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June 26, 1970
AGREEMENT BETWEEN THE REPUBLIC OF THE PHILIPPINES AND THE UNITED NATIONS CHILDREN'S FUND CONCERNING MATERNAL AND CHILD NUTRITION PROGRAMME
Note; The Agreement entered into force, June 26, 1970.
Reference: This Agreement is also published in IX DFA TS No. 1, p. 53.
25 May 1970
Sir:
I have the honour to refer to the Second Addendum to the Plan of Operations for a General Health Services Project in the Philippines, signed by the Government on 23 September 1969, by the World Health Organization on 1 August 1969, and by the United Nations Children's Fund on 11 July 1960, and the Annex I thereto, specifically as it applies to the provision of drugs and dietary supplements to rural health units, paragraph 3.2.1, and to assistance to a malnourished children's ward, paragraph 3.4.1
This is a complementary project related to the Master Plan of Operations for General Health Services Development in the Philippines, signed on behalf of WHO on 20 November 1969 and on behalf of the Government by the Secretary of Foreign Affairs on 20 January 1970 to which UNICEF is related by virtue of a Letter of Protocol signed by the UNICEF Resident Director on 2 January 1970 and confirmed by the Government on 12 February 1970.
1. The purpose of this letter is to formalize the further agreement between the Government, WHO and UNICEF with regard to continued UNICEF assistance to the community health services of the Government, particularly as they apply to maternal and child nutrition, through the end of 1971.
2. Assistance to Rural Health Units. UNICEF will continue to supply drug and dietary supplements in the amount of $68,700 to the existing rural health units, on a diminishing scale, as agreed to paragraph 2.1.2 of Annex I to the First Addendum to the Plan of Operations for a General Health Services Project in the Philippines, signed in June and July 1968 by the Government, World Health Organization, and the United Nations Children's Fund.
3. Assistance to Goiter Control Programme. Under this Exchange of Letters, UNICEF will provide $10,000 worth of iodized oil in 10-cc. vials for use in a highly endemic area and in accordance with a plan of action to be drawn up by the Government with the assistance of a WHO short-term Consultant. It is estimated that this will be sufficient to reach 70,000 patients in a population of approximately 350,000.
4. Assistance to Malnourished Children's Wards
4.1 The Problems. Arising out of nutrition activities of several government agencies and international assistance to nutrition programmes in the Philippines, there has been a growing awareness of nutritional problems of differing degrees:
a. frank clinical malnutrition— especially protein-calorie deficiency (Kwashiorkor and marasmus) and Vitamin A deficiency in toddlers, and nutritional anemias in pregnant women and young children; and
b. borderliner malnutrition and undernutrition in children, often beginning in infancy.
4.2 Role of Hospitals. Frank malnutrition has led to the establishment of malnutrition wards in the National Children's Hospital (Manila), the Southern Islands Hospital (Cebu), and some provincial hospitals (Rizal and Negros Oriental). UNICEF assistance has already been given for equipping the Southern Islands Hospital and Negros Oriental Provincial Hospital, principally with:
a. simple kitchen and related equipment—to facilitate dietary management and teaching of mothers in simple, low-cost child feeding, utilizng available foods;
b. laboratory and ward items—to facilitate appraisal of nutritional status; and
c. a vehicle—to facilitate follow-up of discharged subjects in their home settings and the development of nutritional activities in those places, in collaboration with local health, education and agriculture personnel and to facilitate training of the personnel of the rural health units concerned.
4.3 Future Needs, The Secretary of Health requested (on 31 July 1969) similar UNICEF assistance to seven additional hospitals, including the National Children's Hospital (for this particular hospital, expanded laboratory assistance was requested). He had also requested a WHO Consultant (medical nutritionist) to develop the nutrition work of the National Children's Hospital and WHO is providing this Consultant in 1970. A staff member has been sent on a WHO fellowship to Hyderabad, India (Certificate Course in Nutrition).
4.3.1 A visit was made in September, 1969 by Dr. P.L. Fazzi (Assistant Director of Health Services, WHO/WPRO) and the UNICEF Representative to Cebu and Dumaguete (ref. Report No. WPR/NUTR/FR/63 of 17 October 1969). This report emphasized the need to strengthen particularly the links between the malnutrition ward and the rural health unit (to improve diagnosis, referral, management and follow-up), and to develop training programmes in the existing malnutrition wards, for RHU staff in the provinces concerned.
4.3.2 It was agreed by all parties that there should be co-ordination between developments of (i) the applied nutrition programme of the Department of Education, Bureau of Public Schools (assisted by FAO/WHO/UNICEF, now without international staff; WHO Project Philippine 0508, formerly 0080); (ii) the mothercraft nutrition programme of the Department of Health (assisted by US/AID); and (iii) the development of malnutrition wards, primarily through the Bureau of Hospital Services of the Department of Health.
4.4 Outline of Proposed Developments, 1970/1971
4.4.1 Locations. After due discussion, it was agreed that in principle at least one malnutrition ward should be developed in each of the eight regions and, in some cases, more than one by end 1971. It is proposed that eight new sites be developed, in addition to the two already in operation in Region VI (Southern Islands Hospital in Cebu City and Negros Oriental Provincial Hospital in Dumaguete City). There will be a minimum of one per health region, to be chosen from the following:
The eight additional sites finally agreed upon will be shown in Annex I to this document.
Region I Pangasinan Provincial Hospital (Dagupan City) or Baguio General Hospital (Baguio City).
Region II Cagayan Provincial Hospital (Tuguegarao) or Isabela Hospital (Ilagan). Region III National Children's Hospital (Quezon City—already partially assisted by US/AID). Laguna Provincial Hospital (Sta. Cruz), or Nueva Ecija Provincial Hospital (Cabanatuan City). Region IV Camarines Sur Provincial Hospital (Naga City). Region V Iloilo Provincial Hospital (Iloilo City).
Region VII Zamboanga General Hospital (Zamboanga City).
Region VIII Davao General Hospital (Davao City).
4.4.2 Assistance. The basic pattern of assistance will include:
a. kitchen equipment, nutrition education materials and weighing scales—to be provided by UNICEF.
b. simple laboratory equipment — to be provided by US/AID through the national nutrition programme.
c. a utility vehicle—to be provided by UNICEF.
d. stipends for training of rural health unit personnel and village (volunteer) workers (see Annex II).
4.4.3 Activities
a. Nutritional Rehabilitation. Standardized records will be kept for the admitted subjects. Dietary management will be intensified with maximum use of highly nutritious, low-cost local foods, together with incentive supportive treatment and close assessment of progress.
b. Nutrition Education. Nutrition education will be intensified for the parents during admission. Facilities will be provided so that mothers can practice the preparation of suitable recipes—at least one new one each day; this is necessary since didactic instruction alone is not well absorbed.
c. Follow up. Upon discharge, subjects will be followed up to their homes and links with the local health unit and other concerned agencies established. Where malnourished children are unduly frequent, intensive group educational activities will be developed in the localities concerned.
d. Surveys. In due course, selected areas in the Region or Province will be surveyed to locate and ascertain the prevalence of frank malnutrition ({various forms) and the anthropometric status (amore sensitive indicator of nutritional status). The vehicle will assist in this systematic coverage of the Region.
e. Training of Health Personnel. Training of health personnel will be intensified. It is proposed that at least one physician, nurse and midwife from each RHU will be given five days' training course in the malnutrition ward. During this training, other clinical aspects of importance will be covered, e.g. the fluid and electrolyte rehabilitation of children with severe diarrhea; management of obstetric emergencies, etc. This training may also be coupled with one week's training on public health and family planning, since the Department of Health is currently scheduling field personnel for this training also. (The latter part of this training will be held in the Regional Health Training Centre where one exists — viz., Dagupan, Cebu, Davao, and Iloilo. In the case of Manila, the Office of Health Education and Personnel Training in the Department of Health will be used for this part; the clinical part to be done in the National Children's Hospital.)
This training will enable the health personnel not only to discharge their own nutrition-MCH responsibilities better, but also to give stronger participation and leadership to the ANP, in which the participation of health personnel is not strong enough. For; the 1970 training of RHU personnel in connection with the Southern Islands Hospital in Cebu City and the Negros Oriental Provincial Hospital in Dumaguete City, the funds will be made available from the May 1969 allocation (ref. Annex I to the Second Addendum to the General Health Services Plan of Operations, para. 3.1.2).
f. Toddler Care Centres and Aides. On the basis of some experience of the ANP and the Mothercraft Nutrition programme assisted by US/AID in various localities, it is believed that there is a popular desire for day-care activities, not a formal nursery or pre-school, but a group child-care programme including supplementary feeding (using local foods) in small groups within each barrio. Experimentally, some barrios in Cebu have established such centres and it is planned to extend this activity under the supervision of high-school graduates and other suitable people who are unemployed and resident in the village. The local mothers are willing to contribute PI.00 each monthly for this care. It is crucial to give these girls a simple background in child care. Rural health units will participate in this training in collaboration with ANP personnel and will maintain supervision of the health aspects. Funds for this training are included in the Sixth Addendum to the Plan of Operations for an Applied Nutrition Project in the Philippines (April 1970 recommendation).
This activity will be developed after the training of the RHU personnel. It will be done on an experimental basis only in 1970 in selected areas, with partial extension in 1971 and mainly in 1972.
This activity is envisaged as a practical way of reaching the tod-dler. This group has not been adequately covered by the ANP. Utilizing high-school graduates and others already residing in the villages also encourages generalizing of the US/AID-assisted mothercraft nutrition programme, since the latter utilizes qualified nutritionists to staff the barrio nutrition centres, and the Health Department cannot afford to develop an infrastructure of such magnitude throughout the country.
4.4.4 Plans of Work. Details for each of these activities will be spelled out in plans of work to be drawn up in 1970.
4.4.5 Target Timetable. During 1970, the key personnel from the areas indicated under para. 4.4.1 will be brought to Manila or Cebu for approximately two weeks' intensive training, so that they will be able to organize the necessary ward facilities and training in their own areas of responsibility in 1971. Some of this training of health personnel may not be accomplished until 1972, especially in areas where no formal Regional Health Training Centre has been established as yet (Regions II, IV, and VII).
4.4.6 UNICEF Commitments. UNICEF agrees to provide assistance in the form of simple kitchen ward equipment for the malnourished children's wards and a vehicle for training and supervision, and funds for training of the personnel of the rural health units associated with the wards and for the village (volunteer) workers, as indicated in Annex II. The total cost for implementation in 1971 for eight wards will be $23,000.
In mid 1971 WHO and UNICEF will participate, within the limits of available funds and personnel, with the Government in the evaluation and appraisal of the targets described in this Exchange of Letters.
4.4.7. Commitments of the Government. The commitments of the Government during the fiscal year 1970/1971 will consist of the following:
a. For training of RHU at P5.00 per day for 840 people for 5 days each b. Cost of driver, gasoline, maintenance and spare parts
c. Internal transportation
d. Additional supplies and equipment for the kitchens and wards, to be locally procured by the Government
e. Allowances for health personnel
f. Salaries of health personnel in the wards
Total
4.4.8 Commitments of WHO. The staff of the Western Pacific Regional Office of WHO will provide such technical advice and guidance as may be required for the successful execution of the project.
I should appreciate your confirmation of the above. The signing of nine (9) copies of this Exchange of Letters will constitute an official agreement between the Government and UNICEF, extending the plan of action through the end of 1971. Three (3) copies of this Exchange of Letters are for use of your Government, the remaining six copies are to be returned to this Office for distribution.
Very truly yours, (Sgd.). ANTONY E. MEAGER UNICEF Representative
DONE in 9 copies in English.
CONCURRED ON REHALF OF THE GOVERNMENT OF THE PHILIPPINES:
(Sgd.) JOSE D. INGLES
Acting Secretary of the Philippines
Date: 26 June 1970
ANNEX II*
1. Three-week preservice training.Training of RHU staff. For budget purposes, it is assumed that an average of 35 RHUs will be related to each of the malnourished children's wards and that three staff members of the RHU will require training (this is based on the actual experience in Cebu and Dumaguete). The requirements therefore are: 8 malwards x 35 RHUs x 3 personnel = 840 people x 5 days x P5 = 21,000 or $3,500.
a. Stipend: 25 trainees, subsistence allowance (3 meals and lodging) at P6 per person, 21 days (P6 x 25 x 21)
b. Honorarium for 1 trainer at P10 daily for 21 days (P10 x lx 21)
c. Honorarium for 1 consultant at P19 daily, 21 days (1*19 x 21)
d. One clerk at P8 daily, 21 days (P8 x 21)
e. One artist at P9 daily, 21 days (P9 x 21)
f. Honorarium (meal allowances) for driver, librarian, mimeographer, clerk, P3 daily, 21 days (P3 x 4 x 21)
2. In-service training, one day a week, 35 weeks
a. Stipend: 25 trainees, subsistence allowance (3 meals and lodging) at P6 per person, 35 days, (P6 x 25 x 35) b. Honorarium for 1 trainer at P 10 daily for 35 days (P10 x lx 35)
c. Honorarium for 1 consultant at P19 daily, 35 days (P19 X 35)
Total for one centre
Total for two centres
* Annex I is not available.
** Funds available under the Sixth Addendum of the applied Nutrition Project, reference Annex V.