Unlocking the Functionality of the Health Referral System in Batangas, Philippines

In 2015, Batangas, Philippines, had 86 maternal deaths per 100,000 live births. This high maternal mortality ratio (MMR), along with uncoordinated referral practices, characterized the province's fragmented local health system. This prompted the province to address gaps within its health system performance, beginning with operationalizing a province-wide referral system (PRS). Batangas had previously sought to strengthen care coordination within districts and between hospitals; however, failure to unite stakeholders' visions and maintain collaboration stagnated initiatives. With U.S. Agency for International Development (USAID) support and using collaborating, adapting, and learning (CLA) approaches, in 2016, Batangas used lessons learned from these experiences to restart operationalizing their PRS.

To overcome jurisdictional barriers, we secured the participation of health facilities at different levels in all municipalities and cities and avoided overwhelming stakeholders with tasks by using maternal and child health (MCH) as a tracer program. We created a learning environment that ensured common understanding of service delivery challenges and secured stakeholders' commitment to collaborate against challenges. Through consultations and workshops, we formed a service delivery network (SDN) comprising 67 public and private health care institutions to coordinate delivery of health services. We also installed a PRS monitoring and evaluation (M&E) system to ensure continuous learning and stakeholder engagement in instituting reforms. Since establishing the PRS, referral practices in Batangas have improved, coordinated referrals increased, and MMR significantly decreased. Moreover, M&E data generated local government support to upgrade the capacity of health facilities and make the local health system resilient.