I would like to thank the officers of the Biliran Chapter of the Integrated Midwives Association of the Philippines (IMAP) for the invitation to speak before you during this 3rd Scientific Meeting of your organization.

At the outset, let me clarify a few things. One is that I am not a health professional – not a physician, not a nurse, not a midwife, and not a medical technologist. I belong to a new and upcoming academic discipline called "health social science."

However, I have been into health research for much of my professional life. I was involved in field researches in primary health care and the integration of hospital and public health services, the results and findings of which contributed to national health policy during the early 1980s. I have also been teaching general education courses to midwifery level students of the U.P. School of Health Sciences over the past 15 years.

Perhaps it is these experiences, and not necessarily my professional category, that prompted you to decide that I talk on the topic "The Devolved Midwife."

My idea of a devolved health system was the "district health system" set up and popularized in the Leyte-Samar region (Region 8) by then Regional Health Director Manuel G. Roxas in the 1980s. I was the documentarist of that experiment, the concept of which was endorsed for national adoption by the DOH and eventually picked up by the World Health Organization and promoted for adaption by other Third World countries.

Under that setup, the field health services were coordinated at the nearest district hospital, through which administrative and technical support in terms of referrals, training, resources, and even payment of salaries and allowances were channeled. For the first time in the history of the Philippine health care delivery system, the formerly separate hospital and public health services were rationalized at the interface level. And both hospital and public health personnel evolved a social culture through which they could interact with each other and work as a team.

Those among you who had gone through the years under the district health system setup will probably agree with me that it was a much better system that what we have now.

The devolution of health services to the Local Government Units (LGUs), which was mandated by the Local Government Code of 1991, totally disintegrated the district health system setup that you were familiar with and had gotten used to. The result was massive confusion and demoralization among the field health personnel, which I hope you have come to terms with by now. You were not prepared for, nor had previous experience in, taking the medicine prescribed for the health system by our politicians.

I look at you now, and I see your beaming faces. I guess these were not the same faces you showed in late 1993 and early 1994, when you were going through the crisis of having to make drastic adjustments in your professional routines and having to cope with a new set of bosses who looked at you as a big drain to municipal or provincial coffers.

The word "crisis" is represented by an appropriate Chinese character. A few strokes at the top of the character indicate "danger" and "uncertainty." But what is not often seen are the few strokes at the bottom which indicate "growth" and "evolution." Thus, there might be danger and uncertainty during any crisis. But as Asians and Filipinos, we should also understand that growth and evolution are hidden, and often ignored, outcomes of a crisis.

In your case, you seem to have overcome the feeling of danger and the confusion that characterized the early days of the devolution. You also seem to have accepted the fact that, in spite of everything, you have to grow and evolve both as persons and as professionals under a new set-up.

In some of my writings I have argued that you, rural health midwives, are the most versatile public health workers in the country. As a professional group, more than the public school teachers, and more than the extension workers of other government agencies, you have the most comprehensive coverage and access to the population among all categories of public servants in the rural areas.

In a Maternal and Child Health Survey I coordinated with UNICEF funding and support in Eastern Samar Province in 1993-94, I found out that almost all rural mothers have had contact with a rural health midwife, either for pre-natal and post-natal care, for the immunization of children, and for many other health and medical interventions. Other professions cannot make a similar claim as you can make in terms of general client contact. On this aspect, you are very much unique, and for which I admire you a lot.

Unfortunately, in spite of your vital functions, rural health midwives continue to belong to the least recognized and least appreciated professions in our health-care delivery system, which incidentally remains physician-oriented. I do not have to go into details of this apparent discrimination. You know what I mean.

Five years ago, in 1992, a public health nurse and a rural health midwife were drowned by floodwaters while crossing a river to render immunization services in a remote mountain village of Abra in the Cordillera region. Their display of heroism caught the attention of the national media.

In early 1995, Acting Health Secretary Jaime Galvez Tan told me in Tacloban that the ill fate of these two rural health workers prompted the Department of Health to institutionalize more incentives, awards and recognition for rural health midwives in the field. I hope this gesture of the DOH leadership had benefited some of you here in Biliran Province.

In terms of field performance following the devolution of health services, I would like to cite some statistics that might reflect the laudable services of the rural health midwives in this province.

Birth and death statistics for 1994 at the Biliran Integrated Provincial Health Office and census data adjusted to 1994 levels showed that our province had a crude birth rate of 25.6 per 1,000 population and a crude death rate of 3.4 per 1,000 population. Both rates are lower that the national rates from the 1990 census (27.6 and 5.8, respectively).

The 1995 census showed Biliran Province had a population of 131,808. The average Biliran household has 5.14 members. The DOH projected a population growth rate of 1.3 percent during the 1990s. But the 1995 census figure for Biliran translate to a 2.3 percent growth rate, or a full percentage point average annual growth of the provincial population over the projected rate.

This growth figure suggests the need for a more aggressive and creative population management program to minimize the strain on the province’s ecological carrying capacity. Already, at 237 people per square kilometer, Biliran has the highest population density among the six provinces of Region 8. We must do something to cope with this reality in the short term.

Of course, another statistic suggests superb field performance of the rural health midwives. Biliran had a very low infant mortality rate in 1994. At 6.1 infant deaths per 1,000 live births, the figure is about 90 percent lower that the national figure of 60 infant deaths per 1,000 live births. The low infant mortality rate for Biliran is comparable to First World standards. Congratulations!

Still there are some concerns that worry me both as an external observer and as a native of Biliran. Last week, the Philippine Daily Inquirer reported that 60 percent of Filipino kids drop out of the second grade primarily because of poor brain development traceable to protein-energy malnutrition in their early childhood.

The news report reminded me of the 1995 Health and Nutrition Situation Report for Mothers and Children in Biliran, which was based on a research conducted by Helen Keller International. Their report also highlighted urgent problems affecting the health and nutrition status of mothers and children in our province.

The first item in the report’s recommendations went this way: "To intensify food production to attain food sufficiency and food security."

I must admit that I am always bothered by statements alluding to lack of food as a cause of our nutrition problem. As an agriculturist by basic training, I can tell you that there are enough food materials around us that could help improve our nutrition status. We just did not care to go into food enhancement and food diversification as approaches to solving our rural nutrition problem.

For instance, I know that one of your college courses was Nutrition. But I wonder: how many of you had kamunggay (horse radish leaves), beans, kangkong (leafy vegetable), coconut milk or camote tops in your diet yesterday? If you had none of these mentioned items, just imagine those mothers who did not have the benefit of a formal nutrition course.

In the Eastern Samar MCH Survey, the mothers also mentioned lack of food for their children as a possible cause of their poor nutritional status. Perhaps they got their answers from the rural health midwives, who in turn got their standard answers from the higher-ups. Why this inference? Because the mothers’ answers to other nutrition-related questions contradicted their claims. Items they bought such as Cerelac, Ceresoy, and Cerelac Banana are merely expensive packaged versions of locally available food materials that could be cheaply bought.

I guess the rural health midwives should help disabuse the mothers of some of their harmful perceptions about child nutrition. My whole point is this: we do not lack the essential food materials to keep the population healthy. Many of these items are all around us; some are even considered weeds and can be taken for free. What we perhaps need is some imagination and a little humility. Oftentimes, what we call "food of the poor" or pinobreng pagkaon are often the most nutritious.

In closing, I would like to affirm my deep faith in the capacity of the rural health midwives to contribute to the betterment of the health status of Filipinos in the rural areas. You have the basic technical capacity, attitude, and the rapport of rural mothers and children, which are necessary ingredients to improve the health picture in your respective catchment areas.

Of course, you also need to fellowship among yourselves, if only for self-confidence building, and to periodically share notes and trivia with peers in your profession. This meeting is an example of what I mean.

May you have more success and professional fulfillment in the years ahead. Thank you very much.

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