Monday, July 30, 2007

Creating Roads to Sexual & Reproductive Health

The explicit intertwining of the issues on infrastructure and health is what makes the town of Paracelis, said to be Mt. Province’s last frontier, among the four project areas of the 6th UNFPA (United Nations Population Fund) Country Programme. It has been said that the hierarchy of needs should always be the starting point of all programs seeking to adress the needs at a higher level. This is the case in Paracelis and even in most of the towns in Mt. Province, north of the Philippines, where reproductive health seems to be an abstract in the minds of its people.

Nestled in the interior triboundaries of Ifugao, Isabela and Kalinga is the remote town of Paracelis, Mountain Province. There are two difficult, almost impassable routes to get there – either through the steep and narrow mountainsides of Mount Polis, where boulders and rough mountain rocks combine to make the surface of a road; or by passing through Isabela and the dirt roads of Alfonso Lista, Ifugao. Both paths are characterized by rough, bumpy roads pockmarked with potholes. During the rainy season, the road turns sticky with mud and the two rivers become swollen, making travel next to impossible.

UNFPA’s initial project in the municipality targets four barangays that are equally challenging to reach. Barangays (village) Bantay and Bunot are easier to reach because vehicles can pass through and the routes are relatively passable. Reaching the other two barangays of Anonat and Buringal, however, will require tougher guts.

Anonat can only be reached after an hour-and-a-half motorboat ride in the Siffu River. From there, one has to hike for one-and half hour to reach the town proper. To reach Buringal, the farthest town, one has to pass through several towns in Isabela before reaching the mighty Mallig River in Dommon for an hour-and-a half motorboat ride. The rest of the journey is traveled by long hours of hiking.

During the community appraisal phase of the UNFPA project, the very condition of these roads was identified as central to the people’s quest for better and healthy lives.With the lack of key infrastructures in the area, any development intervention in the towns invariably fails.

No Roads Means No Social ServicesParticipants in the Focus Group Discussions (FGD) have identified different key indicators of poverty and marginalization. They mentioned the lack of road networks as a major indication of government neglect for its constituents. In 2003, Buringal residents protested and threatened to secede from Mt. Province to join the more proximate neighboring province of Kalinga, if a 30-meter road linking the remote barangay to nearby towns will not be provided. Two years after the protest, disgruntled residents articulate the same sentiment. In the eyes of the communities, government neglect continuously breeds the unending cycle of poverty and marginalization.

The absence of adequate road systems was further linked to a host of other problems. FGD findings state that many students drop out because of the long hours of walk to the school. Student absenteeism escalates during the rainy season due to the absence of a hanging bridge linking the barangays to the school/s.

The produce of the people are just laid to waste, especially when they are unable to transport their goods to the nearest road, which is at least an hour or two away from the barangays. Transport of their produce to the nearest market in the nearby province of Isabela is all the more difficult with the half-day travel via the Mallig or Siffu Rivers. There were times when their mango fruits were just fed to pigs since the people did not have access to market areas. The insecurity of income and food for the family always looms big for the hapless farmers and their families. Not only does the absence of road networks hinder the sale of goods to markets, but it has also limited the opportunities of people to seek greener pastures outside of Paracelis. Low income is also attributed to low agricultural productivity due to absence of irrigation system.

Poverty and marginalization is a day-to-day reality in their midst. A barangay leader said that even if the farmers want to produce more, the lack of roads prevents them from bringing their produce to the market. “They no longer produce crops for sale in the market; they only produce what they would consume,” said the leader. Since the farmers could not sell their produce, providing their families with their basic needs becomes a daily struggle. They expressed their woes of undergoing the daily ritual of physical and mental exhaustion just to provide their families with the bare necessities in life.

These scenarios explain the complacency, idleness, and the apparent lack of inventiveness in people. As one remarked, “No matter how diligent one is, if this is the condition, s/he will become idle, for it is useless. Your energies are dissipated…It is difficult.”

Difficult Roads Means Difficulty in Accessing Health Services
The absence of roads aggravates people’s access to the basic health services such as the provision prompt medical attention to ill people. Local officials relate the connection between infrastructure and health. Unable to sell their produce, they will not have the means to access health services. Also, the absence of irrigation systems leads to decreased production, and the scarcity of food. Other key issues and needs identified by the participants are the following:
a. Lack of electricity in passage areas pose hazards to female adolescents
b. Lack of other recreational facilities for the youth
c. Livelihood projects are highly dependent on people more than the government

The participants said that the construction of more schools and health facilities is most wanting in far-flung communities. They proposed that a hanging bridge be built to allow students to cross the river and reach their schools faster. Farmers would also be able to transport their products. They also proposed for the construction of solar pavements for drying corn and rice. Also, a grains buying station in the municipality would minimize the need to transfer crops to Isabela and/or nearby towns.

A Problem of Geography
Geographical accessibility is the problem with regard to the barangay health stations, the rural health unit, and the lone hospital in Paracelis. Another concern is the longing for better roads to facilitate travel and communication. Because of their location, access to sources of information like regular updates, trainings, seminars, capability-building activities, and meetings have become remote possibilities to barangay officials and health workers. Barangay health workers (BHW) narrated how hard and expensive it is to attend seminars. “We have to walk. It takes us four days before we can get back to our homes even though the seminar is only for a day. We cling our way up through the mountain,” said a BHW. Another BHW said that during summer, when vehicles could enter the barangay, they would hire a motorcycle to take them to the training venue, paying a roundtrip fare of P600 (US$13). Since they could not reimburse the amount, it further strains their meager honoraria.

Roads and Sexual Reproductive Health
It is through the foregoing physical backdrop that the issues of sexual and reproductive health (SRH) surface. Reproductive health (RH) is initially associated with sexual activities of males and females. It refers to how people could take care of their bodies and their minds, thus geared toward the improvement of mind and body through healthful living practices. The tight interlinks between roads and sexual reproductive health constantly appears in our discussion below.

Family Planning (FP). Family planning is likened to budgeting. FP is important, especially when the family’s economic condition is of utmost concern, as aptly stated by a mother. “If you are poor, you need FP.” The capability to sustain and provide for the family in the future justifies the limit to the number of children. Very often, a woman with numerous children is given advice to use artificial family planning methods. FP is also resorted to when the life of a woman is at risk, or when the woman foresees some difficulties in her personal health. However, there are basic reasons for the low adoption or stoppage in the use of FP methods. These include: 1) opposition from partner, 2) financial constraints, 3) inaccessibility and distance of sources of FP methods, 4) adverse side effects of artificial FP methods, and 5) preference for a male or female child.

Maternal and Child Health (MCH). Oftentimes poverty and marginalization take their toll on women, especially the young mothers who lack life skills; and mothers with too many children. Also, other problems on SRH (e.g., FP, VAWC, STIs/HIV/AIDs) directly manifest on the health of mothers and their children. Unplanned pregnancies which result to too close childbirths, too many children or risk pregnancies certainly affect the women’s state of health, particularly when pregnant women are not provided with adequate sustenance and nourishment.

Most married women claimed that they take care of their pregnancies by consulting with the midwife, taking vaccination shots, going to a hilot (traditional healer), and by eating whatever is nutritious. However, lack of money and a lot of domestic chores sometimes prevent married women from visiting health facilities for pre-natal check-ups and/or immunization. Problem about money worsens when the birth delivery is by caesarian section. Needs of the family, especially of the children, are prioritized in budgeting the meager family income. It is no surprise when there are pregnant women who never complete their pre-natal visits, if in case they do go for visits to the health centers.

The BHWs observe that immunization is not resorted to among mothers and their children because they have no time to go through the procedure or if they do they would rather not because of its side effect of experiencing subsequent fever which robs them of a day’s work. Farmwork and heavy workload have prevented pregnant women from taking good care of their pregnancies and are perceived as the cause of spontaneous abortions. For example, participants narrated incidents where a pregnant woman fell off a carabao and suffered bleeding.

Adolescent Reproductive And Sexual Health (ARSH). Adolescent reproductive health was identified as one of the areas that need to be focused upon due to the growing number of girl-children (as young as 12 and 13) getting impregnated and turning out to be single mothers. This happens because of lack of educational opportunities. BHWs believe that girl-children enter into sexual relationships early to escape from the rigors of difficult family life where there is acute shortage of food and other daily necessities. So they look for others who they believe will be able to help them survive.

The lack of roads is a condition perceived to lead to risk behaviors among the youth. A number of them had to stop pursuing secondary education because of the difficulty in travelling. For others, it will entail crossing the river that gets turbulent during the rainy season. Still for others, going to high schools means traveling all the way to Isabela towns because there are no secondary schools in their villages. When weariness envelops the young people, there is a tendency to adopt risky behaviors that lead to early pregnancies and unwanted children.
FGD findings pointed out that early marriage among the youth results in uncontrolled procreation and unwholesome married life. A common observation that makes married life so difficult for these young couples is their lack of life skills in managing a family and the lack of material resources in meeting family needs. Hygiene and sanitation, child rearing, and financial problems are contentious issues between young couples that sometimes lead to marital spats and physical abuse of the teenage-wife by the juvenile husband.

STIs/HIV/AIDS . There are no reported or recorded cases of STIs/HIV/AIDS in any of the barangays of Paracelis. However, the most common health concern registered in the Paracelis District Hospital is Urinary Tract Infection (UTI). As of September 2005, there were 107 cases of UTI that were brought to the attention of hospital personnel.

It was apparent that most of the participants lacked the essential information on STIs/HIV/AIDS. They have heard of UTI and it is the only form of STI familiar to them. STIs/HIV/AIDS are diseases that they associate with prostitutes and men who buy sex. Several participants claim that there are no STDs in their barangays but while this might be true, a point of concern to some women and BHWs is the existence of risk conditions and behaviors among men and adolescents in some areas that might lead to contracting STIs. Geographical limitations and the inadequacy of social services (especially transportation and communication) that hinder the dissemination of appropriate information on the prevention and management of STIs/HIV/AIDS make conditions riskier to a community that is isolated and unknowledgeable on the nature of such diseases.

Violence Against Women And Children (VAWC). While there are mixed feelings on VAWC, violence is perceived to be mostly in physical form. A husband who resorts to violence is perceived as a sadist, irresponsible, lazy, ill-mannered, and rude. On the otherhand, women who hit their husbands are described as “very proud.”

There are unreported rape cases in Bantay, which were apparently amicably settled between the relatives of the mother-child victims and the perpetrators. There are cases of rape within the family due to drug dependency and alcoholism. Data culled from the Municipal Social Welfare Development Office from 2001-2005 indicate that most of the VAWC reported cases in Paracelis are sexual and physical assaults. Needless to say, difficult access to these areas will again prevent the monitoring and proper intervention in such cases.

A common reason that surfaced on why VAWC occurs is the difficulties of life that cause the husbands to get impatient with their wives and children. Marital relations get strained because life is overburdened with the lack of roads.

Gender inequalities reflected in community perceptions on VAW are underlying reasons why acts of VAW are committed and perpetuated. Women are expected to live up to some roles and behaviors; and carry out some tasks considered as obligations, such as the fulfillment of their husbands’ sexual needs. Failure to meet such expectations can be a just reason for the husband or male partner to discipline his partner; and if the flaw or shortcoming is gross (again, this is relative from the husband’s vantage point), the disciplining can even become physical, not to mention the verbal attacks that accompany the physical act of violence.

There is a certain degree of tolerance to VAWC permeating the community. For some of the participants, VAW is acceptable as long as the act is not too brutal. Also, participants believe that it is a private concern confined only within the household. This culture of silence perpetuates the condition of disempowerment and inequality that most women experience in terms of their gender and reproductive health rights.

Building Better Roads to Better SRH
Certain factors need consideration in implementing programs and projects on reproductive health at the barangay level. First is the readiness and willingness of the people to accept novel health concepts and methods. A suggested entry point is the establishment of road networks, and eventually the provision of other essential social services like the construction of more primary and secondary schools and the development of potable water sources. It is important to position interventions so that the infusion of infrastructure will be perceived by the people as connected to the pursuit of health.

Equally important in the endeavor is to encourage and develop initiatives of the communities in the achievement of project goals. One way of doing this is the creation of community health schemes that they themselves develop and operate. The inclusion of reproductive health concerns in the Barangay Development Plan should also be prioritized. A health fund should be allocated for this purpose. However, this could only be realized if the municipal LGU will take an active stance in empowering those at the barangay level on the planning and implementation of such programs. The barangay councils are unprecedently open about the idea of including RH programs in their development plans; they just expressed the need to be oriented and trained. The institutionalization of more RH and gender programs at the barangay level, which include among others, an orientation and training program for a gender-responsive, rights-based integrated RH service delivery is an integral step in capacitating barangay local government units (LGUs).

Another factor to be considered is the readiness of health providers to accommodate the demand of the community. The lack of skilled health workers and health facilities needs attention. Barangays are widely dispersed and accessibility to only one district hospital, one rural health unit, and nine barangay health stations for each of the nine barangays have inadequately addressed the health concerns of the people. Nevertheless, there are many ways to strengthen the exisiting health systems in the areas. This could be done by reinforcing the Inter-local Health Zones for efficient service delivery, care and support at all levels of society alongside infrastructure development to facilitate accessing the said IHZs. This initiative could go hand in hand with the development of efficient referral and information management systems. Local Health Boards and Barangay Health Committees should also be institutionalized, activated, directed and focused. It should be taking the lead in RH management in the barangay, municipal and provincial levels.

It is important to note that the primary role of creating a good environment that will promote and nurture these intitiatives rests on the LGUs. Local chief executives should be in the forefront of advocating health policies and initiatives. This could be achieved, for instance, by instituting sustainable community-based activities that would center on RH, gender and population development programs. Preventive education, for example, should be started early, so health-seeking behaviors and behavioral change can be developed.

There is also a great need for the LGUs, including various sectors of society to network/link/collaborate with each other on health concerns. At the barangay level, it is necessary to bridge the gap between the barangay council and the barangay health unit through open communication, mutual support and integrated health planning. LGUs should also develop IECs to increase public awareness on MCH, FP, VAWC, ASRH and STI/HIV/AIDS and make this a continuous and sustained process. There has to be a concerted effort to organize practitioners for medical service provision on these RH elements. A general orientation on the flow of relationships, communication and information, referral system, reporting, and monitoring is necessary to be able to determine the magnitude of cases, and to document proficiently these cases. The LGUs should look at creative interventions that require fewer funds but will produce more results. Furthermore, LGUs should adopt a holistic intervention in educating for health development through disciplinary/ multidisciplinary/ transdisciplinary approaches to addressing RH-ASRH issues. The interplay of economic, social, political, cultural, and environmental factors will greatly facilitate education for health development.

About PHSSA The Philippine Health Social Sciences Association (PHSSA) is an NGO comprising of health professionals and health social science advocates. It encourages community participation in developing approaches that would integrate health social sciences in policy and program formulation and implementation. PHSSA may be reached at

The original article of this appeared in Health Alert Asia Pacific Issue No. 10, 2007 (Supplementary issue). For copies of the newsletter, please email