communities and in communities continues to be an important component of WHCF's efforts to increase women's access to health care.
"It was decided that the clinics should not just wait for clients," Dr. Tadiar says. "The staff needed to reach residents around the clinics," not just to inform potential clientele about the clinic's services, but also to provide local residents with information and training in basic and reproductive health care.
WHCF conducted outreach clinics -- weekly field visits by teams of health care personnel and community health workers, who provided basic health consultation and services to poor communities. Small group discussions on reproductive health issues and training of community health workers became part of the outreach program. Staff members visited homes to promote clinic services and to conduct seminars on responsible parenthood, family planning, sexually transmitted diseases and other topics. To increase clientele, WHCF encouraged women to bring their menfolk and children to the clinics.
Currently, WHCF operates four outreach clinics: in communities in Muntinlupa; in Olongapo, the site of a former United States Naval base, which still attracts a large population of sex industry workers; at the YWCA building in Diliman for urban poor communities; and the latest, in Angeles City, another site of a former U.S. military base with a busy "entertainment strip" that caters to local and foreign tourists. At the request of civic and religious groups, the WHCF also conducts clinics and seminars on reproductive health and rights in areas outside of Metro Manila.
During medical consultations in community settings, clinic staff teach women about proper health care for themselves and their children. Those with more complicated health and legal problems are referred to health facilities, specialists, legal aid offices, counseling centers and shelters.
An important part of WHCF's community relations is the training of local women as health workers. In interviews, these community health workers said they felt their training and work had given them added status and prestige among their neighbors. They were looked upon as authorities and experts in their own right. In addition, community health work may have given some women a sense of self-esteem. Said one worker, a woman with a fifth grade education, "Now I am not afraid to talk with people."
The work of CHWs is largely voluntary, though they receive a transportation allowance both during their training and when an outreach program is taking place in their communities. The CHWs undertake all the preparatory work prior to an outreach project, including surveying the health needs of the community, informing neighbors about the health team's visit, and setting up the site of the "clinic."
The WHCF has identified residents who enjoy a position of respect and a reputation for integrity among their neighbors to work as community-based distributors of contraceptives, such as pills and condoms. Hormonal methods are sold only to replenish the supplies of acceptors who have previously consulted with medical personnel. The contraceptives are sold to distributors at cost, and CHWs are allowed to add on a few pesos for profit.
Recently, WHCF started recruiting street vendors as community-based distributors. The vendors, who work in the same areas as sex industry workers, also have been trained as safe sex motivators. The program is based on the assumption that the vendors, who peddle newspapers, fast food, cigarettes, sampaguita (garlands of sweet-smelling blooms) and other items, can be effective salespeople, as well as sources of information on fertility management and prevention of STDs, including HIV/AIDS.
One way that WHCF staff learn what services community residents need is by simply asking them. As part of the UNFPA-funded project launched in 1991, field staff conduct small group discussions where women and youth (both young men and young women) are asked to talk about their reproductive health needs and problems. Staff ask residents about their ideas on such topics as pregnancy, family planning, sexually transmitted diseases, menopause, and abortion. Seminars are later organized, where myths and misconceptions that surfaced during the discussions are addressed and corrected.
In evaluating women's health, the WHCF realized that one of women's greatest needs was for accurate information. Without facts, women could not behave responsibly and knowledgeably regarding their reproductive health. Word-of-mouth advice was replete with claims about the health risks of contraceptive methods, which frightened women not only from using specific methods, but from fertility management altogether. And even when women had already become family planning acceptors, they would discontinue using methods because "they [do] not have skills in making proper decisions or are not motivated to continue," Dr. Tadiar says.
With regard to other health needs, Filipino women are not usually inclined to seek health care for themselves. They are accustomed to putting the needs of husbands and children first. And with very little information on their own health needs, apart from scant information on reproductive physiology, women are not equipped to recognize any health problems that arise or to know where and from whom to seek treatment.
To help meet women's need for accurate health information, the WHCF established the Institute for Social Studies and Action (ISSA) in 1983. The Institute provided information, training and research activities, with staff from both institutions working cooperatively, initially under one executive director and board. ISSA received support from the Ford Foundation to conduct information, education and communications (IEC) activities and advocacy work. The WHCF offered staff development. At Dr. Tadiar's direction, ISSA became a separate organization, but both ISSA and the WHCF maintain a close relationship and engage in joint advocacy campaigns.
For example, the WHCF and ISSA have conducted educational efforts to train female police officers to work with women who are battered by their husbands. Additionally, the WHCF and ISSA have worked with women who operate small stores from their homes. The stores sell rice, biscuits and other foods -- and barrier contraceptives -- to neighbors.
In providing services for women and their families, the WHCF staff realized that while one organization might have an important impact on women's health, several organizations working together could have an even greater effect.
Building solidarity -- through collaborative efforts with women's groups and women's health advocacy organizations -- has been an important component of WHCF's work.
Referrals from women's groups account for a significant portion of the clinics' clientele, while some of these groups have contracted with WHCF to perform annual physical examinations of their staff. In turn, the WHCF taps these organizations for services, not only for clients, but also for staff, including training in feminist counseling.
An example is the outreach clinic in Angeles City, established in cooperation with the Women's Education, Development, Productivity and Research Organization (WEDPRO), a nongovernmental organization that has conducted in-depth studies and projects with women in the sex industry. WHCF also has worked with WEDPRO's organized community group, Nagkakaisang Kababaihan ng Angeles City (United Women of Angeles City).
WHCF's collaborative efforts extend to partnerships with local businesses. The Foundation obtained sponsorships from businesses to subsidize prenatal care, normal delivery (at home or in the clinic), and postnatal care. WHCF staff have approached the business community about educational/training workshops for employees on a variety of topics, such as fertility management; sexually transmitted diseases, including HIV/AIDS; reproductive tract infections; reproductive health; and reproductive rights. For employees who complete the series of lectures offered by WHCF, discounts on clinic services are offered.
"Many department stores and factories, whose general or personnel managers became convinced of the need for reproductive health information among the employees, accepted this opportunity for an hour or two during lunch or coffee breaks, or before the store was opened to the public," Dr. Tadiar says. "Some companies even asked for Pap smears and other procedures to be done on their premises."
When WHCF was founded in 1980, it was isolated even within the Philippine women's movement since few, if any, other organizations chose women's health as a focus for advocacy or action. However , this changed in 1986 as a new Philippine Constitution was drafted.
At that time, the WHCF, together with ISSA, implemented a strategy for advocacy: personal distribution of published materials on reproductive rights to Constitutional commissioners. Subsequently, WHCF staff began writing letters to newspapers; conducting seminars and workshops on women's rights and health issues; appearing on radio and television programs; participating in panel discussions, press conferences or Congressional public hearings; and granting interviews for publications.
In 1987, pro-choice advocates obtained a copy of a draft executive order, to be signed by then-President Corazon Aquino as part of her "revolutionary" power, which was to make illegal the use, dispensation and distribution of all forms of artificial contraception. Only natural family planning would be promoted by the government, and funding to NGOs involved in contraceptive distribution and sterilization was to be terminated. It was later learned that the order was drafted by conservative elements of the Catholic Church and had the enthusiastic support of the Social Welfare Secretary, who at that time exercised administrative control over the Commission on Population.
WHCF and ISSA called a meeting of women's groups with whom they had worked successfully to get a "gender equality" provision in the new Constitution, and together they launched a lobbying and public information campaign protesting the planned executive order. Although President Aquino never signed the executive order, the women's groups felt the need to continue monitoring government policy on women's health issues and working for changes in policies and programs to make them more responsive to women's needs and concerns.
The formal outcome was the creation of a new organization, WomanHealth Philippines. Its aim was to promote the Filipino woman's right to health and reproductive freedom. WomanHealth served as secretariat during the First National Convention of Health NGOs, sponsored by the Department of Health with funding from Japanese sources. Dr. Tadiar, representing the WHCF and ISSA, was chosen as chair of the organizing committee. For the first time, women's health and rights emerged as a major plank in the platform of the women's movement in the Philippines.
WHCF has since gone on to "mother" other alliances among family planning organizations, women's health advocates, legislative lobbying groups and HIV/AIDS support networks. Among the organizations that have emerged from collaborative efforts between WHCF and other NGOs are: the Philippine NGO Council for Health and Welfare; KALAKASAN, organized to counter domestic violence; the Alliance for Women's Health, Bukluran Para Sa Kalusugan ng Sambayanan (BUKAS); and Women's Vote for Family Planning. These groups worked together to prepare and later monitor the Programs of Action from the International Conference on Population and Development in Cairo and the Fourth World Conference on Women in Beijing.
Because of her activities in these organizations, Dr. Tadiar has emerged as a prominent spokesperson for the women's health movement and is recognized as an authority in the field of women's health, representing the NGO sector in various international conferences, often at the invitation of government, and testifying before legislative committees. WHCF has built an international network of supporters and allies. It has established close relations with USAID, UNFPA, UNICEF, Ford Foundation, Margaret Sanger International, Johns Hopkins University/Center for Communication Programs and FHI.
WHCF also has worked with government agencies, such as the Department of Health, the Department of Science and Technology, the Department of Social Welfare, and the Department of Labor and Employment, which have tapped WHCF staff as resource speakers and consultants.
WHCF has played a pivotal role in emphasizing health rights as an important component of women's rights. The organization's pioneering work to involve women's groups in the public debate over health issues, particularly the issue of reproductive health, has been especially valuable. Attacks on reproductive rights have been launched by conservative elements in the Catholic Church, who wield a disproportionate influence over policy-makers and program implementers. Through WHCF and ISSA's efforts, women have found a voice and expressed their viewpoints in this debate.
Since it was founded 17 years ago, the WHCF clinics have served approximately 35,000 clients. Many are married women, employed, with at least a high school education. A significant number are young single students, overseas contract workers, or professionals. A majority of the clients for clinic-based services comes from the middle-class (either walk-in clients or referrals from former clients), women's organizations (including crisis centers and shelters) and other NGOs.
Interviews with clinic staff reveal that the demand for WHCF services has gone beyond women's reproductive health needs. At the clinics, but especially in outreach services, staff find themselves treating a wide range of simple health problems, especially common childhood diseases such as measles, chicken pox, diarrhea and respiratory tract infections. "When we send out a call for women," confided a community health worker, "the women always come with their children in their arms. You cannot treat the women without treating their children."
Health care for children can be a means to introduce and educate women about their own health care needs, says Dr. Tadiar. "A lot of women will not go to a health clinic. Family planning is not a priority in their lives. Survival is. When they come for the children and their spouses, that's when you bring up the subject of family planning."
The WHCF has helped improve women's access to reproductive health services in the Philippines. Established to bridge the gap between the services that were offered and the services women needed, WHCF considers the "whole" woman in its service delivery plan, thereby ensuring that reproductive health is more broadly defined than maternal health and family planning.
In retrospect, the strengths of the organization can be attributed to the following factors:
The WHCF focused on one area -- health information and services -- then expanded services within that domain.
Because women's health is affected by the political environment in which they live, the WHCF made advocacy a part of its work.
WHCF built a strong network of support, including support among NGOs and other organizations that shared an interest in women's health and welfare.
WHCF made a commitment to continually improve its staff's technical and management skills, as well as staff awareness of gender issues.
In the WHCF, health is not narrowly defined as a state of physical well-being but also a state of emotional and mental well-being. Consequently, a variety of services are provided to women, as well as their family members (for example, immunizations for children). And women are referred to other social service agencies for problems that fall outside the scope of WHCF services (for example, domestic violence).
While WHCF has taken a lead role in advocacy and lobbying efforts for women's health, it has not publicized its work or advertised its services. The clinics rely mainly on walk-in clients or referrals, expanding the service area through outreach efforts in depressed communities or to sectors historically underserved by health service providers.
Promotion is done mainly through small street signs and paid notices in telephone directories and newsletters. The WHCF has no budget for advertising or public relations, though it regularly distributes a newsletter and related publications. An important venue for promotion is special events, such as the annual celebration of International Women's Day, which WHCF marks by providing medical services, including Pap smears and breast exams, for free or for a nominal fee. During its anniversary, WHCF also hosts a symposium, preceded by a month-long program of outreach services, usually targeted to underserved sectors, such as postmenopausal women and adolescents.
WHCF's difficulties in promoting its clinic-based and other services to wider clientele have impeded future growth of its programs. A limited clientele means its independent income, which is used for operations, remains negligible and necessitates the Foundation's continued reliance on project-based funds from mostly foreign sources.
At the same time, there is a real and potentially lucrative demand for the services provided by the clinics. The Philippine health situation is such that people in need of treatment have a choice between two extremes: (1) free or very low-cost services from government-run centers and hospitals, often struggling to balance available personnel and facilities with a large patient volume; and, (2) expensive private services, often from tertiary institutions, that are not particularly geared to women's health needs. Clinics such as those of WHCF can assure women safe, professional and compassionate care at reasonable cost -- if only more women were aware of them.
WHCF should give serious thought to a promotional drive that would not only tell the public about its services, but also educate them on health issues. There have been a number of successful public education campaigns on such issues as domestic violence, incest and women's empowerment, which were crafted with the help of advertising agencies, production houses and media, who consider it part of their pro bono work. Perhaps WHCF can conceive a campaign on women's health along these lines.
Sustainability
As stated earlier, the fees earned by the individual WHCF clinics are not enough to sustain their operations. Though in existence for 17 years, WHCF remains dependent on grants from funding institutions, linked to specific projects. This means that any new money granted to the Foundation also carries with it additional work for WHCF staff, in addition to the services already provided by the clinic. Project-based funds are also limited in coverage, and thus a service begun by the clinics may need to cease after three to four years, the normal cycle of most grants. It is difficult to earn the loyalty of clients if services are erratic.
Focus
Though its mandate continues to be to make information and clinical services available and accessible to women across all ages, economic and social classes and social status, the WHCF has found itself expanding this mandate to include the health needs of men and children as well.
This is largely because the health infrastructure in the Philippines as a whole remains inadequate. While most municipal public health centers are no more than a ride away by public transport, for numerous reasons, they remain inaccessible to many people. As one of the few organizations that provide health care to inaccessible and underserved communities on a regular basis, WHCF finds itself trying to meet the health needs of entire families and demands for a wide variety of services. Given its own limitations of personnel and facilities, this cannot but detract from its original focus on women's health concerns.
It is difficult, however, to discern where -- and whether -- health workers should draw the line between their women clients and the other family members with them, especially their children. It is also doubtful if women will continue to come to the clinics if they cannot be assured that other family members will receive treatment and advice as well. At least, it brings the women to the clinics (or to the health team), where they can be reached and served. This remains a difficult dilemma.
Even within the domain of women's health, the WHCF has been called upon to provide many individual services (family planning, maternal and child health care, STD prevention and treatment, and physical examinations). Maintaining an array of high quality services with a small staff and a relatively low number of clients presents a technical challenge.
WHCF fills a unique niche in health care services in the Philippines. Its clinics and outreach programs provide much-needed services that are affordable, accessible and gender-sensitive. Yet, in spite of the value of its work, the WHCF continues to wrestle with issues of balance: how to keep client fees low but sustain services; how to maintain a focus on women, but address the health needs of those close to women -- their children and partners; and how to promote services to a wider clientele with a limited budget.
A key component of the WHCF's work has been the provision of not only health services, but also health information. The WHCF has provided: information to women, to empower them to improve their health; information and training for health providers, to enable them to strengthen their technical competency and their awareness of gender issues; information to women's advocates and grass-roots organizations, allowing them to build a solid network of support for women's rights; and information for policy-makers to encourage them to adopt laws and policies that meet women's needs.
Through its work, the WHCF offers lessons to others in health programs. It has strengthened health care services to women in the Quezon City area and expanded women's access not only to services, but also to information about reproductive health. In addition, advocacy efforts have raised awareness of women's health issues among policy-makers, government officials and NGOs. Because of its diverse activities, the Women's Health Care Foundation has improved the quality of women's health and the quality of women's lives in the Philippines.
-- Rina Jimenez-David and -- Dr. Florence M. Tadiar
Seven board members; officers are chairperson, corporate secretary, treasurer and assistant treasurer
Acts as the highest policy-making body; approves all contracts entered into by the Foundation; determines investment areas for WHCF funds; confirms personnel appointments, hiring and firing; gives advice and support to the organization.
Management
Executive director and the associate executive director (AED)
The executive director acts as the chief executive officer of the Foundation and is assisted by the AED for the day-to-day operations. Responsible for planning, monitoring, evaluation and organizing, financial and administrative controls. Leads in advocacy and networking activities.
Health service and health education providers
(There are four teams within WHCF organized in this manner: one for each clinic and one for the outreach activities.)
Physician/clinic manager nurse
-- Midwife
-- Medical technician
-- Health educator
Note: A medical director oversees the quality of care being provided by the clinics.
Delivers reproductive health services to clients; conducts IEC activities and training programs; participates in advocacy activities and research projects.
Administrative and support services
Finance officer
-- Bookkeeper
-- Administrative assistant
-- Personnel
-- Maintenance
-- Utility
-- Publications
-- Transportation
Purchasing/delivery of supplies and materials; equipment and facility maintenance; personnel matters -- appointments, payroll, leaves, benefits, etc.; data/statistical information collation and reporting; advocacy activities.
(NOTE: WHCF clinics are expected to be bright, free from clutter and clean with comfortable places to sit. The arrangement within the clinics assures as much as possible the comfort and privacy of clients. IEC materials on contraceptive methods, STDs and HIV/AIDS are available. Outreach clinics are usually conducted in people's houses or in community halls. IEC activities are conducted while clients wait for medical services.)
Nurse/Midwife
Greets client. Offers a seat. Introduces self and asks client's name.
Inquires about client's needs or problems. Answers noted on clinic information sheet.
Takes client history (physical illnesses, family planning, past obstetrical and gynecological health).
Brings client to doctor's office. Introduces client to physician on duty.
Physician
Greets client. Offers a seat and ensures patient's privacy. Introduces self.
Asks patient's complaints, problems or needs and re-checks/adds to patient's data, history and vital signs.
Does a complete physical exam from head to toe, including breast exam. Teaches patient to perform self breast exam. Where indicated (i.e., obstetric/gynecologic clients), performs an internal examination. Explains to the client the purpose of the exam and what to expect during the exam.
If laboratory examination/s is needed, writes down request and sends client with request to the medical technologist.
Lab Personnel
Greets client. Introduces self.
Reiterates the type of lab exam to be done and explains the procedures for the examination. Asks the client additional information needed to perform exam.
Instructs client about what is needed from him/her. Asks client to go to reception room while waiting for results.
Does the laboratory examination. Writes down results of examination and makes the report to the doctor.
Physician
Talks to patient regarding lab exam result, illness, describes the method of treatment.
Explains medications to be taken, indication, dosage and adverse reactions. Explores other client needs, such as family planning, counseling, referrals. For new FP clients, counsels about various contraceptive methods, advantages and disadvantages, or asks nurse/midwife to counsel. Respects client choice.
Schedules follow-up visit.
Refers client back to nurse or midwife.
Nurse/Midwife
Explains treatment again. Explains again medications to be taken, including dosage. Inquires whether all the concerns and needs have been addressed.
Reiterates follow-up visit and logs it in appointment book. Gives client a card noting next appointment time.
Makes the appropriate charges for services, medicines, or procedures. Receives payment and issues an official receipt to the client.
Following are profiles of three WHCF clients. Clients' real names are not used to protect their privacy.
Mrs. Mariano, a homemaker, lives with her family in Quezon City, in the Payatas B, a slum area in and around one of the biggest garbage dumpsites in the country. Her family, including the children who are old enough to work, make a living by scavenging through the trash for scraps of metal, bottles, and other items that they can sell for change at junk shops. Mrs. Mariano is only 38 years old, but she has already given birth to five children and would have conceived her sixth had she not heard of the nearby WHCF outreach clinic. Her numerous pregnancies and her responsibilities for taking care of her children, who range in age from nine years to 18 months old, have left her weak and fatigued.
During one of the small group discussions held by the WHCF staff, Mrs. Mariano and other women learned that they have a choice about family size and birth spacing. It took a lot of work to persuade her husband that it was not a sin to use artificial contraception, but Mrs. Mariano was able to convince him. She and her husband chose to use pills and condoms.
Today, Mrs. Mariano has a new-found self-esteem. She does not dread an unplanned pregnancy. She and her husband now understand that births can be a matter of choice, not chance.
Miss De Mesa is a student completing her last two years of law school. She and her boyfriend have been together for six years and have relied on natural family planning methods, particularly withdrawal and rhythm. Twice she has missed her menstrual period and feared that she might become pregnant before she graduates. Fortunately, Miss De Mesa's pregnancy tests have been negative.
At 26, Miss De Mesa -- intelligent, self-reliant, and an advocate of women's rights -- feels that the fear of getting pregnant keeps her from enjoying her sexuality and exercising her sexual rights. Although Miss De Mesa is an educated woman, her knowledge of family planning is very limited. Attending one of WHCF's reproductive health lecture series not only gave Miss De Mesa information about family planning, it also gave her access to counselors, who eventually helped her answer questions on sexuality, gender awareness, and other issues. She understands that she has choices about contraceptives and can choose the one that is most suited to her lifestyle.
Ms. Estrella also is a homemaker. Her husband holds an eight-hour-a-day job, which leaves her to take care of the children and the house. After sending her children to school and her husband to the office, Ms. Estrella finishes her household chores, then begins her part-time job of selling lingerie and cosmetics to neighbors and friends. In addition, she is a volunteer community health worker for WHCF.
She helps the Foundation's outreach staff conduct small group discussions in her community and in other neighborhoods. She offers her home as a venue for small group discussions, where basic reproductive health issues are the topic. Ms. Estrella also helps in the outreach clinics -- noting clients' weights and blood pressures on their charts. As a community health worker, she is knowledgeable about different family planning methods and makes recommendations to her neighbors and community members on what method to use. She also re-supplies pills or condoms to them.
In 1995, WHCF expanded its activities, and its number of clients significantly increased. Reproductive health services were delivered in Olongapo, and outreach clinics were held in Cavite, Bulacan, and several areas in Metro Manila including Tondo, Payatas, Muntinlupa, Fairview, and Diliman.
The client mix also expanded to include overseas contract workers and sex workers. While the largest portion of WHCF clients continues to be employees of business establishments near clinics and women living in communities in and around Quezon City, WHCF has seen a significant increase in pediatric cases, most of whom are outreach patients.
Table 1: Number of Clients
Note: 1991 figure is an average of clients from 1989-1991.
Table 1 shows the total number of clients served by WHCF during the past five years. The current year shows a 31 percent increase from the previous year (1994).
______________________________________ ** Note for all data presented in this section: The fiscal year for WHCF was changed from the calendar year to a July to June fiscal year, effective 1995. The data used for this current year were collected from July 1995 to June 1996.
Table 2: Number of Clinic Visits
Table 2 shows the types of services used by clients who visited WHCF clinics. The overall total shows a nearly 50 percent increase in the use of services provided by WHCF. The largest increase was in pediatrics services, although the other services also show an increase. These increases could be attributed to an active core of community health workers (in Muntinlupa and Quezon City) and an increase in outreach activities including providing reproductive health information in small group discussions and lectures.
This case study, the third in a series of profiles of women-centered health programs supported by the Women's Studies Project (WSP) at Family Health International (FHI), highlights the work of the Women's Health Care Foundation (WHCF), based in Quezon City, a middle- to lower-class commercial and residential district and one of the biggest, fastest growing cities in the Philippines.
This publication was researched and written by Rina Jimenez-David, a columnist with the Philippine Daily Inquirer, and by Dr. Florence M. Tadiar, executive director of the Women's Health Care Foundation. Research into the operations of the WHCF was carried out by Ms. David, primarily through firsthand observations conducted at the three main clinics: Cubao, Muntinlupa and Quezon Avenue. Interviews with clinic staff and clients were conducted by Ms. David, who also traveled with a team from the Muntinlupa clinic to an outreach program in a urban poor community. Key personnel and officials of WHCF were interviewed at length.
The section on the health status of Filipino women was compiled from surveys, reports and analyses prepared by both government agencies and private individuals working with health nongovernmental organizations (NGOs). The authors also relied on annual reports prepared by the WHCF and on newsletters, brochures, and articles written primarily by Dr. Tadiar.
The authors wish to thank WHCF staff and WHCF clients for their cooperation in granting interviews and answering questions. Also, the authors thank those who reviewed this case study and offered comments: Dr. Jennifer Adams, Dr. Eilene Bisgrove, Ms. Kathy Hinson, Ms. JoAnn Lewis, Dr. Priscilla Ulin, Dr. Nancy Williamson, and Dr. Emelita Wong. Thanks also are due to Ms. Barbara Barnett, who edited this publication, and Mr. Salim Khalaf and Ms. Karen Dickerson, who assisted with layout and production. The artwork is taken from issues of "Marhia," a publication of the Institute for Social Studies and Action (ISSA). ISSA is the secretariat for the WSP in the Philippines.
Finally, the authors wish to thank the U.S. Agency for International Development (USAID) for its generous support. This case study was funded under Cooperative Agreement USAID/CCP-A-00-93-00021-05 from USAID to Family Health International. The conclusions expressed in this report are those of the authors and do not necessarily reflect the policies of USAID or FHI.
