The Provincial Government of Bulacan [PGB], through its public health arm, the Bulacan Provincial Health Office [PHO], in partnership with the different local government units [LGUs] and their health offices shall implement the 2009 Annual Operations Plan [AOP]. The AOP takes off from the mid-term, 5-year 2009-2013 Bulacan Provincial Investment Plan for Health [PIPH], incorporating learned lessons and strategies in improving the delivery of quality public health care. The AOP PIPH shall continue health sector reform initiatives in the province aimed at further improving the way quality health care is delivered, regulated, financed and governed.
Towards this end, the Bulacan 2009 AOP shall continue to achieve better health outcomes, a more responsive health system attune with the changing conditions of the province and needs of its constituents, and proving equitable health care financing, particularly for the marginalized and poor sectors of the provincial population.
General Description of the AOP
1. Health Situation as of end of 2008
1.1. Rabies Elimination Services
For 2008, Bulacan registered a total of 8,584 animal bites and six  cases of human rabies. San Jose del Monte City registered 3,854, Malolos City with 944, Hagonoy with 601 and Marilao with 521 animal bite cases. The province of Bulacan has established animal bite centers in the six  district hospitals and at the Bulacan Medical Center to initially assess and provide treatment to animal bite cases. If vaccination was needed, the centers provided the initial doses of active immunization vaccine. Human rabies cases are immediately referred to San Lazaro Hospital in Manila City.
Animal bite cases in the province were primarily due to the neglect of owners to vaccinate their pets with anti-rabies. Moreover, stray dogs continue to proliferate in the streets. More than twenty  LGUs have no mechanism to register pet dogs. Due to limited funds, LGUs have inadequate free vaccines for anti-rabies. LGUs did not have adequate resources to impound stray dogs, making children, the youth and old alike vulnerable to dog bites.
The PHO is working hand in hand with the Provincial Agriculture Office [PAO] that has the mandate for dog immunization and has the resources for dog vaccines for immunization. Dog immunization is done by the PAO in coordination with the Municipal Agriculture Offices [MAOs]. These offices also handle health promotion in terms of responsible pet ownership at the level of the community.
LGUs lacked the resources and manpower to enforce existing ordinances on the vaccination of pet dogs in their respective areas. Also, most public health personnel were not trained on Animal Bite Treatment and Management. There was also the problem of delayed management of animal bite cases in 19 municipalities/cities where there is no dog bite center. Referral system for animal bites is weak among health facilities.
Due to the lack of knowledge of the public on rabies, poor families resorted to “tawak” for the treatment and management of rabies. The limited supply and/or expensive anti-rabies vaccines for pre- and post-exposure exacerbated this. Only when symptoms become critical that families sent the victims to the bite centers, making treatment difficult.
1.2. Leprosy Elimination Services
In 2008, Bulacan registered 13 patients afflicted with leprosy located in the municipalities of Angat, Balagtas, Baliuag, Bocaue, Guiguinto, Marilao, San Miguel and Santa Maria, with a prevalence rate of 0.04/10,000 population. While the number of cases is considered low compared to the other provinces in Region III, there is a need to conduct active case finding in the 24 municipalities/cities. Training on leprosy detection, treatment and management needs to be provided to health workers and volunteers at the community levels for case finding.
The poor health seeking behavior of leprosy patients and their families, lack of awareness on the signs and symptoms of the disease and mode of transmission, social stigma associated with the disease, individual preferences for consultation and limited financial resources contributed to the prevalence of leprosy in the affected municipalities/cities of Bulacan.
Treatment for leprosy cases is at no expense on the part of the patient. Drugs and medicines for leprosy cases are provided free by the DOH and are available at the health centers for the whole duration of the treatment course.
1.3. Malaria Control Services
For several years, four  municipalities and one  city of the province are endemic to malaria. Malaria is seen in the 15 barangays in the four  municipalities of Doña Remedios Trinidad, San Miguel, Norzagaray, San Ildefonso and San Jose del Monte City, afflicting the poor upland dwellers, settlers and indigenous peoples of Aetas and Dumagats roaming in the hinterlands of Bulacan.
The Annual Parasite Incidence in 2008 is 30.7 per 100,0000 population, with 30 confirmed cases out of the 766 clinically diagnosed patients. Morbidity rate of malaria was 26.2/100,000 population. Only 96 of the confirmed and clinically diagnosed cases were given treatment due to lack of anti-malaria drugs at the RHUs. In addition, malaria control program is not devolved yet to the LGUs.
The occurrence of malaria cases in these areas was primarily due to the lack of information of community residents and health personnel on malaria transmission, prevention and treatment. Also, upland human settlements and indigenous peoples make it difficult for patients with malaria symptoms to seek attention from medical facilities. More often than not, malaria cases are found among the indigenous peoples belonging to the Dumagat and Aeta tribes. Due to the nomadic character of these tribes, health care providers find it difficult to identify suspects, modes of transmission and control of the vector because of their mobility, culture and practices. Adding up to new malaria cases are “imported” cases from neighboring endemic provinces of Neva Ecija and Zambales. Many cases came from shipyard workers in Zambales.
There is only one  medical technologist, out of the five  endemic areas, was trained in malaria microscopy. There is a need therefore to identify, train and deploy community health workers to far–flung areas, carrying with them rapid diagnostic test [RDT] kits, collecting smear samples from asymptomatic patients. Vector control materials, e.g., mosquito bed nets and insecticides, are far from the reach of the affected communities. Most often, malaria patients are poor and rarely can afford to purchase untreated mosquito nets, much more treat these with insecticides. Malaria control to be successful in the province must implement the twin strategy of vector control and active case detection and treatment at the local level.
Malaria drugs are provided for by the DOH through the CHD 3. Led by the Bulacan provincial government in partnership with the concerned LGUs, steps must be taken to ensure the availability of anti-malaria drugs to endemic areas through centralized procurement and distribution; promotional activities on the effective and regular use of insecticide-treated bed nets must be conducted in the endemic areas; and the continuous promotion of early diagnosis, management and referral of malaria cases.
2. Intensified Disease Prevention and Control
2.1. Tuberculosis Control Services
TB ranks 5th as the leading cause of mortality and 8th as the leading cause of morbidity. Since 2000 DOTS have been fully implemented in the province’s 57 RHUs. However, provincial performance on case detection rate [CDR] is 63% against the national target of 70% and cure rate of 80% in 2007 compared to national target of 85%. 2008 data shows that ten  out of the 24 municipalities/cities have reached the national standard of CDR of 70%. They are Balagtas, Baliuag, Bocaue, Bulacan, Norzagaray, Obando, Plaridel, San Miguel, Doña Remedios Trinidad and San Jose del Monte City. While six  have reached the national standard of TB Cure Rate of 85%. They are Balagtas, Bulacan, Meycauayan City, Pulilan, Santa Maria and San Jose del Monte City. Records from the Provincial Health Office reported that for 2008, there were 2,088 sputum+ cases, an increase of 25% from the previous year.
Aware of the increasing cases of TB in the various municipalities and cities in the province, 21 LGUs have put in place policies for the purchase of anti-TB Category III drugs; 20 LGUs have policies on the procurement of drugs for primary complex affecting children; while 18 LGUs have detailed policy [free and user’s fee] on the distribution of anti-TB drugs.
TB continues to afflict the poor and non-poor alike in Bulacan. Some of the causes were preference of TB symptomatic patients to seek medical help from private doctors instead of the more accessible public health system; patients did not immediately seek medical attention due to the social stigma associated with the disease; and the overall poor health-seeking behavior of affected households and communities.
In the recent TB validation, monitoring and evaluation of the TB Control program, there were still quite a number of municipalities belonging to the low quadrant meaning low CDR and low cure rate, and these has been given priority by the province in terms of prevention and control. The municipality of Paombong has been subjected to a provincial initiative called TB Patrol. The implementation of the project has garnered 100% local support both from the municipal and barangay officials and the community as well. The impact of the project resulted to active case finding and treatment of positive cases.
While the TB Patrol program has been successful in the identification, organization, training of community members for the anti-TB program, its reach has been limited to only a number of barangays. The project was seen as a “best practice” and is now being targeted for replication to the other LGUs in the province on a staggered basis. There is a need to expand its coverage to 555 barangays of the province.
Health care providers from the public and private health sectors still need to be trained on the WHO/DOH standards for TB detection, treatment and management; more so for newly-hired public health nurses. In Bulacan, some public hospitals still preferred to use chest x-ray in the diagnosis of TB rather than the standard and accurate sputum examination. Also, there was no standard protocol for the treatment and management of children with TB.
Though a number of capacity building activities had been conducted in TB control, much more has to be done to completely reduce the TB morbidity and mortality in the province. With the fast turnover of health workers, particularly doctors and nurses, there is an immediate need to orient and re-orient health workers in the efficient and effective implementation of the program.
A total of 40 microscopy centers are located in the main RHUs throughout the province and a quality control laboratory at the PHO. Validation of sputum slides is done by the program coordinator, in tandem with a medical technologist at the QC Laboratory in the province.
Based on the recent monitoring and validation of the TB program, it was found out that 15% of microscopy services did not comply with established standards of laboratory procedures. This puts into question sputum examination done by these laboratories. On-board medical technologists from Guiguinto, Paombong, Angat, Bocaue and Norzagaray have to undergo refresher course on laboratory procedures and TB sputum examination. Also, sputum collection area at the RHU facilities needs to be upgraded to conform to NTP standards. This is one factor why only twelve  out of the 57 rural health units are TB-DOTS-accredited by the PHIC.
The constant exposure to residues by laborers within the pyrotechnics industry in the province contributed also to TB morbidity and mortality. Around 100,000 individuals are dependent on this industry. These are located in Bocaue, Santa Maria, Baliuag and neighboring municipalities; while the marble industry is located in San Ildefonso, Doña Remedios Trinidad, San Rafael, San Miguel and Norzagaray. Due to the nature of these industries, workers and communities alike are vulnerable to lung-related diseases. Government must encourage companies to provide healthy work environments for its workers.
The role and practice of private physicians in the province as to TB treatment protocol need to be addressed. The incomplete [indigents/poor] and unsupervised treatment practice of TB patients by private physicians have added up to the increase in multi-drug resistance (MDR) among TB patients in the province. Thus, one strategy to resolve this problem is a collaborative effort among private practitioners is through the Public-Private Mixed DOTS (PPMD). The municipalities of San Miguel and Hagonoy had established a PPMD referral system. The TB Diagnostics Committee [TBDC] will have to review referrals and recommend appropriate treatment management for the projected increase in the number of sputum+ patients.
2.2. HIV/AIDS/STD/STI Control Services
With the highly urbanizing character of Bulacan and its proximity to a former military American base [Clark Air Field in Angeles City, Pampanga] and the National Capital Region, there is a strong trend for the commercial sex industry to proliferate in the province, particularly in Bocaue, Marilao, Pulilan, Malolos City, Baliuag, Bustos, Meycauayan City and San Jose del Monte City. These areas are host to a large number of karaoke bars, watering holes, and assorted commercial establishments suspected of employing commercial sex workers [CSWs]. Aware of this situation and as an interim measure, the National STD Program is being vigorously implemented by the different RHUs. The STD program includes regular smearing and treatment of registered and unregistered CSWs. For 2008, total smear examined was 5,485 and 375 cases were treated for gonorrhea and other STDs/STIs. However, a more comprehensive strategy and appropriate approaches need to be developed to respond to the threats posed by HIV/AIDS/STD/STI.
Target municipalities need to conduct rapid risk assessment to map out high-risk groups in their localities. There is a need to establish social hygiene clinics in strategic areas to cater to high-risk groups such as CSWs, men having sex with men [MSM], and the growing number of drug dependents using needles, among others. Regulation in the operation of establishments catering such kind of businesses needs to reach the attention of local officials.
Also, health care providers need to be trained on HIV/AIDS/STD/STI detection, treatment and management protocols. At the provincial level, there is a need to establish a reporting and monitoring mechanism to immediately identify potential HIV/AIDS/STD/STI breakout areas. A technical assistance package on HIV/AIDS/STD/STI prevention program is currently being supported by the national government and implemented in the province of Bulacan. One mechanism being discussed is the formation of the Bulacan HIV/AIDS Council to serve as an advisory board to the province to respond to the growing threat of HIV/AIDS/STD/STI.
2.3. Dengue Control Services
Dengue morbidity, with more than 100 cases in 2008, were noted in the municipalities of Calumpit and Plaridel and the cities of Malolos and San Jose del Monte. Death was usually due to late detection of signs and symptoms and late referral to hospital care making its treatment difficult at best. Morbidity was distributed in the 24 municipalities/cities. Factors contributing to dengue prevalence in Bulacan are the following: improper waste disposal that waste materials have become breeding sites of the vector, lack of discipline of the community residents in maintaining the cleanliness of their immediate environment; weak implementation of local ordinance in support of waste management and community cleaning practices such as proper waste disposal, de-clogging of waterways and cleaning of backyards of open containers to eliminate mosquito breeding sites; and inadequate information of the community on the early symptoms of dengue.
The province had taken steps to reduce dengue morbidity and mortality. To address this problem, the province held the Dengue Summit last year, in collaboration with the different stakeholders. Highlighted in the summit was the creation of Dengue Skul Watch teams that served as extension units of the surveillance arm of RHUs. Its tasks were to locate suspected cases of dengue in schools, monitoring of absentees due to simple signs of fever and reporting to health officials for immediate mitigation measures. Parallel activities conducted were health promotion and intensified advocacy campaign in the province and LGUs.
In a collaborative effort with the Department of Education, health care providers continuously conduct information drive to elementary and secondary schools targeting children, parents and teachers. Around 50 central schools sustain the project “Sa Iskul Ligtas Ako Sa Dengue” started last June 2007. The program was launched at the Balagtas Central School, Balagtas, Bulacan. The province is on its expansion effort of increasing the organized Dengue Skul Watch teams. There is a need to increase information materials to be provided to these teams as roving health advocates.
Efforts by LGUs to fumigate known and suspected breeding sites of carrier mosquitoes can be complemented by an aggressive information campaign to increase knowledge of communities in combating dengue. The “search and destroy operations” by frontline health personnel, the barangay health workers, proved to be an effective vector control measure.
The cooperation of the different barangay LGUs is needed in the formulation and enforcement of sanitation ordinances as another vector control measure. There is a need also to continue monitoring and conduct surveillance activities to eliminate the breeding sites and the dengue vector as well through the activation of City/Municipal Epidemiology and Surveillance Unit [MESU].
2.4. Emerging and Reemerging Infection Prevention and Control Services
The province was not spared when the first A[H1N1] case was detected in a secondary school in Bulakan, Bulacan. After the disease panned out, 44 cases of A[H1N1] were recorded in the province. No death was recorded and all cases have recovered from mild influenza. Initial reactions to disease resulted to the temporary cancellation of school until the required 7 days lapsed putting a cut on the transmission of the virus.
It was also in Bulacan that the first Ebola Reston case was detected. Two  human cases, farm workers at the Win Piggery Farm were subjected to laboratory examinations and treatment and closely monitored by the DOH. As a confirmed source of the virus, a piggery farm terminated 6,000 heads of pigs to prevent the further spread of the disease among animals and possible transmission to human. No mortality among suspected/affected human farm workers was noted. Health personnel conducted a series of debriefing sessions among affected farm workers and their families.
Health workers in the field are constantly monitoring suspected cases. Prompt reporting and referral to higher level care facilities contributed in case and mortality control. Existing disease surveillance system established at the provincial and district hospitals as sentinel sites and 12 municipalities trained in surveillance and basic epidemiology have proven to work in instances where it is needed. The need to expand the training on basic epidemiology to the remaining 12 LGUs and newly hired health workers is an immediate concern to respond to emerging and re-emerging diseases.
The province has been pro-active in responding to health emergencies through the enactment of ordinances and/or issuances of memoranda mobilizing all levels of responses for health and health-related emergencies. The draft Provincial Plan for A[H1N1]/Bird Flu needs to be finalized in coordination with the PAO for publication, reproduction and implementation. Efforts are currently being undertaken to finalize the Bulacan referral system as guidelines for public health workers at the RHUs and hospitals in the province.
Further orientation and capacity building activities on the prevention, detection, treatment and management of these diseases need to be conducted at the level of frontline health workers. Though the Influenza A[H1N1] epidemic has panned out in the province, efforts must be exerted to train RHU personnel on sample collection and updates be regularly conducted.
A comprehensive communications plan needs to be developed for the province. The plan will include the development of promotional materials informing the public on the preventive measures people must take in cases of disease outbreaks.
2.5. Avian Influenza
While the rest of our Southeast Asian neighbors are reeling from the effects of bird flu or avian influenza, the Philippines is still avian influenza-free [bird-flu]. However the conditions that make the Philippines high risk for avian flu is present due to the following reasons. Bulacan is near the Candaba Swamp of Pampanga, considered a haven of trans-migratory birds frequenting the country. Bulacan hosts a large number of poultry farms where there are no bio-security measures in place. There is lack of public awareness about avian influenza. Emergency response and preparedness systems are weak or absent at the local levels. Another contributory factor is the limited participation of the private health sector in the management and treatment of bird flu.
The eight  municipalities of Calumpit, Pulilan, Paombong, Baliuag, Hagonoy, Bulacan, Plaridel, San Ildefonso and Malolos City are the most-at-risk due to its proximity to the Candaba Swamp in Pampanga. Commercial poultry farms are meanwhile concentrated in Pandi, Santa Maria, Pulilan, Baliuag and San Jose del Monte City. Due to the recurring threat of avian flu, the national government formed the National Avian Influenza Task Force to take the lead in the prevention, treatment and management of avian influenza outbreaks. The Task Force identified the province of Bulacan, one among twenty  critical provinces, where the Department of Agriculture’s Bureau of Animal Industry [DA–BAI] conducts bi-annual surveillance of poultry farms. In 2006, the province and the 9 at-risk areas, with assistance from the DOH, DA–BAI and USAID, formulated their AI Preparedness and Response Plan. IEC materials in support of the avian influenza awareness campaign were distributed. The P/LGU organized the Bulacan Provincial AI Task. Local plans are currently under review.
3. Child Health
Reducing infant and under-5 mortality from 5.76/1,000 LB to 2/1,000 LB by 2013 is one of the goals of the DOH under its National Objectives for Health.
For the past several years, pneumonia topped the leading cause of death with 90 deaths or 29.51% of total infant deaths. Prematurity ranked second with 35 deaths or 11.48%; and congenital anomalies ranked third with 26 deaths or 8.52% of total infant deaths. For 2008, the IMR was only 4.72/1,000 LB, which is very low compared to the national average. Norzagaray reported the highest IMR at 14.71 per thousand live births, followed closely by Angat at 14.51% and Hagonoy at 14.42%.
3.1. Expanded Program on Immunization [EPI]
While immunization average has slowly improved in some areas, recently, there is wide disparity between barangays, municipalities and cities. There have been difficulties observed in the delivery of health care services to the marginalized and unreachable populace, particularly in the upland villages of Bulacan. For this program the province of Bulacan has immunized a total of 75,325 infants. This number covers 86% of the total children needing immunization, with an unmet need of 9%.
The high coverage of the immunization program in the province was primarily due to the availability of vaccines provided by the DOH during its Garantisadong Pambata [GP] activity. However, there is a need to systematize recording and reporting of children to address universal coverage, at least 95% of all children.
Another positive factor is the strong technical relationship between the DOH and the LGUs that has been evident during the conduct of the specific health program mobilization. Trained and capable health program coordinators and local counterpart staff are readily available to provide the support and services whenever immediate or long-term health actions are needed. The continuing national and local technical sharing and arrangements facilitate the establishment of a functional coordinating mechanism and delivery structure for public health programs such as immunization.
Public health care providers may conduct community assemblies, mother’s classes and house visitations to inform mothers and caregivers not only on the importance of vaccinating their children but also to encourage them on the proper child growth and rearing practices.