INTRODUCTION

In its efforts to improve the delivery of health and family planning services, the Department of Health (DOH) has instituted a Health Volunteer Program. Barangay Health Volunteer Workers (BHWs) have been assigned under this program to serve as the immediate link between the community and health centers.

In Lanao del Norte and Lanao del Sur, the 1992 DOH report revealed that out of 633 volunteer workers recruited, only 283 have remained active. Another problematic finding was obtained by a recent study on the health seeking behavior of PTB symptomatics in Region XI (Lacuesta et al., 1992) which reported that the BHWs were not visible in the community. They were, in fact, least preferred by respondents among all health providers.

Informal discussions with the DOH midwives and nurses further indicated that some volunteer workers have failed to perform as expected because of the lack of incentives for this type of work. Too often, the need to attend to other means of livelihood prevailed over community work.

An earlier document (DOH Circular 1990), noted that . under the present devolution process, the current implementation of the outreach program is still a problem. The same article stated that limited knowledge of local executives about population issues resulted in their minimal support for outreach efforts. Such observations underscore the need to provide local government executives with information that will make BHWs more functional and effective in the delivery of (Family Planning) and health services in their local communities.

Objectives of the Study

The study sought to determine the factors affecting the FP performance of the BHWs in eastern and western Mindanao specifically:
1. to examine the background and characteristics of BHWs

2. to understand their recruitment and selection process

3. to determine their training needs

4. to identify the factors affecting the performance of BHWs. In this latter category may be included the volunteers’ relationships with midwives acting as the supervisors of BHWs. logistics, membership in BHW-organizations, local government support. Availability of BHWs, self-perceptions on BHW- roles, FP practice and job satisfaction among BHWs.

BHW performance was originally defined in terms of an index of performance consisting of a number of acceptors motivated, number of drop-outs remotivated, number of clients referred, and number of clients supplied or resupplied with pills or condoms. However, as a result of the pre-field visits in the survey sites and a review of available records, performance in the present study was subsequently defined as the number of FP services extended by BHWs.

In order to find out whether the measure of performance as envisioned in this study would be possible or not, pre-field visits were conducted in the survey sites, i.e. two municipalities from Davao del Sur (Sta. Cruz and Digos) and one municipality from Davao del Norte (Tagum). BHWs and midwives were interviewed at this time about the performance of BHWs, their record-keeping activities and the structure of DOH. During these visits, reports forms were likewise collected from the midwives of the Regional Health Units (RHUs) and the BHWs from Sta. Cruz and Digos. The reports consisted of the Family Planning Service Records of the RHU, FHSIS/M-1, Family Profile and the BHW monthly reports. The FP service Record of the RHU was informative in terms of the FP performance of the Health Center. The FHSIS provided data on FP-clients classified according to FP-method used, status of clients on FP-usage and the referrals received by the health center.

BHWs in Sta. Cruz and Digos were required to submit the family profile and the BHW Monthly Report Form. These reports contained the general health profile and services offered to their clients. FP-data, however, were limited to the type of acceptor according to the method used, the ages of the clients and their spouses. BHWs in one of the three areas visited were not required to submit a report. The most common reason cited was that BHWs could not be required to do this because they are not paid and have very few incentives. BHWs also claimed that they had no supplies to use.

In one group discussion which involved participants from the Five Municipalities in Davao del Sur, it was found that only one area reported that BHWs were required to make reports. A similar pattern was also noted by the initial field investigations which were conducted in Lanao.

As a result of these findings, the measure of performance was altered. Performance was then measured by the number of the FP services rendered by the BHWs. The questions were designed in such a way that probing was also utilized to elicit more feedback regarding BHW-performance.

Sampling was subsequently modified to include 100 BHWs and 150 clients per area instead of the original plan of 250 BHW-respondents. The client-respondents were further asked to validate the perceptions of BHWs concerning their performance.

This study limits itself to analyzing the following variables: performance of BHWs, relationships with midwives, training on basic FP, regular technical inputs, incentives, perceptions of roles, regular monitoring and feedback, participation in the BHW organization, availability, practice of FP, job satisfaction and local government support.

Methodology

The research design investigation employed the survey method involving the use of interview schedules. Modified focus group discussions (FGDs) with BHWs and their supervisors were also conducted. Three FGDs were carried out for instrumentation phase and another two during the validation phase. The discussions were conducted to enhance and validate the information available from the interview schedules.

The study was conducted in two provinces of Southeastern Mindanao (Davao del Sur and Davao del Norte) as well as in two provinces of Central Mindanao (Lanao del Norte: and Lanao del Sur). The inclusion of the latter provides an interesting comparison since these areas have a large proportion of the minority Muslim population. They are further characterized by low contraceptives prevalence (DHS, 1993).

Two groups of respondents were sampled in this study, In lieu of the original sample of 250 BHWs per region, the final sample consisted of 100 BHWs and 150 regional clients as a result of the findings of the initial visits. The difficulty of getting data related to the performance of the BHWs deemed it necessary to validate the responses of BHWs and to substantiate performance-related variables.

The BHWs were classified as being “very active “less active”. The “very active” BHWs refer to those who regularly attended the BHW activities. The “less active” ones were those names were found on the. list of the midwives but who rarely attended meetings and activities of the BHW’s. The “inactive” BHWs were not included since most of them were hardly to be found. Some had already transferred their residence. The clients were Married Women of Reproductive Ages (MWRAs) who were assisted by the BHWs sampled in the study. However, only the clients of BHWs in the three sampled barangays per area site were included in this study.

The sampling procedure consisted of two parts:

A. BHWs

1. The sample size of 100 BHWs per area (Davao Provinces and Lanao Provinces) was established using the Table of Sample Size in Determining the Minimum Sample Size. Hence, a total household population of 822,962 in Region XI is approximately covered by 40,000 BHWs (based on the assumption of one BHW assigned for every 20 households). In the two Lanao provinces, the household population of 210,339 gives a total of 10,516. Using the table mentioned above, a sample size of 100 per area is required at reliability + 10 percent (Arkin:1950).

2. Two provinces were chosen in Region XI to present “high” and “low” performing areas as contained in 2990 DOH report. Specifically the provinces selected were Davao del Sur and Davao del Norte, respectively. From each province. five municipalities (or a total of 10 municipalities per region)were randomly selected.
Two barangays ( one urban and one rural ) were likewise randomly selected from each municipality. Overall, then, there were 20 barangays (10 urban and 10 rural).

3. In the same manner, five municipalities and two barangays were randomly selected from each of the two Lanao provinces (del Sur and del Norte).

4. In both areas, the list of BHWs per municipality and per barangay from 1991 to 1993 was collected from the provincial BHW coordinators. The list of BHWs in the sampled barangays was validated by the midwives. The available listings, however, did not include the “inactive” ones because most could no longer be located.

5. Volunteers were then randomly chosen. Ten BHWs were randomly selected per municipality (or 5 BHWs per sampled barangay) using the list of BHWs in the sampled barangay.

B. Clients
One hundred fifty clients per area (Davao and Lanao Provinces) were determined using non-probability sampling. These 150 client-samples were equally distributed among three barangays which were randomly selected from the ten barangays in each area originally chosen for the BHW samples.

Data Collection

A structured interview schedule was used in obtaining the data necessary from the midwives, BHWs and clients. These survey instruments were reinforced by the results of the FGDs conducted with selected BHWs and their supervisors. Pretest activities had first been undertaken as a means of validating the questions contained in the survey-instruments. The pretest instruments were then reviewed and revised for final reproduction and field use.

Four field interviewers were trained in each region. Spot-checking was also undertaken during the field interviews.

Data Processing and Analysis

The data were coded and processed in Davao City. PS S was used for computerized processing of the data. Frequencies, percentage distributions and means were used to describe the one-way tables. Person’s Product Moment was also used to determine the relationships between the independent and dependent variables. Step-wise regression analysis was conducted to determine the predictors of performance.

RESEARCH FINDINGS  

Socio-demographic Characteristics

Age. The ages of the BHWs ranged from 16 years old to 77 years old, with a mean age computed at 39.6 years. Lanao BHW-respondents appeared to be relatively younger (mean age of 38.0) than those in Davao (mean age of 41.4).

Sex. Survey results indicate that BHW-related work is significantly female-oriented. In the Davao provinces, the females (96%) greatly outnumbered the males. The Lanao provinces revealed an all-female group of respondents. This finding implies the need for recruiting male volunteers considering that FP is not a woman’s issue per se.

Civil Status. The majority of the respondents were married (89%), with a few (11 %) having never married at all. Almost all respondents from the Davao Provinces were married, worth a lower proportion among the Lanao respondents (81%).

Religion. More than half of the BHWs were Roman Catholics (59.5%). The Davao respondents were predominantly Roman Catholics (73%) while 50% of the Lanao respondents are followers of Islam. This shows the distinct cultural differences between the two study sites. The Roman Catholics do not necessarily reject family planning although they often prefer natural family planning as the method. For their part, the Muslims value large families and seem to reject family planning. Further analysis on this dimensions will be interesting to note.

Education. The data on educational attainment of the respondents indicate a high literacy rate. All respondents had undergone some form of formal education. In the Davao provinces, mot BHWs had completed their secondary education (58%) with a lower proportions completing elementary education (23%) or college (19%). In the Lanao provinces, most of the respondents had completed primary education (65%) while the resit. attended secondary (19%) or college (12%). Thus, the BHWs from the Davao provinces appeared to be somewhat better educated. Education, in this sense ( and as confirmed in the focus group discussions), seems to be given less importance in the recruitment of BHWs. One possible reasons might be the difficulty in finding highly educated volunteers who are available and able to provide time for volunteer community service.

Number of Years Residing in the Survey Sites. For the overall sample the BHWs have been residing in the survey sites for an average of 26.4 years. Comparing the two study areas, respondents of the Davao provinces were relatively “new” in the survey sites with an average of 22.8 years. In comparison. Lanao respondents have an average length of stay of 30.1 years in the survey sites. (This finding corroborates earlier observations regarding the tendency of the Muslim population to remain in areas traditionally populated by Muslims.)

Economic Characteristics

A majority of the BHWs were not gainfully employed (59.5%). Those who were employed were usually involved in trading activities such as vending vegetables in the market or selling cosmetics (11%), farm-related (6%) or teaching (5%). The spouses of the BHWs (64%) were mostly engaged in farm work while family income was primarily derived from service-related activities (40%). This holds true in both the Davao and Lanao provinces. Secondary sources of income included business and trading, services and agriculture.

The total monthly household income of BHW appeared to be low relative to the national poverty threshold of P5,000. Overall, the average monthly household income of BHWs was P3,194. The average monthly incomes of the Lanao BHWs (P3,489), however, were relatively higher than those established for Davao (P2919). The average total monthly household figures indicate a possible explanation for the level of performance of the BHWs relative to family planning. Being cash-strapped relative to the poverty threshold of P5,000. per month, the BHWs will more likely engage in various marginal income-generating activities in the course of their community-based service delivery thereby affecting their performance.

Number of Children

The average number of children ever born to the respondents was computed at 5.3. Similar figures were found for both the Davao and Lanao provinces. In general, however, BHWs from Lanao appeared to have more living children (4.9) than those from the Davao provinces (4.7) The relatively high fertility levels found among the BHWs may help in providing lessons for mothers on the importance of family planning. Focus group discussions confirmed that BHWs with relatively large number of children were in a better position to explain the importance of family planning among their clients. Such personal testimonies appeared to be well appreciated by the clients.

Knowledge of the BHWs include FP methods heard and known, side effects of the FP methods and the corresponding remedies, sources of information on FP methods, and self-ratings on the adequacy of their FP knowledge.

FP-Methods Heard and Known

All BHWs from the Davao provinces have heard about pill, tubal ligation, vasectomy and condom. Almost all have heard about IUD (99%) and rhythm (98%), with a lower proportion (74%) mentioning withdrawal. In the Lanao provinces, while all of the respondents have heard about pills. a decreasing proportion claimed to have heard of condoms (90%), IUD (94%), rhythm (86%), tubal ligation (81 %) and vasectomy (76%).

When BHWs from the Davao provinces were asked about the FP methods known, only the pill appeared to be familiar to all respondents. The top ranking methods known were IUD (98%), condom (98%), tubal ligation (93%) rhythm (91%) and vasectomy (90%). On the other hand, Lanao respondents were most knowledgeable about pills (98%) and rhythm (78%).

The side effects identified by the BHWs are as varied as the FP methods known. Nervousness is said to be related to pills and withdrawal; stomach and intestine-related diseases were indicated for pills, rhythm and withdrawal. Diseases related to the reproductive system were mentioned for withdrawal, IUD, tubal ligation, vasectomy, Depo Provera and condoms. Vascular-related complaints were also noted, particularly for pills while behavioral-related side-effects were felt for withdrawal, tubal ligation and vasectomy. Still. Others complained of method failure, specifically for rhythm, cervical mucus and condoms.

Remedial measures taken for side effects consisted mainly of visiting the physician for check-ups or consultations for pills, withdrawal, IUD, tubal ligation, vasectomy and condoms. Discontinuance or shifting to other FP methods was likewise common, particularly among those using pills, rhythm, withdrawal, IUD and condoms.

The sources of FP information were varied, with midwives being mentioned most often, followed by doctors and nurses. Some mentioned their relatives, and POPCOM or other FP agencies. Most of the BHWs from Davao and Lanao mentioned midwives as the main source of learning about FP methods. Cervical mucus-related information was generally learned from POPCOM and other FP agencies for the Davao BHWs. In comparison, nurses were cited for rhythm and lactational amenorrhea for Lanao BHW-respondents.

When asked how adequate their knowledge on FP methods was, most of the BHWs from the Davao provinces felt inadequate (68%) while a majority of the BHWs from Lanao claimed otherwise (72%). It appears that there is still a large percentage of BHW respondents who felt inadequate in terms of their knowledge on family planning (48%). Their knowledge is limited to the methods that are approved by the Catholic Church such as the NFP methods. Being family planning providers, BHWs are expected to provide more information as a basis for more choices of FP methods among couples.

As service-providers of family planning, it is important to establish the actual FP practices of BHWs, i.e. whether they practice what they teach. FP practice here refers to the BHW-respondents’ actual use of FP methods usually recommended to clients, the basis for these recommendations, the persons consulted regarding problems on FP use, and the encouragement given their clients in discussing the choice of FP methods with their husbands.

The BHWs were categorized into “non-users” and “users” of FP methods. The “users” included 48 percent current users along with other women who had now stopped using family planning, either because they were “beyond age 45”, (27 percent), were “currently pregnant” (4 percent) or simply because they had decided to discontinue use (21 percent). Toughly one-fourth (26%) of BHWs claimed to be “non-users” of FP methods (33% in the Lanao provinces and 20% in the Davao provinces).

The “users” were more frequently found in the Davao provinces (80%) than those from the Lanao provinces (67%). Similar trends were observed for the current-users, i.e. more than half (60%) of the users from the Davao provinces were current users of FP methods, as compared to 32.8 percent registered in the Lanao provinces.

Most of the BHWs used traditional methods typically involving periodic abstinence (34.3%) particularly rhythm. withdrawal, and lactational amenorrhea. Users of permanent methods (20%) such as tubal ligation and vasectomy were next in rank. Other FP methods used included IUD (20%). barrier methods such as condoms (4.3%), herbal (2.9%) and combinations of methods (2.9%).

The data seem to indicate that BHWs, as FP service providers, used methods that are closely related to NFP. However, our earlier findings had indicated that they lack knowledge on NFP. Furthermore, such findings suggest that the FP methods used by the BHWs are less effective even though they are generally expected to be promoting effective FP methods. This indicates that cultural barriers may also have affected the practice of the BHWs who are themselves local FP service providers. There is thus a need to provide more information about other FP methods and to reorient them on the FP program.

Comparing survey sites, NHWs from the Davao provinces revealed the following widely used FP methods: traditional methods such as rhythm, withdrawal, and combinations of FP methods (31.3%), followed by permanent methods such as tubal ligation (13.5%%) and hormone-related methods such as pills (12.5%). Those from the Lanao provinces mostly used traditional methods such as rhythm, lactational amenorrhea and combinations of traditional methods (40.9%) along with hormone-related methods such as pills (22.7%).

Those who discontinued using the FP methods were subsequently asked their reasons for doing so. Reasons for discontinuance were attributed to the desire to get pregnant. (29%) and to the irritability/uneasiness experienced in using such methods (22.6%), Another 12.9 percent said that they experienced fever. To a lesser extent, others mentioned method failure/accidental pregnancy, the absence of menstruation, the fear of side effects, and the demise of the husband (9.7% each). A limited number cited that FP methods were contrary to religious beliefs, the absence of breastmilk and the methods being expensive (6.4% each), or cited such problems as bleeding, varicosity, and abdominal pain (3.2%).

Davao respondents mainly cited their desire to get pregnant in discontinuing the use of FP methods while those from Lanao generally experienced irritability and uneasiness, prompting them to stop using the methods.

As consistency check to BHWs’ practice and FP promotion, they were further asked about the FP methods recommended to their clients. The three FP methods cited most frequently were pills (71.5%), intrauterine devices (39.5%) and rhythm (37%). While similar trends were observed among_ respondents of the Davao provinces, those in Lanao indicated pills (70%) rhythm (55%) and intra-uterine devices (20%). The latter likewise did not recommend cervical mucus and vasectomy while those in Davao had the least preference for lactational amenorrhea. Three Davao respondents did not recommend any FP methods at all. The recommendations made for using any FP method were based on such considerations as the clients’ preference for a method (82.7%) and the BHWs’ own experiences regarding the method (42.1%). Similar bases were cited by the respondents from Davao and Lanao provinces.

To better understand the performance of the BHWs regarding delivery of FP services, it is important to look into their attitudes towards the latter. The more positive their attitude, the better will be their promotion of family planning.

Except for one BHW from Lanao, the BHW-respondents all approved of family planning. While three married respondents from the Lanao provinces reported that their spouses did not support family planning, all the Davao-based married respondents claimed that their spouses were in favor of this. In Lanao, the husbands’ attitude was not seen as a barrier to FP-usage as might have been expected from a place where children are highly valued.

The perceived ideal number of children provided insights online priorities of the respondents regarding children. Findings revealed the high value of children still persisting among this group. Only a few of the respondents (10.5%) considered 1-2 children as ideal vis-a-vis those considering three children or more as ideal. Such findings would seem to indicate that the BHWs may not prove to be highly assertive in advocating a small family size on the part of their clients. The respondents revealed an average ideal number of 3.79 children. This figure is slightly lower than the average figure established for the Lanao provinces (4.2) but greater than those computed in Davao (3.36). The perceived ideal gap between two children is computed at 3.4 years. The Davao respondents favored a longer period between having children (3.6) than their Lanao counterparts (3.1).

The respondents have served as BHW-volunteers from a minimum of one year to a maximum of 25 years, with the highest number serving from 6 to 10 years (27.5%). Two Davao respondents have been BHWs for more than 20 years. On the average, they have been serving as BHW for at least 7.4 years. Davao respondents appeared to have slightly longer (7.6 years) than those in Lanao (7.3 years).

The majority of the BHW-respondents have not been involved in any community-related activities (55%) prior to their recruitment as BHWs. A number were either community leaders (16.5%), church workers (9.5%) health workers (6.5%), or BSPOs of POPCOM (5%). More than half of the BHW-respondents have likewise not been involve in any FP-related activities prior to serving as BHWs. The rest (87 respondents or 46%) claimed being involved in FP-related activities earlier, i.e. 56 being Davao-based and 31 in Lanao. Those who were involved in FP-related activities mainly participated in mothers’ classes (90.8%). The rest were attending nutrition seminars (23%), pre-marital counseling (16.1%) and the church-iniated community-based “Gagmay’ ng Kristohanong Katilingban” (GKK) health training seminars (14.9%). A limited few were involved in information dissemination on FP methods, BSPO follow-up activities and counseling on responsible parenthood. Those who participated in FP-related activities generally served as. FP service-providers for an average of 7.7 years. Davao respondents served the longest (8.1 years) compared to those in Lanao (7 years).

Generally, they served either as volunteer health workers (49.4%), as local health trustees as “Katiwalas” (24.1 %), as POPCOM’s BSPOs (12.6%) or as barangay nutrition scholars (10.3%). Others served as full-time outreach workers of POPCOM, as teachers, and as barangay health nutritionists. Davao respondents mainly served as volunteer health workers (67.*% while those from Lanao were “Katiwalas” (48.4%).

The respondents were recruited as BHWs during the period 1976 to 1993, with the majority (89%) being recruited during the period 1981 to 1993. This indicates that the increase in the number of BHWs closely followed the introduction of Primary Health Care (PHC) in 1980. BHWs were then considered as a component of this approach. An equal proportion of the respondents were recruited between 1981 to 1985 and 1986 to 1990 (31% each). More than half were recruited between 1986 and 1993 (52%).

Focused group discussions further revealed that most of the BHW trainings were conducted at the time when PHC was introduced between 1980 and 1985. Such findings may probably explain why only a third of the BHWs were trained as BHWs. Lanao BHWs were mainly recruited between 1981 to 1985 (43%).

Overall, the midwives were the major BHE-recruiters (64.5%), with the same trends observed for Davao (59%) and Lanao (70%) respondents. Twenty-seven respondents claimed to have volunteered (rather than being recruited) as a BHW, i.e. 19 from Davao and eight from Lanao. Only a few of the respondents identified the barangay captain as having recruited them as a BHW.

Davao respondents further identified other individuals as BHW-recruiters, e.g. barangay captain, doctors, other BHWs, NGO workers, barangay nutrition scholars (BNS) and the community members. Lanao respondents, on the hand, mentioned a variety of recruiters such as the barangay captain, doctors, nurses, diocese/sisters, and neighbors. The data thus suggest that the original criteria in the recruitment of BHWs outlined under the PHC program were not fully observed. The focus group discussions noted that through the years, the community has given the midwives the responsibility of choosing her own BHWs. Thus, BHWs were recruited based on their availability and involvement in community or health center activities.

More than half of the respondents (58.5%) believed that the consideration in being recruited as a BHW was their availability, with a lesser proportion citing their being active (47%) in community-related and health center-related activities. Similar trends were observed for both Davao and Lanao respondents.

In 1994, DOH prepared the “Rural Health Midwife’s Teaching Manual on Primary Health Case for Barangay Health Workers” to train BHWs on their roles as volunteers. While explaining the BHWs have no specific role to perform, the manual merely suggested those roles related to Primary Health Care and Family Planning. It also clarified that BHWs, being counters, were not expected to do all the identified roles but rather can select those roles deemed compatible with their skills. capabilities and interests. Hence, there is no constancy in their roles. The midwives can only encourage or motivate them to perform some of the recommended roles.

When BHWs were asked about their role in general, they believed that assisting health centers in general activities was the main role of BHWs. This was true in both Davao and Lanao (64.0%). Client motivation ranked second (39.6%), while resupply of pills was the one of those least mentioned (5.6%). Research findings thus suggest that BHW-roles were not specific to any program. Further still, BHWs considered that assisting health centers was generally expected of them by the midwives themselves. This was indicated during the FGDs with the midwives and the BHWs. The BHWs often serve as health aides in the health centers, especially during ” Health Center Days”, filling in for manpower shortage among the different health services. Such observations follow closely those of Ventura et al. (1992), wherein the DOH staff, the MHOs and midwives perceived the role of BHWs as primarily assisting the midwives perceived the role of BHWs as primarily assisting the midwives in clerical and technical matters, even as they can relied upon for information dissemination and following-up certain health case.

In the two survey-areas, BHWs spent approximately the same period in the health center (70%) and field activities (69%), specifically 1 to 2 days a week. This indicated that aside from community-related acclivities, BHWs believed that they were also expected to assist in the health centers during the week. However, DOH documents on the roles, functions, tasks and competencies of a trained volunteer barangay health worker indicate that the BHWs have 24 tasks in relation to their role as the link between the community and the health services. BHWs roles include acting as motivator, counsellor, community organizer, health provider, facilitator of the community in providing immediate access to the health resources and as data gatherer, reporter and recorder. The data thus revealed that the present activities of the BHWs which are related to the health center tasks seem to be a deviation from the original role expectations set by the DOH.

Training is an important vehicle to carry out strategies for making providers, including BHWs, perform their roles. As mentioned earlier, the manual of primary health care for BHWs states that BHWs are not limited to the roles taught during training. The midwives would have to use their creativity to make the BHWs perform, given the limitations of the BHWs as volunteers and the midwives themselves having no formal trainings. Thus, BHWs use the trainings only to enable them to select the ideas and activities that seem suited to their interest and capabilities.

Since the BHW respondents were recruited from 1977 to 1993, the type and number of trainings attended varied. The study first looked into the trainings that were given after they were recruited regardless of the year of recruitment.

Out of 200 respondents, 133 (66.5%) were trained whereas 33.5 percent were not trained at all. When asked how soon the first training was given after recruitment, a majority had it 10 months or less after recruitment (80.4%). Out of 133 who had attended trainings, less than a fourth had trainings solely on FP (23.3%). Three-fourths (76.7%) had FP-trainings that were incorporated with other health programs like Primary Health Care, Maternal Care and other health care programs of government organizations (GOs) and non-government (NGOs ).

When asked which aspects of FP were discussed during training, the main topics mentioned were the efficacy of FP methods (97%) and remedies and side effects (90.2 %). Interpersonal relations, which are very important to BHWs as motivators in their communities, was mentioned by a much smaller group (15%). BHWs from the Davao provinces identified more varied topics compared with the respondents from Lanao. All Lanao respondents mentioned remedies and side-effects, while 95 percent indicated the efficacy of FP methods. Again, discussions on interpersonal relations were very limited (7.1%). Davao respondents also had two topics other than those mentioned by the Lanao respondents, i.e. the importance of FP (15.9%) and the type of FP methods (4.8%).

Most of the trainings attended after recruitment were sponsored by the DOH (81.9%). To a much lesser extent, other sponsoring agencies mentioned were POPCOM (9.8%). DMSF (5.3%), CRS (2.3%) and others (1.5%). In Lanao. respondents mostly attended the DOH trainings (91.4%), with only 12.7 percent attending those conducted by POPCOM. In the Davao provinces, more than a fourth (28.6%) had trainings sponsored by other agencies and about three-fourths by the DOH (71.4%). The data seem to show that BHWs from the Davao provinces had more participation in the activities of other agencies aside from those of the DOH.

Trainings attended ranged from a minimum of one to a maximum of 14 days. About half (50.4%) attended an average of 1 to 3 days training on FP while more than a fourth (28.6%) spent from 7 to 9 days. A limited number (44.5%) attended training lasting 14 days. Since most attended trainings which were incorporated with other health programs, this would suggest that the trainings held from 1 to 3 days could not provide adequate time for detailed discussions with BHWs, who described the FP discussions as “superficial” or lacking in depth or thoroughness. As contained in the survey results, out of the 133 respondents who had attended training activities, approximately two-thirds (67.7% learned about using FP methods while less than a fifth (18.8%) learned about motivating clients (18.8%). Given such findings, it appears that as many as third of the respondents did not learn anything about FP-usage from the trainings attended.

To be a FP-provider requires knowledge about FP-usage. The respondents were asked where they learned about their roles as FP-providers. The major sources of information mentioned were midwives (61.5%), trainings (58%), and experience (57.9%). However, when the two areas were compared, a majority of the BHWs from the Lanao respondents identified the trainings attended. Of the 133 respondents, 57.9 percent had attended other trainings related to FR Similar patterns were observed in the two areas sampled.

Having attended trainings on FP since their recruitment, BHWs were further asked whether the trainings provide them sufficient knowledge for their work as BHWs. The ratings given were generally positive, closely following the findings of Ventura et al. (1992) that BHWs believed their trainings were adequate enough to allow them carry out their tasks as BHWs. However, comparing data in the two areas, the Davao respondents (60.3% ) generally felt their trainings were inadequate while only 31.4 percent believed so among respondents.

Those who claimed that the trainings were inadequate mainly cited their insufficient understanding of the use of FP methods (60%). To a lesser extent, others indicated the lack of understanding of side-effects (26.7). The Davao respondents regarded the limited understanding of their use of FP methods as the most problematic (54,5%) as more difficult. A little more than half (57.1%) were able to attend FP-trainings within the last two years, with the rest attending such activities more than two years ago. These findings indicate that the last trainings sessions attended were often quite recently.

The BHWs made various recommendations, mainly the need for training on FP methods, their use, and side effects, including advantages and disadvantages (38.5%). A limited number mentioned the need for training on Natural Family Planning (NFP), new FP-methods, and demonstrating the use of IUDs. As gleaned from survey results, BHWs themselves felt the need for more training. In Ventura’s study cited earlier, the clients of BHWs pointed out the need for more trainings so that BHWs could not help them regarding health-related problems.

Being volunteers, BHW do not receive any regular remuneration but may be given incentives to motivate them in their work. The present study includes those incentives given to them as BHWs regardless of program activities.

That the majority of the respondents expected cash incentives (88.4%). A smaller group mentioned FP kits (27.1 %) equal proportion and medical assistance (20.6%). However, when asked about the types of incentives actually received, an  of the BHWs from the Davao provinces reported receiving material incentives with a smaller group (37.5% mentioning cash incentives.

It appears that, on the whole, respondents were not satisfied with the incentives. However, when comparing the two areas, the Lanao respondents appeared to be more satisfied (62.5%) than those in the Davao provinces (40.5%). Those who were not satisfied mainly cited the lack of financial support (69 .6%). Having inadequate supplies such as office or contraceptives ranked second.

However, when asked whether the lack of incentives would discourage them from continuing their volunteer work, the majority felt otherwise (93.0%). In explaining such motivations, the respondents generally cited their desire to help the community (61.1%) cited were not being used to receiving incentives (8.1%), love for work (5.4%), desire to learn more about health (3.8%0, to provide medical assistance (3.2%) and others volunteerism provided the necessary access to medical services and the opportunity to learn about basic medical remedies which they found useful for both for the or clients and for their own families. While a number complained about the time lost for pursuing livelihood activities vis-a-vis BHW-related work, they nevertheless recognized the benefits gain in doing work as a worthwhile trade-off.

The results of the study revealed that a significant majority of BHWs (91.5%) were under direct supervision of the midwives. To a lesser extent, others worked closely

with DOH nurses (17.5%), while a smaller number were directly supervised by the BHW President and Barangay Captain (5.0%).

Midwives regarded monitoring as a tool for following up the performance of BHWs. They explained that monitoring was done either by conducting monthly meetings (37.5%), by following-up BWs (35.0%), by collecting reports (27.5%) or by following-up clients (22.5%). Field visits for BHWs at least one to two days a week in the area. In Lanao, about the same percentage visited their BHWs at lest once to twice a week (31.0%) with others visited more frequently, i.e. three to four time a week (32.0%). Overall, the BHWs were visited by their midwives 1 to 2 rimes a week (50.5%).

BHW-respondents claimed that the main activities of midwives during their visits included filed observations (45.5%). filed reporting (25.5%), consultations (23.5%) and clinic-based activities (114%). In both areas, monitoring activities were conducted through consultations and field observations . In Lanao, evaluation activities were reported by six percent of thee respondents. These findings appear to be consistent with the findings of Ventura (1992), i.e. that supervisors and midwives of the health stations visited their BHWs more than once a week. These visits not only serve as monitoring schemes but also as opportunities for informing midwives regarding the problems encountered by BHWs in their work.

When asked about the midwives’ monitoring activities. BHWs claimed that aside from field visits, the midwives also conducted meetings (93.5%), usually on a monthly-basis (82.9%). However, in Lanao , about three-fourths of the BHWs claimed that there were not regular schedules for meetings (28.7%).

Most of the meetings in the Davao provinces and Lanao were held 9 to 12 times during the previous year (44.3%). Davao provinces, though, had more meetings than Lanao with 38-8% reported having more than 12 meeting last year. In Lanao, only 9.2 % attended more than 12 meeting last year.

When asked about the frequency with which they had attended meetings for the past 12 months, a majority of the BHWs attended from nine to twelve meetings (67%) last year. Attendance, however, appeared to be better among Davao-based BHWs (89.9%) than those in Lanao (40.2%. Generally, the number of meetings attended closely matched the number of meetings called.

The most common problems cited in attending meetings were the transportation expenses incurred (37.7%) and conflicting schedules (24.6%). Davao-based BHWs mainly indicated problems of availability or conflicting schedules (43.8%) while those in Lanao cited in the lack of money for transportation.

FP-related topics were generally discussed (83.4%) during said meetings, especially the motivation of MWRAS (88.5%). BHWs from the Davao Provinces mainly mentioned discussions on “side-effects” (41%), use of FP (14.1%) and the health performance of BHWs (10.9%). Lanao BHWs, on the other hand, indicated such topics as the performance of BHWs (20.5%), income generating projects (14.4%) and FP health center problems (13.7%). In both areas, family planning was considered a priority topic.

At least four reports were expected from the BHWs for submission to their supervisors, with client-records as the most frequently mentioned (78.2%). Other reports include the BHW daily activities (27.5%), accomplishment reports 98.3%) and the yearly report (1.6%). BHWs from the Davao provinces submitted at least four reports (e.g. client record. accomplishment report, BHWs daily activities and yearly report) compared to only tree reports submitted by their Lanao counterparts. It is interesting to note that 22 percent of the BHWs from Lanao indicated that they were not expected to submit any report to their supervisors.

Generally, these reports were submitted either on a monthly (58.3%) basis, if not quarterly (27.8%, annually (7.3%) or weekly (2.6%). Some of the Lanao respondents reported that submission of reports was on an annual basis (14.9%), as compared to none of those from Davao. The type of FP-methods used and clients’ background characteristics were the usual contents of the reports submitted to the supervisors.

The interaction between the midwives and the BHWs needs a closer look. As explained earlier, BHW-volunteers were not obliged to perform all the possible roles identified by midwives. According to the manual of Primary Health Care for BHWs, midwives can only motivate BHWs to perform various roles. They could not be required to report regularly and could only come whenever they are available. Hence, the supervisor-subordinate type of relationship may not be useful in encouraging volunteer-work among BHWs. Midwives have to motivate and use their creativity in improving BHWs’ performance.

Overall, BHWs expect their supervisors to be more concerned with them (67.6%) and to allow them to do their work with less supervision (31.8%0. This is true in both areas. Midwives offering close relationships seem to be more appealing to the BHWs. The most undesirable qualities of supervisors which were cited included favoritism (24%), delayed action on problems presented to them (12.5%) and failure to initiate planning-requirements (5.5%).

Recognizing the importance of their work as BHWs was regarded as an important expression of support to the BHWs (94.5%). The “good” supervisors were described as midwives who offer good relationships (59.5%), who encourage their BHWs (52.0%), show trust (46.5%), give due respect (27.5%) and exhibit openness (26.5%). The same perception were expressed by the respondents in both the Davao and Lanao provinces. On the whole, BHWs believed that a good supervisors must be able to develop good interpersonal relationships with BHWs in an environment of mutual trust and confidence.

Logistics consist of the means by which contraceptives, condoms or pills and IEC materials are made available from the health centers.

Those who requested for supplies during the past six months received pills regularly (74.3%). However, comparing the two areas, Davao BHWs claimed that pills were distributed more regularly than condoms while the opposite as true in Lanao. Davao respondents reported that pills were more regularly available than condoms with distributions on a weekly basis. As mentioned in the focus group discussions, pill were given to the BHWs as needed. Weekly distributions to the different clients was one way of monitoring the supply of pills. In Lanao. BHWs were given their supply of pills on a monthly (34.5%) or yearly (31.0%) basis— with the latter arrangement mainly due to the limited supplies in Lanao.

Comparing the distribution of pills and condoms, the health centers appeared to be more lenient in the distribution of pills (particularly in Davao). In both areas, however, condoms were supplied to BHWs on a monthly basis. In Lanao, a considerable percentage mentioned annual supplies (24.2%). Similarly, the lack of regular supplies may possibly explain in the wide interval of distribution schedules. This is evident when asked what problems were encountered relative to the supply of contraceptives. They considered the lack of supplies as the only problem in the procurement of supplies. This proved consistent with their supplies were not readily available (55%). Since they were deficient in the supply of condoms and pills. they could only distribute them whenever they were available and that would be on an annual basis.

In the Davao provinces, the procurement of supplies by the BHWs seemed to be more regulated than in Lanao. Aside from weekly distributions, the respondents were asked to present their list of acceptors (17.4%), to fill up the forms in the health centers (26.1%) and, in some cases, they were required to submit client records (21.7%). BHWs usually had to present at least three requirements before they were given supplies. In Lanao. BHWs were only required to present the list of acceptors (60%) and their BHW identification card (15%). However, almost half of the respondents were not required to submit anything when receiving supplies from the health centers.

When asked whether BHWs were able to provide contraceptive supplies immediately upon request by their However, Coot he clients, more than half gave negative responses (58.2%). Davao respondents responded positively (61.3%) compared to Lanao respondents, with 64.2 percent claiming otherwise.

The absence of contraceptive supplies appeared to be the most mentioned problem encountered by the BHWs from resupplying their clients. An equal proportion of BHW  the Davao provinces cited problems on the lack of supplies and the health centers being closed (19.4% each). Majority of the respondents from Lanao complained of the absence of stocks (54.9%). Solutions made relative to problems in resupplying clients with contraceptives were mainly in terms of advising clients to buy their own supplies (46.6%). This holds true in both survey sites.

             SUMMARY

The data showed that BHWs provide indispensable services to their communities. Close to seventy percent of volunteers reported to have spent 1-2 days in the field performing the following functions: motivating clients, conducting household health surveys for the health center, referrals, disseminate health information, including use of herbal medicine, and to a certain extent resupply pills. Also about the same proportion reported to have spent 1-2 days in the clinic to assist midwives and other health personnel in the maintenance of the clinic or during immunization periods when the clinics are short of help.

The performance of the BHWs was measured in terms of types of FP services rendered during the year preceding the survey. The most often reported FP services rendered are: motivating clients (93%), referring then to health centers ( 92%). accompanying the clients to the health center (88%), and disseminating information on family planning (49%). Further strengthening of the IEC component and training among BHWs are suggested by these findings.

Performance (based on self reports) was higher for Lanao workers compared to those in Davao. Attempts of researches to obtain more objective data on performance were not succesful because of these records. There exists no systematic records on BHWs performance from the side of the health facilities and the workers themselves since they do not keep these kinds of records.

When asked how they perceive their role to be, volunteers gave varied and often confused responses. This observation was quite apparent in the focus group discussions. Furthermore, the fact that many (64%) reported their role to be “assistants” in the health center appear to defeat the whole idea that they are community based and therefore accessible to the community.

The guidelines in the clinics were also vague about volunteers responsibilities. This situation opens possibilities for misuse of volunteer work, e.g. doing personal chores for their supervisors is not uncommon. A clearer definition or DOH guidelines regarding the volunteer’s role can help in this regard.

Information obtained from the clients living in the community indicated that the volunteer services are important especially in family planning. About half of the clients interviewed admitted to have consulted the BHW about their family planning, except those who are single or past their childbearing age. Their spouses generally approve of FR They admit to having “inadequate” knowledge of family planning. In general, they were recruited by midwives who work in the health centers.