Country Report

Fifth Asian and Pacific Population Conference 11-17 December 2002 Bangkok

PHILIPPINES

Republic of the Philippines Commission on Population September 2002

FOREW ORD

In a span of only five years, the population of the Philippines grew by 7.7 million from 68.8 million in 1995 to 76.5 million in 2000. During this period, the population growth rate (PGR) was 2.36 percent per year, which means the population doubling time will be within 29 years if the rate does not decline (NSO, 2001). Side by side with rapid population growth is poverty, which still grips about a third of the country's 15.3 million households (NSO, 2001a).
This Country Report is timely in that it revisits the link between population/development and poverty, environment, and resources. The Report has two purposes. First, it intends to review the Philippine population/development situation, including issues of reproductive health and gender equity, from the perspective of goals affirmed in the Bali Declaration, the ICPD Program of Action and other related documents. The report's second purpose is to highlight priority population issues in the context of alleviating poverty and improving the quality of life of Filipinos. To reduce poverty significantly within the coming decade, the Philippines must face the challenge of building the capacities of its vast human capital. Only in this way can Filipino families, especially the poor, meaningfully, responsibly, and productively participate in the development process.

CONTENTS

FOREWORD CONTENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . LIST OF TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . LIST OF ACRONYMS USED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SECTION 1. OVERVIEW: POPULATION AND DEVELOPMENT SITUATION AND PROSPECTS, WITH A SPECIAL FOCUS ON POVERTY Demographic Situation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Poverty Situation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Interrelationship Of Population, Development, And Poverty . . Policy Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Challenges And Future Directions . . . . . . . . . . . . . . . . . . . . . . . . SECTION 2. FERTILITY LEVELS AND TRENDS: IMPLICATIONS FOR RH/FP PROGRAMS Situationer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Major Issues And Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Future Prospects And Directions . . . . . . . . . . . . . . . . . . . . . . . . . . SECTION 3. MORTALITY AND MORBIDITY Situationer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Policies And Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Issues And Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Future Prospects And Directions . . . . . . . . . . . . . . . . . . . . . . . . . . SECTION 4. MIGRATION, URBANIZATION, AND POVERTY Patterns, Trends And Levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Internal Migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Urbanization Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . International Migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Impact of Public Policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Challenges and Future Directions . . . . . . . . . . . . . . . . . . . . . . . . . ii v vi 1 2 2 4 5 6 8 9 9 13 13 15 15 18 20 21 22 22 22 23 25 28 30

ii

SECTION 5.

POPULATION AGEING Situationer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Programs and Initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Issues and Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

32 32 33 34 35 37 37 39 40 44 44 46 Profile 46 48 48 51 51 54 55

SECTION 6.

FROM FAMILY PLANNING TO REPRODUCTIVE HEALTH: A PARADIGM SHIFT IN POLICIES AND PROGRAMS Programs and Initiatives . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . State of Reproductive Health . . . . . . . . . . . . . . . . . . . . . . . . . . . Operationalizing RH Programs .. . . . . . . . . . . . . . . . . . . . . . . . Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prospects and Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

SECTION 7.

ADOLESCENT REPRODUCTIVE HEALTH Socio-Economic

...............................
Health Situation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adolescent Health Risk Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . Policy and Program Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . Initiatives and Best Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Future Directions and Prospects . . . . . . . . . . . . . . . . . . . . . . . . . . SECTION 8. ECONOMIC AND SOCIAL IMPACT OF HIV/AIDS Status and Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Policies and Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Best Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Issues and Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SECTION 9. GENDER EQUALITY AND DEVELOPMENT Policies, Plans and Programs . . . . . . . . . . . . . . . . . . . . . . . . . . The State of Gender Equality and Equity . . . . . . . . . . . . . . . . . . . Current Initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

56 56 57 58 59 61 61 62 65 66

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SECTION 10.

IEC, ADVOCACY AND ICT IEC for Behavioral Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . Advocacy and IEC for a Supportive Policy Environment . . . . . . Strengthening IEC and Advocacy efforts through ICT . . . . . . . . Prospects and Future Directions . . . . . . . . . . . . . . . . . . . . . . . . . .

67 67 67 71 72 73 73 74 76 77 77 78

SECTION 11.

DATA, RESEARCH AND TRAINING Philippine Population Database Information System . . . . . . . . . Population and Development (POPDEV) Indicators and Databases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sources of Data ......................................... Training on Data and Information Management . . . . . . . . . . . . . Issues and Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Future Prospects and Directions ...........................

SECTION 12.

PARTNERSHIPS AND RESOURCES Partnership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . What Needs to be Done . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

79 79 83 86 89 ix

SECTION 13.

SUMMARY AND CONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . .

REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

iv

LIST OF TABLES

TABLE 1-1.

BOTTOM 15 PROVINCES BY POVERTY INCIDENCE, IMR, MMR AND TFR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . WANTED FERTILITY RATES: TOTAL WANTED FERTILITY AND TOTAL FERTILITY RATES FOR THE THREE YEARS PRECEDING THE SURVEY, PHILIPPINES 1998 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . UNMET NEED FOR FAMILY PLANNING SERVICES, PHILIPPINES 1998 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
...................

TABLE 2-1.

11 1 2

TABLE 2-2.

TABLE 3-1. TABLE 3-2. TABLE 4-1.

DECELERATING INFANT MORTALITY DECLINE. . . . . . . . . . . . . . . . LIFE EXPECTANCY AT BIRTH BY SEX : PHILIPPINES, 1970-1995. . . GROWTH RATES OF URBAN, RURAL, AND PHILIPPINE POPULATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..............

15 17 2 3

TABLE 4-2. TABLE 4-3.

THE URBAN-RURAL DIVIDE IN THE PHILIPPINES: 1960-1995 . . . . . TOP TEN SOURCES OF REMITTANCES AND PERCENTAGES OF WOMEN OFWs: 1998 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..............

24 2 5

TABLE 4-4. TABLE 12-1.

OFW FOREIGN EXCHANGE REMITTANCES BY YEAR: 1990-2000. . . FUNDING OF THE PPMP, 1994-1998 (IN MILLION PESOS). . . . . . . . .

28 84

LIST OF ACRONYMS USED ADB AHYDP AO APARH APCRH APPC ARH ARI AusAID AYH AYHDP BCYA BSPO CAIS CAR CBA CBMIS CHED CII CPA CPR CRC CYC DCAHD DECS DepEd DEVCON DOH DOLE DSWD DTC FAD FHEP FP FPOP GAD GNI-PPP GO GPTRC GTZ HAIN HLURB HSRA ICPD ICT IEC IMCCSI IMCH IMR IRA Asian Development Bank Adolescent Health and Youth Development Program Administrative Order Asia Pacific Alliance for Reproductive Health Asia Pacific Conference on Reproductive Health Asia Pacific Population Conference Adolescent Reproductive Health Acute Respiratory Infection Australian Agency for International Development Adolescent Youth Health Adolescent and Youth Health Development Program Baguio Center for Young Adults Barangay Supply Point Officers Communications and Advocacy Information System Cordillera Autonomous Region Collective Bargaining Agreement Community Based Management Information System Commission on Higher Education Contraceptive Interdependence Initiative Country Population Assessment Contraceptive Prevalence Rate Convention on the Rights of Children Cebu Youth Center Department of Child and Adolescent Health and Development Department of Education, Culture and Sports Department of Education Development Concepts, Inc. Department of Health Department of Labor and Employment Department of Social Welfare and Development Davao Teen Center Foundation for Adolescent Development, Inc. Feminine Hygiene Education Program Family Planning Family Planning Organization of the Philippines Gender and Development Gross National Income in Purchasing Power Parity Government Organization Geriacare Physical Therapy and Rehabilitation Center German Technical Cooperation Health Action Information Network Housing and Land Use Regulatory Board Health Sector Reform Agenda International Conference on Population Development Information, Communications Technology Information, Education and Communication Integrated Maternal and Child Care Services, Inc. Institute of Maternal and Child Health Infant Mortality Rate Internal Revenue Allotment vi

IRR ISSA JHU JICA JOICFP JSI KALAHI KfW LEPOPHIL LGUs LPP LPP MCH MCHS MDG MGP MMR MTPDP MTPIP NAPC NCR NCRFW NDHS NDS NEDA NFP NGO NPDIS NSCB NSO NYC NYDP ODA OSY OWWA PAFLO PCPD PLCPD PNA PNGOC POEA POPCOM POPDEV POPED POs PPAOP PPIC PPMP PPMP-DP PRRM PVOs RA REAP RH RHAN

Implementing Rules and Regulations Institute of Social Studies and Action Johns Hopkins University Japan International Cooperation Agency Japanese Organization for International Cooperation in Family Planning John Snow, International Kapit-Bisig Laban sa Kahirapan Kreditanstalt fur Wiederanfpan League of Population Officers in the Philippines Local Government Units Labor Population Program Local Performance Program Maternal and Child Health Maternal Care and Health Survey Millennium Development Goal Matching Grant Program Maternal Mortality Rate Medium Term Philippine Development Plan Medium Term Public Investment Program National Anti- Poverty Commission National Capital Region National Commission on the Role of Filipino Women National Demographic and Health Survey National Demographic Survey National Economic and Development Authority Natural Family Planning Non-governmental Organization National Population and Development Information System National Statistical Coordination Board National Statistics Office National Youth Commission National Youth Development Plan Official Development Assistance Out-of- School Youth Overseas Workers Welfare Administration Population Awareness and Family Life Orientation Philippine Center for Population and Development Philippine Legislators Committee for Population and Development Philippine Nurses Association Philippine NGO Council for Population Health and Welfare Philippine Overseas Employment Administration Commission on Population Population and Development Population Education Peoples Organizations Philippine Plan of Action for Older Persons Philippine Population Information Center Philippine Population Management Program Philippine Population Management Program Directional Plan Philippine Rural Reconstruction Movement, Private Voluntary Organizations Republic Act Responsible Adolescent and Parenting Reproductive Health Reproductive Health Advocacy Network vii

RTI SCARTY SEXTERS SHAPE SMAM SOP SPPR STDs TESDA TFG TFR TUCP TWG UDHA UN UNFPA UNICEF UPPI USAID VAW WHO WID YAFSS YHES

Reproductive Tract Infection Sorsogon City Advocacy for Responsible Team of Youth Sexually Responsible Teeners Sexually, Healthy and Personally Effective Adolescents Singulate Mean Age at Marriage Strategic Operational Plan State of the Philippine Population Report Sexually Transmitted Diseases Technical Education and Skills Development Authority The Futures Group International Total Fertility Rate Trade Union Congress of the Philippines Technical Working Group Urban Development and Housing Act United Nations United Nations Population Fund United Nations Childrens Educational Fund University of the Philippine Population Institute United States Agency for International Development Violence Against Women World Health Organization Women in Development Young Adult Fertility and Sexuality Survey Youth for Human and Ecological Security

viii

EXECUTIVESUM M ARY

The purpose of the Philippine Country Report for the Fifth Asian and Pacific Population Conference is to review the Philippines population-development situation, including reproductive health and gender equity concerns, from the perspective of the goals affirmed in the Bali Declaration, the ICPD Program of Action, and other related international commitments. This report highlights priority population issues in the context of alleviating poverty and improving the quality of life of Filipinos. Population and poverty variables in the Philippines appear to be closely associated. The 76.5-million Philippine population continues to grow at a fast pace. At the same time, the proportion of 15.3 million households below the poverty threshold also continues to increase. Population momentum makes it a certainty that the Philippines will have a young population in the coming three decades. This implies an increasing need for reproductive health and family planning supplies and services for a major segment of the population in the age group 15 to 49 years old. It is likely that they will want help to attain the number of children that they want. Nevertheless, if the current demographic trend will continue, it is also likely that they will bring into being one child more, on average, than their desired fertility. Poverty alleviation continues to be the governments priority program, and has been since the 1980s. Despite the glaring lack of comprehensive legislation that addresses the close link between poverty, development, and population, the country to some degree has incorporated the population dimension into development planning. The main instrument for this is the current MTPDP produced by NEDA and the Philippine Population Management Program, managed by the Commission on Population. As this Country Report will discuss, the Philippines is still far from achieving its population and human development goals. Happily, there have been modest but concrete gains, particularly in reducing infant and under-five mortality, and even in family planning practice. These are reflected in improvements in the general health condition and survival indicators of the population. Many challenges remain, especially in the areas of contraceptive security and program sustainability. These and other issues are discussed at length in this report.

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S E C T I O N 1

OVERVIEW POPULATIONAND DEVELOPM ENT ITUATION : S AND PROSPECTS WITH A SPECIAL FOCUS ON POVERTY ,

The Philippines implements poverty alleviation and broad-based development policies in the face of a rapidly growing population. The Government pursues a population management program, which as stated in the 2001-2004 Medium Term Philippine Development Plan (MTPDP), seeks to improve the reproductive health of women, men, and adolescents (NEDA, 2001). The Philippine Population Management Program (PPMP) upholds the freedom of couples to choose from a menu of family planning services and respects cultural and religious beliefs in support of responsible parenthood. The national government continues to forge partnerships with Local Government Units (LGUs) and NonGovernment Organizations (NGOs) to achieve the program's goals and ensure that poor couples are guaranteed access to family planning services. This section chronicles population policy developments and programs implemented as they address targets set in the Bali Declaration on Population and Sustainable Development, the ICPD Programme of Action, and the Millennium Development Agenda. The relationship between poverty and the Population and Development situation is discussed by assessing the capability of the country to meet the commitments it made in the various forums cited. The concluding portion then discusses challenges and options for the future.
DEMOGRAPHIC SITUATION

Of the estimated 37.1-million increase in population from 1995 to 2020, 66.3 percent will be due to population momentum, 18.1 percent to high family size preferences, and 15.6 percent to unwanted fertility (Herrin and Costello, 1996). The population is considered young. In 1995, about 38 percent of Filipinos were below 15 years, 23 percent were adolescents (10-19 years old), and 20 percent were considered 2

youth (age 15-24 years). The female population aged 10-49 was estimated (based on medium assumption) at 62.23 percent of the total female population. Clearly, in addressing the reproductive health (RH) needs of this large segment of the population, particular focus must go to needs and risks related to sexual and fertility behavior (POPCOM, 2000a).

The Philippines is still far from achieving its fertility targets. The 1993 National Demographic Survey (NDS) and the 1998 National Demographic and Health Survey (NDHS) revealed that the total fertility rate (TFR) declined slightly between 1991 and 1996, i.e., from 4.1 to 3.7 children.1 The 1998 NDHS also revealed that the total wanted fertility rate was 2.7 children. The one-child difference in desired fertility and actual fertility of women in 1996 (POPCOM, 2000a) strongly suggests an unmet need for family planning. The TFR in the Philippines is expected to go down to 3.2 in 2002 (NSO, 1995). This is still much higher compared with other Asian countries such as Thailand (1.8), Vietnam (2.3), Indonesia (2.3), and Malaysia (3.1) (UN, 2001). Given the high fertility rate, the Philippines will continue to find it difficult to achieve replacement level fertility of about 2.2 children by 2020, which is among the commitments it made in international conferences and assemblies, such as the 1992 Fourth Asia-Pacific Population Conference (APPC) in Bali. Efforts at reducing infant and under-five mortality rates, and maternal mortality ratio (MMR) appear to have gained better results. The infant mortality rate (IMR) declined from 45.6 to 35.1 deaths per 1,000 live births between the periods 0-4 and 10-14 years preceding the survey (NSO et al., 1999). The under-five mortality rate decreased from 72.3 to 48.4 deaths over the same period (NSO et al., 1999). More recent data on infant and under-five mortality rates are far beyond the 2000 goal of 50 deaths per 1,000 live births and 70 deaths per 1,000 children aged below five years old, respectively. The maternal mortality ratio (MMR) in the Philippines was 209 deaths per 100,000 live births during the 1983-1991 period (NSO et al., 1999). In the absence of accurate data on the pace of MMR decline, it is not possible to assess whether the millennium development goal for MMR (i.e., reducing MMR to about half or 105 per 100,000 live births in 2000 and further reducing it by half in 2015) is achievable (NEDA, 2002). In terms of general health conditions and survival prospects, Filipino males born in 1970 were expected to live for about 57 years while females were expected to live for about 61 years, on the average. In 1990, life expectancies increased to 62 years for males and 67

Number of children born to a hypothetical cohort of women assumed to have completed their reproductive years using the current fertility schedule of women age 15-49 years (NSO and Macro International, 1994; NSO et al., 1999).

years for females. In 1995, these indices were estimated to have increased further to 64.5 years for males and 69.7 for females (NSCB, 1995). Longer life expectancies could lead to a larger proportion of the population surviving to more advance ages. There were 3.74 million persons aged 60 and above in 1995. They accounted for about 5.4 percent of the total population. It is estimated that older persons will reach 13.5 percent of the population by 2030 (NEDA, 1980, 1990, 1995 Census; Philippine Population Projections 1980-2000). The older persons have specific needs that have to be addressed by national government agencies, local government units, and even nongovernment organizations (NGOs). Some initiatives have been put in place for this sector. However, more research for this age group is needed to identify appropriate interventions. Because of the relatively young age structure of the population, the Philippine government does not consider population ageing as a problem in the near future. The spatial redistribution of the population, especially by age, and the varying pace of urbanization across geographic space in the Philippines have often been linked to uneven economic development. The force of poverty in the countryside has figured prominently in literature as the engine of urban-ward migration, which in turn has resulted in severe environmental deterioration of highly urbanized areas (Perez, 1998). The growth of slum and squatter settlements, accompanying sanitation problems, water/air pollution, and traffic congestion, among others, are clear proofs of this condition. The population growth rate in cities far exceeds job creation. This increases pressure on real wages, and leads to high levels of unemployment and poverty (HLURB, 1994 as cited in the Philippine Population Management Program Directional Plan for 2001-2004). The segment of the population that is displaced by lowland industrialization and not absorbed by either urban or industrial activities is compelled to seek refuge in upland and coastal areas. Upland-coastal migration increases forest population density. It adds to the strain on the unstable natural environment, which may lead to complex environmental problems (PPMP DP, 2001). POVERTY SITUATION Poverty alleviation continues to be the Government's priority program since the 1980s (NEDA 2002). Over the years, many factors have exacerbated the poverty situation in the country. These include rapid population growth, the Asian financial crisis, the El Nio dryweather phenomenon, and the secessionist conflict in Mindanao. The poverty incidence the proportion of families with per capita income below the poverty threshold declined from 39.9 percent in 1991, to 35.5 percent in 1994, and to 31.8 percent in 1997. However, it increased to 33.7 percent in 2000. This translates to about 5.2 million families who lived in poverty in 2000 (NSCB, 2002). 4

As a proportion of the total population, poverty incidence was estimated at 40 percent or approximately 32 million individuals in 2000. In urban areas, poverty incidence rose from 17.9 percent in 1997 to 19.9 percent in 2000. In rural areas, poverty increased from 44.4 percent to 46.9 percent for the same period. This trend has implications on the poor population's access to health, nutrition, education, and housing services. For the period 1991-2000, more than half (56.7 %) of the poorest families experienced a reduction in income. About a third (37.5 %) experienced an increase in their working hours. The poor save very little of their income, spend two-thirds of their money on food, rely more on public and private income transfers, and are less likely to belong to a cooperative or even a people's organization. They receive public basic education and have less tertiary schooling. Poverty incidence is highest among those who did not finish elementary education (37.8 %) and those who only finished grade six (30.8 %) (MTPDP, 2001). Most of the poor are unable to visit a hospital as a benefit from government Access to public subsidy/programs on health, public housing, livelihood, and credit. infrastructure tends to be low in poor areas (MTPDP, 2001). Majority of the poor (77.4 %) are in the rural areas (Balisacan 1999a; Family Income and Expenditures Survey 1997, as cited in the "Philippine Poverty Assessment" of the World Bank, 2001). Two-thirds depended on agriculture for their income as lessees, tenants, and small owner-cultivators. Compared to poverty in the cities, poverty in the countryside declined at a much slower pace because growth was not sustained and unemployment remained high (World Bank, 2001). INTERRELATIONSHIP OF POPULATION, DEVELOPMENT, AND POVERTY Extreme levels of poverty means families can no longer afford even the minimum basic needs, such as food. Given any fixed level of family income, a large family will have lower per capita expense for basic needs compared with that of a small-sized family. To reduce poverty at the family level, therefore, Filipino couples should have access to the necessary information, resources, and services that can empower them to attain their desired number of children. Women who want to space births or postpone pregnancy but are not using any family planning (FP) method have an unmet need for family planning. Recent data show that unmet need for family planning is largely due to the high costs (monetary and psychological) associated with contraception and obtaining the services (POPCOM, 2001). Nevertheless, it does not follow that couples will practice family planning even if they have access to FP services. Possible reasons for non-use are, among others, fear of side effects, less information, and cultural and religious beliefs. 5

By allowing couples, especially women of reproductive age who have unmet need for family planning, to have access to FP information and services, they will be able to exercise their reproductive rights, achieve their desired fertility, and space births. This will contribute significantly to the well being of their families because couples will have enhanced opportunities to do productive and satisfying work. They also will have the opportunity to be well nourished and be freed from avoidable illness. Planned families are more likely to be economically productive, and thus, less poor. An analysis of the FP/RH situation of 15 poor provinces in the Philippines show that the 10 poorest provinces outside of ARMM and all ARMM provinces have infant mortality rates ranging from 52.09 to 84.08 deaths per 1,000 live births. These are higher than the national level of 48.93 (see Table 1-1). Except for Albay (Region 5), all provinces have maternal mortality ratios ranging from 159.53 to 346.01 maternal deaths per 100,000 live births. These are higher than the national level of 179.74. Except for Sulu, Tawi-Tawi, and Basilan, all other poor provinces had TFRs in 2000 that were higher than the national figure of 3.38.
TABLE 1-1. BOTTOM 15 PROVINCES BY POVERTY INCIDENCE, IMR, MMR AND TFR. Poverty TFR IMR MMR Region Province Incidence 2000 1995 1995 2000 PHILIPPINES 33.7 3.38 48.93 179.74 ARMM Sulu 76.6 2.31 84.08 333.60 V Camarines Norte 67.7 4.33 61.60 218.68 ARMM Tawi-Tawi 66.4 2.52 60.21 299.14 ARMM Basilan 63.2 3.17 60.52 234.08 VIII Eastern Samar 63.0 4.59 65.82 204.35 V Masbate 62.8 5.01 64.34 216.02 CAR Ifugao 60.6 4.49 64.57 236.36 VII Bohol 57.3 3.79 53.86 208.40 VI Negros Occidental 53.0 3.70 52.09 196.70 ARMM Lanao del Sur 52.9 3.56 69.62 346.01 ARMM Maguindanao 51.0 4.17 59.81 278.32 VIII Leyte 48.9 4.39 57.84 201.47 V Albay 47.9 4.15 53.83 159.53 CAR Abra 47.7 3.65 58.57 234.51 Zamboanga del IX 46.7 3.95 58.80 210.80 Norte
Sources: NSO; 1995 TFR Projections as computed by the TWG on Population Projections, NSCB; SPPR 2000.

POLICY MEASURES The Philippine population policy is based on Republic Act (RA) 6365, otherwise known as the Philippine Population Act. This was issued in 1971 and amended by Presidential

Decree No. 79 in 1972. This law created the Commission on Population (POPCOM) and mandated it to study the population problem and implement suitable remedial measures. The strategy adopted was fertility reduction. In the 1987 Constitution, couples are given the right to decide how many children they wish to have according to their religious beliefs and the demands of responsible parenthood. A so-called "cafeteria approach" to family planning allowed married couples to choose the method most appropriate for them from a range of choices that include both natural and artificial methods. This was affirmed by President Gloria Macapagal-Arroyo in declaration of her population policy on Responsible Parenthood for Sustainable Development (APCRH 2001). Under the Arroyo administration, the MTDP embodies the anti-poverty and overall development framework of the administration. The Plan aims to expand and equalize access to economic and social opportunities, inculcate receptivity to change, and promote personal responsibility. It also recognizes the importance of addressing rapid population growth to reinforce the efforts of the administration in infusing a social bias to development (NEDA, 2001). The Philippine Population Management Program Directional Plan (PPMP-DP) for 2001-2004 serves as the blueprint for all programs and projects geared toward attaining rational population growth and distribution in the context of sustainable development. The Program pursues development through an empowered population that is healthy, productive, and sharing in the development process of the country. It has four components: Reproductive Health/Family Planning, Adolescent Health and Youth Development, Population and Development Integration, and Resource Generation, Programming and Mobilization. Also included is a plan to carry out population advocacy efforts more efficiently and effectively at all levels (POPCOM, 2000a). The general objective of the Population Program is to attain sustainable development by helping couples and individuals achieve their desired fertility of 2.7 by 2004 and improve their reproductive health. The Department of Health (DOH) has issued a number of Administrative Orders to provide the policy framework for RH and FP. Administrative Order (AO) 1-A created the Philippine Reproductive Health Program. The AO identified and adopted 10 essential service elements of RH including FP. AO 50 contains the National Family Planning Policy of the government. It refocuses the FP program from a demographically driven program to one that upholds FP as a health intervention. This policy shift promotes the health of all Filipinos with special attention to women and children. It aims to improve the health status of Filipinos by helping couples of reproductive age to attain their desired fertility. It seeks to promote a rate of population growth that matches the pace of economic growth, thereby contributing to sustainable 7

development. This AO prescribes essential policies for family planning as an element of RH (DOH, 2002). The most recent policy instrument is AO 125, which is the National Natural Family Planning (NFP) Strategic Plan for 2002-2006. This strategic plan focuses on the policies, standards, strategies, and activities needed to mainstream NFP methods within the Philippine Family Planning Program for the period 2002-2006 (DOH, 2002). CHALLENGES AND FUTURE DIRECTIONS The ability of the government to supplement household investments in health is held back by demographic forces. Given the country's rapid population growth, it is difficult to maintain a constant increase in public expenditures in health. It is important to reduce the rate of population growth by (a) addressing the unmet need for family planning services, and (b) inculcating responsible parenthood, especially among couples whose family size exceeds their desired number (NEDA, 2001). The PPMP-DP is currently being reinforced through the development of a Strategic Operation Plan (SOP) for 2002-2004 that will focus interventions (e.g., programs and projects) on the poorest areas of the country. The emphasis is on three strategies service delivery, IEC/advocacy, and capability building for the four program components. A companion document is the Population Investment Plan (PIP), which is the list of programs, projects, and activities of the national government, LGUs, NGOs, and the donor community to be undertaken for the period 2002-2004 in support of the three SOP strategies.

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S E C T I O N

FERTILITYLEVELS AND TRENDS : IM PLICATIONS RH/FP P FOR ROGRAM S

This section examines levels and trends in fertility, focusing on issues related to reproductive health programs and future prospects for fertility decline. The relationship between fertility and poverty will also be discussed. Given the socio-cultural milieu and the country's relatively high fertility compared with that of other Asian countries, policy measures that may facilitate further fertility decline will be discussed. SITUATIONER During the 4th Asia Pacific Population Conference (APPC) in Bali in 1992, participating countries pledged to adopt strategies to attain replacement level fertility of around 2.2 children per woman by year 2020 or sooner. Replacement level fertility means couples have only enough children to replace themselves, about two children per couple. Based on the 1998 NDHS, the Philippines is still far from achieving replacement fertility. The TFR was 3.7 in the 1995-1997 period, which is a mere 10 percent decline from the 1990-1992 TFR of 4.1 (NSO et al., 1999). The estimated TFR in 2002 is 3.2 (NSO, 1995). The Philippines lags behind other Asian countries like Indonesia, which in 1991 had a TFR of 3.02 (declining further to 2.86 in 1994). Thailand outpaced Indonesia, achieving replacement fertility of 2.17 in 1990, from a TFR of 5.4 in 1972, or a 60 percent decline in only 18 years. The Republic of Korea achieved replacement fertility of 2.1 in 1984, six years ahead of Thailand (UNFPA, 1999). Fertility declines have been modest in the Philippines, despite high female educational attainment and the relatively high status of women. Rural women exhibited higher fertility than their urban counterparts. The urban TFR of 3.0 in 1996 represented a 15-percent decrease from the 1991 TFR of 3.5, while rural TFR minimally declined from 4.8 in 1991 to 4.7 in 1996 (NSO et al., 1999). While urban fertility in the Philippines has been substantially decreasing at all ages, rural fertility slightly decreased at young ages and minimally increased at ages 25-29 and 35-39. In comparison, Indonesia had an urban TFR of 2.4 in 1997, which is not far above the replacement level. Indonesia's rural TFR, however, was 3.0 during the same year. There are also variances in fertility among the different political regions of the country. At over 5, the fertility levels in

Eastern Visayas and Bicol Regions were more than twice that of Metro Manila (2.5 TFR). These two regions are marked by low levels of development compared with other regions of the Philippines (NSO, 2001). Family size in the Philippines is influenced by factors such as value of children, wanted fertility, unmet need for family planning, contraceptive prevalence rate, age of marriage, and education of women, among others (POPCOM, 2001). The desire for more than two children is associated with the prevailing cultural expectation that children will contribute to family welfare through helping out with household chores and provide financial security for parents in their old age (UNFPA, 1999). According to the 1998 NDHS, the desired fertility rate in the Philippines is 2.7 children per woman, again, above replacement level. Even in urban areas, where about half of currently married women use a contraceptive method, the wanted fertility rate is slightly higher (2.3) than replacement. However, this is somewhat lower than the wanted fertility in urban areas recorded in the 1993 NDS (2.6). A slight increase was noted in the wanted fertility rate of college-educated women (i.e., from 2.4 in 1991 to 2.5 in 1996). Hence, neither urban nor college-educated Filipino women exhibited a reduction to replacement level of their wanted fertility. In rural areas in the country, desired fertility remains one child more than replacement level. The wanted fertility rate in 1996 for rural women was 3.3, which is the same as what was reported five years before (UNFPA, 1999). One way of measuring unwanted fertility is to subtract total wanted fertility rate from TFR. This is, however, an indirect estimate for the number of births that a woman would like to bear by age 50. A more direct definition of unwanted fertility is based on whether any particular pregnancy was planned, unplanned but wanted eventually, or not wanted at all for each child born in the five years preceding the survey. With this later measure, it appears that there was an increase in unwanted fertility from 15.9 percent (1993 NDS) to 18.2 percent (1998 NDHS). However, there was a decrease in the proportion of mistimed or wanted at a later time from 28 percent (1993 NDS) to 26.9 percent (1998 NDHS). Combining the births not wanted at all and those wanted later in the three years prior to the survey shows a 2.6 percent increase in unplanned births from 43.9 percent to 45.1 percent. Table 2-1 presents wanted fertility rates in 1991 and 1996 against the corresponding total fertility rates for the same years by place of residence and women's education level. It appears that Filipino women fail to attain their desired fertility by about one child, on average. In 1996, the actual TFR of 3.7 is higher than the wanted fertility rate of 2.7. The main reasons for this are: (a) high non-use of contraception among women who want to limit and space births; (b) non-use of contraception due to concerns about adverse health effects and husbands objection; and, (c) general higher fertility preference of husbands. 10

As expected, the fertility level is negatively associated with educational attainment although a monotonic decline in actual fertility is not evident in the last two national surveys. Although a slight decrease in fertility is evident among those with elementary and high school education, there seems to be minimal increases in fertility among those with no education and among those with college education. Increasing the educational attainment of the youth today would contribute to a decline in fertility mainly because schooling postpones marriage.
TABLE 2-1. WANTED FERTILITY RATES: TOTAL WANTED FERTILITY AND TOTAL FERTILITY RATES FOR THE THREE YEARS PRECEDING THE SURVEY, PHILIPPINES 1998 Background Wanted Fertility Rates Total Fertility Rate Characteristics 1991 1996 1991 1996 Residence Urban 2.6 2.3 3.5 3.0 Rural 3.3 3.3 4.8 4.7 Education No Education 4.0 3.9 4.9 5.0 Elementary 3.7 3.3 5.5 5.0 High School 2.9 2.7 3.9 3.6 College or 2.4 2.5 2.8 2.9 Higher Total 2.9 2.7 4.1 3.7
Note from source: Rates are based on births to women 15-49 in the period 1-36 months preceding the survey. Sources: NSO, DOH and Macro International, 1999, National Demographic and Health Survey, 1998 as cited in the State of the Philippine Population Report (SPPR) 2000.

The inter-regional and inter-provincial analysis of fertility in the 1998 NDHS further reveals that poor regions and poor provinces have high unmet need for family planning information and services (NSO et. al., 1999). Women have unmet need for family planning if they want to limit or space birth but are not using any family planning methods. In 1993, the unmet need for FP was 26.2 percent. This declined to 19.8 percent in 1998 (see Table 2-2). The slow decline in unmet need for FP may be attributed to the following reasons: (a) strength of fertility preferences; (b) perceived risk of conceiving; (c) perceived effects of contraception on health among both husbands and wives; (d) husbands fertility preferences; and, (e) husbands and wives acceptance of family planning (Casterline, et. al., 1997). Unmet need is highest for spacing among women in the 15-19 and 20-24 years old categories, and for limiting among rural residents and women with at most an elementary education. The unmet need of women stems largely from the high costs that are associated with practicing contraception or getting access to the existing service delivery system (Bongaarts, et. al., 1995 as cited in the State of the Philippine Population Report, 2001). These costs include not just the expenses for access and provision of services but also the non-money 11

costs of the health, social, emotional, and psychological consequences for women. These two costs discourage women from availing of family planning methods (POPCOM, 2001).

TABLE 2-2. UNMET NEED FOR FAMILY PLANNING SERVICES, PHILIPPINES 1998 Unmet Need for Family Planning (%) Characteristics For Spacing For Limiting Total Age 15-19 27.4 4.6 32.1 20-24 21.2 8.2 29.4 25-29 13.5 10.3 23.9 30-34 7.2 11.9 19.1 35-39 4.6 15.2 19.8 40-44 2.3 13.5 15.8 45-49 0.0 6.3 6.3 Residence Urban 7.3 9.0 16.3 Rural 9.8 13.4 23.3 Education No education 14.0 14.5 28.4 Elementary 8.1 15.8 23.9 High school 9.1 9.6 18.7 College or higher 8.1 7.5 15.6 Total 8.6 11.2 19.8
Sources: NSO, DOH and MI, 1999; National Demographic and Health Survey, 1998 as cited in the SPPR 2000.

The decline in unmet need for family planning is reflected in the contraceptive prevalence rate (CPR), which increased from 40.0 percent in 1993 to 46.5 percent in 1998 (NSO, 2001). The increase in CPR occurred in both urban and rural areas. However, the CPR increase was larger in urban than in rural areas. These figures indicate important progress toward contraceptive protection for couples who did not want to conceive. Program factors related to availability, accessibility, and affordability need to be improved as well as the acceptability of contraceptive practice through educational approaches and broad social changes in the values and meaning of children. In examining the changes in the relative contribution of the proximate determinants of fertiiity, Cabigon (2002) and Casterline and others (1988) showed that contraception was the primary factor in explaining the fertility decline over time. Nuptiality played a minor role in curbing fertility while breastfeeding forestalled the fertility inhibiting role of contraception and nuptiality. The singulate mean age at marriage (SMAM) in the Philippines has remained at 24 years based on the 1993 NDS and the 1998 NDHS.

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Experts and stakeholders attribute the slow decline in fertility in the Philippines to the following:

Relatively weak institutional environment for the Philippine Population Program; Perceived influence of the Catholic Church on political leaders; High unmet need for family planning and reproductive health services; Public health infrastructure not fully developed to provide Reproductive Health (RH)capable facilities and providers; Limited financial and organizational ability of nongovernment organizations engaged in FP/RH service provision to scale-up their contributions to the FP program (they now account for only 3 percent of service provision);

Lack of support or even active opposition of some local government leaders; and, Donor-driven nature of the FP program.

MAJOR ISSUES AND CHALLENGES

TFR is still 1.5 births above replacement. The TFR declined much slower during the past decade than UN projections for the next fifteen years. Desired fertility remains above replacement in all major population groups. Unwanted fertility is still relatively high. There is still inadequate access to family planning goods and services for much of the population, especially among poor households. The traditional methods with relatively low use-effectiveness are also more prevalent among poor households.

Local governments give less priority to population programs under devolution. There is a problem of contraceptive security, brought about by the anticipated phase-out of contraceptive support from the USAID starting 2003. The Philippine Family Planning Program still does not give sufficient emphasis to educational strategies that inculcate the value of responsible parenthood. The IEC component of the Program needs to go down from its predominant mass media approach to the interpersonal level. Couples, especially the women, need to be empowered so that they can decide when and how many children to have. Among those already convinced of the value of limiting family size, there is still inadequate access to family planning goods and services, especially among poor households.

FUTURE PROSPECTS AND DIRECTIONS The Philippine Population Management Program Directional Plan (PPMP-DP) for 2001-2004 was prepared and finalized in 2000 under the Estrada Administration. On the assumption into office of President Gloria Macapagal-Arroyo, the National Economic and

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Development Authority reformulated the Medium Term Philippine Development Plan and Medium Term Public Investment Program for 2001-2004 to align it with the new governments anti-poverty agenda. In consonance, POPCOM updated the PPMP-DP and its companion document, the Population Investment Program (PIP). In a meeting on 3 May 2002, the POPCOM Board of Commissioners directed the Commission to draw up a PPMP Strategic Operational Plan (SOP) and Population Investment Program (PIP) for 2002-2004. The PPMP SOP will focus on addressing the unmet need for family planning among poor couples, and the sexuality and fertility information needs of adolescents/youths, especially among the poor. The target of the national government is to reach the desired fertility level of 2.7 by 2004 and ultimately reach replacement level by 2015. The government is working strategically toward a multi-stakeholder collaboration approach that will include a partnership with the Catholic Church on Natural Family Planning (NFP) to:

Improve service delivery for FP/RH, including the reactivation of Barangay Supply Point Officers, strengthening the Community-Based Management Information System, mainstreaming of NFP Methods, and providing Home Service Delivery, among others;

Strengthen advocacy in support of more resources for family planning and RH goods and services, including a Community Outreach Program, advocacy for male involvement in FP/RH services, and a media campaign for women empowerment, among others;

Provide capacity building to equip service providers with necessary knowledge and skills in FP and RH; and,

Work with the government's poverty alleviation strategy, Kapit-Bisig Laban sa Kahirapan or KALAHI (Arms Linked against Poverty), to strengthen family planning and reproductive health programs in poor communities.

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S E C T I O N

MORTALITYAND MORBIDITY

This section of the Country Report reviews recent trends in mortality rates and patterns of morbidity and causes of death vis--vis the Millennium Development goals. Challenges to improve the accessibility of health services to all segments of the population particularly the poor, the older persons, women and children will be discussed. sustainable development will be presented. SITUATIONER In the Philippines, gains have been achieved in terms of major health indicators, particularly through significant declines in mortality indicators. However, the current health status of Filipinos still leave much room for improvement when compared with the performance of neighboring countries based on maternal, infant, and child mortality. Recent trends show that efforts to reduce infant mortality, under-five mortality, and the maternal mortality ratio (MMR) have paid off. The infant mortality rate shows a steady decline (see Table 3-1). Based on the 1998 NDHS, the infant mortality rate (IMR) fell from 45.6 deaths per 1,000 live births 10-14 years before the survey to 35.1 deaths per 1,000 live births 0-4 years before the survey, or 23-percent decline. However, the 1996 Philippine infant mortality rate of 35.1 deaths per 1000 live births is still higher than the reported rates of Thailand (31) and the Republic of Korea (22). These countries also have under-five mortality rates lower than the 48.4 deaths per 1,000 births in the Philippines in 1996 (NSO et al., 1999).
TABLE 3-1. DECELERATING INFANT MORTALITY DECLINE. Years Preceding the Infant Mortality Rate (Per 100,000 % Decline Survey live births) 10-14 45.6 5-9 36.8 19.3 0-4 35.1 4.6
Source: 1998 NDHS (NSO et al.,1999).

Health programs

implemented to reduce morbidity and mortality, and prospects for poverty reduction and

The Department of Health (DOH) and the National Statistics Office (NSO) reported that as much as 46 percent of under-five mortality might be due to acute respiratory infection, diarrhea, measles, malaria, dengue, hemorrhagic fever, and nutritional deficiencies. The

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leading causes of infant mortality are respiratory conditions of the fetus and the new born, pneumonia, congenital anomalies, diarrheal diseases, birth injury, and septicemia (OP, 2000). The well being of mothers may be assessed in terms of the maternal mortality ratio (MMR). MMR in the Philippines is 209 deaths per 100,000 live births during the 1983-1991 period (NSO et al., 1999). In the absence of accurate data on the pace of MMR decline, it is not possible to assess whether the millennium development goal for MMR (i.e., reducing MMR to about half or 105 per 100,000 live births in 2000 and further reducing it by half in 2015) is achievable (NEDA, 2002). The lifetime risk of dying from maternal causes is about 1 in every 100 Filipino women (NSO et al., 1999; UNFPA, 1999). Maternal deaths made up less than 1 percent of the total deaths in the country in 1988, but they contributed about 14 percent of all deaths of women aged 15-49 (NSO 1998). Major causes of maternal deaths identified are post-partum hemorrhage, eclampsia, and severe infection (UNFPA, 1999). High incidence of high-risk births, inadequate prenatal care, and lack of information and means to manage complications in difficult pregnancies account for much of the increased risks of dying during pregnancy and childbirth. The above-mentioned mortality indicators show that the country is successful in meeting its Millennium Development Goal (MDG) of reducing IMR to 50 deaths per 1,000 live births by year 2000. Likewise, the under-five mortality rate of 49 deaths per 1,000 live births, indicates that the Philippines performed better than its target for year 2000 of 70 deaths per 1,000 live births. However, a further reduction of MMR is necessary to meet the MDG goal of 50 maternal deaths per 1,000 live births by 2015. Improvements in the health status of the population may also be viewed in terms of increases in survival expectancies. The decline in life expectancy at birth slowed in recent years compared with its rapid decline during the early postwar period. Filipino males born in 1970 could expect to live for about 57 years while females for about 61 years. In 1990, life expectancies for males and females increased to 62 years and 67 years, respectively. Five years later, life expectancies at birth further increased to 64.5 years for males and 69.7 for females. Compared with other Asian nations, however, Philippine gains in life expectancy were relatively modest. In 1995, life expectancies in Thailand were estimated at 72 for females and 66 for males. In the Republic of Korea the corresponding expectancies were 77 years for females and 69 years for males (UNFPA, 1999).

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TABLE 3-2. LIFE EXPECTANCY AT BIRTH BY SEX : PHILIPPINES, 1970-1995 Year Male Female 1960 55 59 1970 57 61 1990 62 67 1995 64.5 69.7 2000 67* 72*
Source : Cabigon and Flieger (1999). *Projection made by the Technical Working Group on Population Projections, NSCB based on 1995 Census data.

Mortality differentials are also evident across educational status, income levels, and geographic location (UNFPA, 1999). In particular, lower mortality rates are observed among educated mothers and in urban areas compared with rural areas. Data for 1993 show that IMR was much higher in cases where mothers had only elementary education or no education at all (76 deaths per 1,000 live births) as compared with cases where mothers had at least a high school or even college education (27 deaths per 1,000 live births). Similarly, the highest child mortality rates, at 81 deaths per 1,000, were among children whose mothers had no education, and the lowest rates, at 8 deaths per 1,000, were among children with collegeeducated mothers. Modest gains have also been achieved on levels and factors related to risks of maternal mortality, particularly in the proportion of women who receive prenatal checkups, took iron supplements, gave births attended by skilled health professionals, and received postpartum care. The 1998 NDHS revealed that 77 percent of mothers received the minimum prenatal checkups while 75 percent of women received iron supplements, and a little over 57 percent received iodine supplements (NSO et al., 1999). The 2000 Maternal Care and Health Survey (MCHS) showed that 70.9 percent of women have received tetanus toxoid injections. Not all pregnant women are reached by trained prenatal care providers. Both the 1993 NDS and the 1998 NDHS data showed that urban women were more likely to receive adequate prenatal care than women in rural areas. Likewise, access to trained prenatal care providers is much greater among women with some college education than among those with lower education. Of women who received prenatal care, few obtain complete care. Most women receive only 6 to 11 of the 12 required elements of antenatal care (UNFPA, 1999). The 1998 NDHS data further showed that 56 percent of deliveries were attended by skilled health professionals while 59 percent of women received post-partum care. In terms of interventions influencing infant mortality, 1998 data showed that 73 percent of children age 12 to 23 months have been fully immunized (POPCOM, 2000). Sustained efforts of the government in implementing nationwide immunization programs are geared toward improving this level.

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Other factors related to the incidence of mortality and morbidity such as access to potable water and sanitary toilet facilities also have increased significantly. Based on the 1993 NDS, the proportion of families with access to potable water increased from 69.9 percent in 1985 to 78.1 percent in 1998. Access is greater in the urban areas at 87.2 percent in 1998, compared with only 69.8 percent in the rural areas. Moreover, access is 58 percent for the poorest decile and 93 percent for the richest decile of the population. Access to sanitary toilet facilities has also increased significantly over the same period from 71.6 percent in 1991 to 80.4 percent in 1998. Urban families have greater access at 89.5 percent, while rural families have lower access at 72.2 percent. Among poor families, 67.4 percent have access, while non-poor families have greater access at 89.4 percent. In terms of other infectious diseases, the Philippines has one of the highest TB prevalence rates in the world. The incidence of AIDS/HIV, however, remains very low with less than 1 percent of the high-risk population infected. The Gross National Income (GNI) in terms of Purchasing Power Parity (PPP) for the Philippines has been estimated at US$3,990 (Cabigon, 1999). This is about the same level as Sri Lanka (US$3,230, and China (US$3,550). Countries with lower incomes than the Philippines include Nepal (US$1,280), Cambodia (US$1,350), Laos (1,430), Bangladesh (US$1,530), Pakistan and Vietnam (US$1,860), India (US$2,230) and Indonesia (US$ 2,660). The Philippine income is significantly lower compared with Thailand (US$5,950), Malaysia (US$7,640) and with the most economically advanced countries in the region (Japan, US$25,170, Singapore, US$22,640 and South Korea, US$15,530). It is apparent that countries with very high infant and child mortality rates have lower GNI-PPP. The sluggish improvement over time in infant mortality rates appears to coincide with a rise and fall in GNP per capita around the same periods under consideration. POLICIES AND PROGRAMS Government efforts to reduce mortality levels can be seen in priority health programs for children and mothers. The major goal of health planning efforts for children in the first year of life is to improve survival, growth, and development. Health programs also seek to increase the awareness of mothers and caregivers about proper child rearing practices. To achieve its Millennium Development Goals (MDG), the government institutionalized the Health Sector Reform Agenda (HSRA) in 2000 to better address the public health needs of the population especially the poor. The HSRA aims to improve health care financing, health regulation, hospital systems, supply of essential medicines, and public health programs that have a direct impact on mortality and morbidity. It addresses in the medium term the following issues and concerns:

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First, the persistently high rates of infectious diseases and prevalence of chronic and degenerative diseases;

Second, the large variation in health status across population groups, income classes, and geographic areas, largely due to inequities in access to health facilities and services and the limited coverage of social health insurance; and,

Third, inadequate funding and management systems, which have limited the impact of public health, programs. Part of the mechanisms for implementing the HSRA at the community level is the

Health Passport Initiative. This increases access of the poor to quality health services through subsidized health care financing schemes. This approach draws its mandate from the National Health Insurance Act of 1995. The Act aims to increase access to health services, especially by the poor, and to provide health insurance coverage to the 25 percent of the population with the lowest incomes within five years, and universal coverage within 15 years. Reducing maternal mortality and disability will depend on identifying and improving those services that are critical to the health of Filipino women and girls, including antenatal care, emergency obstetric care, adequate postpartum care for mothers and babies, family planning, and STI/HIV/AIDS services. High priority is given to womens health through programs like the Safe Motherhood and Womens Health Program, which employs strategies such as skills upgrading so that as many births as possible are attended by knowledgeable, caring, and skilled care providers. The government also carries out IEC to encourage There are also quality informed decisions and promote better health-seeking behavior. public health facilities at various levels. The government also implements an Expanded Program in Immunization (EPI) that aims to reduce infant and child mortality caused by six immunizable diseases (TB, diphtheria, tetanus, pertusis, poliomyelitis, and measles). The government also has a nationwide program that provides vitamin A supplements to children 12 to 59 months old. Likewise, post partum mothers nationwide are also provided with vitamin A capsules. Various groups and donor agencies such as the United States Agency for International Development (USAID) support the government's interventions to boost vitamin A coverage in the seven lowest performing regions in the Philippines. These interventions include: (a) support for the social mobilization of health workers and volunteers to provide all pre-school children with vitamin A capsules; (b) technical assistance to organize communication campaigns to increase vitamin A 19

assurance schemes such as the Sentrong Sigla, which sets certain minimum standards for

coverage; and, (c) tapping local-level partners and leverageing donors to assist in awarenessraising and service implementation. These interventions support the DOHs National Immunization Day or Garantisadong Pambata campaign. Promotion and improvement in breastfeeding practices is another component of the health program that contributes to better infant health and nutrition. Pambata Program. The USAID assists the Philippine Government to improve the capacity of private voluntary organizations (PVOs) and their local partners to carry out effective child survival interventions and improve infant and child health and nutrition. Currently, three PVOs are implementing various child survival activities (immunization, vitamin A supplementation, breastfeeding, control of diarrhea and respiratory infections, and integrated management of childhood illness, among others.) in three depressed areas in the country. Strong community participation and social mobilization characterize these projects. ISSUES AND CHALLENGES Efforts to improve mortality and morbidity levels in the country face issues and challenges related to health care financing, including the mismatch between health needs and expenditures. National health expenditure patterns show that more funds are spent on curative health services than on preventive health care programs and services. Access and sustainability of health care also constrain the countrys efforts to attain its health-related goals. Subsidized health care and insurance financing schemes catering to the poor are needed to address this. The challenge, therefore, is to put in place effective health care financing mechanisms especially at the grassroots level. A further challenge is the devolution of health care services to local governments. Many local governments do not have adequate institutional preparation to take on the responsibility for health care. They suffer from shortages of technical manpower for health operations, lack equipment, deal with inadequate health facilities, and have inadequate referral systems among health facilities. Dissemination of essential information to mothers and caregivers is carried out through the Garantisadong

FUTURE PROSPECTS AND DIRECTIONS In partnership with civil society, the government will pursue by end of 2004 efforts to reduce levels of the following indicators:

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Maternal mortality rate from 172 deaths per 100,000 live births in 1998 to less than 100 deaths per 100,000 live births;

Infant mortality rate from 35.3 deaths per 1,000 live births in 1998 to 32 deaths per 1,000 live births; and,

Under-5 mortality rate from 48 deaths per 1,000 live births in 1998 to 33.6 deaths per 1,000 live births.

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S E C T I O N

MIGRATION URBANIZATIONAND POVERTY , ,

PATTERNS, TRENDS AND LEVELS In the Philippines, internal and international migrations represent family strategies for survival that have been associated with social and economic transformation (Lauby, 1985; Traeger, 1987). Migration and urbanization are major demographic factors that shape and are consequences of development. Poverty in the countryside is an important factor that propels urbanward migration, which contributes to the environmental deterioration of highly urbanized cities (Perez, 1998). Paganoni, 1992). Unmanaged rural-to-urban migration has resulted in a mismatch between population and urban physical infrastructure and basic services (HLURB, 1994 as cited in the PPMP Directional Plan 2001-2004). Slum and squatter settlements, sanitation problems, water and air pollution, and traffic congestion are urban-specific issues. The rate of population growth in cities far exceeds job creation, leading to more unemployment and worsening poverty. Populations displaced by lowland industrialization and not absorbed in urban or industrial economic activities are forced to seek refuge in the uplands. Upland and coastal migration plays an important role in increasing forest population density, adding stress to the increasingly unstable natural environment. Program. INTERNAL MIGRATION Low and unsustained economic growth of the past decade has deepened poverty in many parts of the country. Limited opportunities in the less developed areas of the country and the increasing constraints in the more developed areas are major factors that have influenced the movement of people since the 1920s. There are three major internal migration streams (Perez, 1998 as cited in Herrin, 2002). The first is a unidirectional, frontier-ward, male-dominated stream from rural to rural destinations. This consisted of migrants from Luzon and the Visayas to Mindanao in the The tight relationship between migration, urbanization, and poverty is a priority concern of the Philippine Population Management The movement of labor from less developed to more developed areas has profound, undetected, and far-reaching consequences (Battistella and

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1950s and 1960s (Perez, 1998). The second stream was in the 1970s. It was largely femaledominated and urbanward to urban areas (Perez, 1983; Engracia and Herrin, 1984). The primary destination was the National Capital Region (NCR) and its surrounding regions. The third stream is urban to urban from overcrowded Metro Manila to peripheral areas of the metropolis. The rural-to-urban movement has continued to be an important stream. Table 4-1 shows the contrasting growth patterns of urban and rural areas.
TABLE 4-1. GROWTH RATES OF URBAN, RURAL, AND PHILIPPINE POPULATION Year Urban Rural Total 1948-1960 3.76 2.55 3.48 1960-1970 3.76 2.78 3.08 1970-1980 4.32 1.93 2.75 1980-1990 4.82 0.6 2.35
Source: Cabegin and Arguillas, 1997.

The National Anti-Poverty Commission (NAPC) identifies rural poverty as the root cause of high out-migration. Migration data shows that majority of migrants to the NCR come from the poorest regions in the country (Go, Collado, Abejo, 2001). Rural-to-urban migration continues in less developed regions and urban-to-urban migration has become more important in recent years in most urbanized regions. Except for the NCR and Cagayan de Oro, which continues to have higher growth rates in the 1995 period compared with those in 19801990 (UNFPA, 1999), large cities continue to attract people, although at a lower pace, suggesting some degree of urban deconcentration. Statistical evidence indicates that rural-to-urban migrants increasingly consist of unmarried women below 25 years old and married young women in their peak childbearing ages (25-29 years old) (UNFPA, 1999). They are propelled by their limited participation in income-earning opportunities in their communities of origin (Perez, 1998). They usually end up in jobs in the service sector, where they work longer hours for lesser remuneration. URBANIZATION TRENDS Today, urban problems are so acute that they are no longer viewed as mere local government problems but as major sub-regional and national concerns (Cabegin and Arguillas, 1997). The Philippines has about 230 urban areas with populations exceeding 50,000. These include Metro Manila and Metro Cebu, which are counted as single metropolitan areas and not as multiple local jurisdictions. The number of urban areas is expected to increase as new cities and urban clusters are formed around the older settlements. 23

Some studies estimate that by 2020, the Philippines may have as many as 600 urban centers (World Bank, 2000). The Philippines is classified among the world's fastest urbanizing countries. Urbanization grew by 5 percent annually between 1980 and 1990. If this trend continues, an estimated 65 percent of the total population will be living in urban areas by the year 2020. The population classified as urban rose steadily, from less than 30 percent in 1960 to 37.2 percent in 1980 and 48.6 percent in 1990. By 1995, the level of urbanization reached 54.1 percent, exceeding the urban shares of total population in Indonesia (35 %) and Thailand (20 %). The country's high urbanization rate is attributed to the high national growth rate, urbanward migration, limited land area, the progressive concentration of economic development in few locations, and the concentration of land ownership in the hands of a few (World Bank, 2000). In 1995, urban residents became the majority for the first time, with 54.1 percent of the total population residing in urban areas (Gonzales et al., 1998; NSO, 1995). Most of the urban population is concentrated in growth centers such as Cebu, Bacolod, Iloilo, Cagayan de Oro, Davao, General Santos City and, the National Capital Region. About 9.4 million Filipinos or 13.7 percent of the total population live in the NCR, the nation's prime urban area. With an average growth of 3.3 percent a year, the NCR's population is expected to double in size in 21 years (UNFPA, 1999). The NCR continues to be the center of human activity and absorbs the fastest growing segment of the national population.
TABLE 4-2. THE URBAN-RURAL DIVIDE IN THE PHILIPPINES: 1960-1995 Indicators 1960 1970 1975 1980 1990 1995 Per cent urban 29.8 31.8 33.3 37.2 48.6 54.1 Urban Growth Rate 2.7 4.0 3.0 4.9 5.0 5.0 (%) Rural Growth Rate (%) 2.5 2.6 2.6 1.5 0.3 0.3
Adopted from UNFPA Country Assessment, 1999 p. 24. Note: The 1995 estimates are based on a 1990 projection on urban population by Eduardo T. Gonzalez, et al. "Population and Urbanization: Manageing the Urbanization Process under a Decentralized Framework," Settlements, Growth Zones and Urbanization (Manila, December 1998). Source: Census of Population and Housing 1960-1995.

One-third of the population can be found in 14 major cities (UNFPA, 1999), which gives the Philippines the highest level and rate of urbanization in Southeast Asia (POPCOM, 2000a). Inadequate social services, proliferation of squatter areas, traffic, congestion, severe problems in water supply, inadequate sewerage system, uncollected garbage, deteriorating quality of health and education services, are the most likely consequences of rapid urbanization taking place without the benefit of improved economic activity.

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The poor suffer the most from this deterioration in the quality of life in urban areas. Due to the limited choices available to them, the urban poor are forced to locate themselves either at the fringes, where access, employment, and livelihood opportunities are limited, or at the urban core where they suffer from overcrowding, lack of services, and lack of suitable housing. Latest figures from the Technical Working Group (TWG) on Income and Poverty Statistics of the National Statistical Coordination Board show that while the incidence of urban poverty declined between 1985 and 1997, the urbanization of poverty rose again following the onset of the Asian financial crisis. The urban poor live mostly in high-risk areas, such as along riverbanks or highly sensitive coastal areas, canals, railroad tracks, utility corridors and watersheds, which are considered high-risk areas. The TWG data show that in 1999 35 percent of the urban population lived in areas where access to services is either poor or non-existent. The Medium Term Philippine Development Plan for Shelter (MTPDP-S) estimates the country's housing need at 3.362 million units for the period 1999 to 2004. This consists of an estimated 2.224 million units comprising future need resulting from population growth, plus some 1.138 million units in total housing backlog. It is a huge target that government would be hard pressed to attain. The historical performance of government housing institutions indicates that they can only address some 30 percent to 40 percent of the country's housing needs due to limited resources. For the period 1998 to 2000, government provided 279,538 households with shelter security units 8 percent of the total estimated housing need for the period. Some P44.53 million in government funds were spent for this purpose (Alonzo and Esguerra-Villamor, 2002). INTERNATIONAL MIGRATION The Philippines is the second largest labor-sending country in the world, next to Mexico. On average, about 2,500 Filipinos leave the country everyday. About 7.5 million Filipinos, 10 percent of the total population, are classified as Overseas Filipino Workers (OFWs) distributed in 182 foreign countries (POEA, 2000). This number does not include the estimated 3 million migrant workers who are undocumented and illegally working abroad (Jimenez, 2002). Among the top 10 sources of remittances of OFWs are destinations with large proportions of female OFWs (see Table 4-3).
TABLE 4-3. TOP TEN SOURCES OF REMITTANCES AND PERCENTAGES OF WOMEN OFWs: 1998 Country Remittances (US$ in % of Women OFWs* Thousands) USA 3,961,125 80

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TABLE 4-3. TOP TEN SOURCES OF REMITTANCES AND PERCENTAGES OF WOMEN OFWs: 1998 Country Remittances (US$ in % of Women OFWs* Thousands) Hong Kong 171,353 99 United Kingdom 130,961 75 Japan 107,807 90 Germany 78,846 80 Singapore 69,288 98 Italy 54,464 70 Saudi Arabia 33,433 27 Canada 25,010 67 Malaysia 23,505 78
Source: Foreign Exchange Department, Bangko Sentral ng Pilipinas. *Data culled from sources: NGOs, NSO, POEA.

Gender stereotyping of OFW occupations exists. Women dominate the service workers (9 out of 10), as well as the professional and technical worker categories (3 out of 4). In 2000, an estimated 600,000 women OFWs were domestic helpers in 19 major destinations worldwide. There are at least 47,017 Filipino entertainers in five countries in Asia of whom 95 percent are in Japan. The rest are in Hong Kong, Macao, South Korea, and Saipan (POEA stock estimates, 2000). Official statistics clearly reveal an increasing number of women both in the internal and international migrant flows. The percentage share of deployed women OFWs has steadily increased from 12 percent in 1975, to 47 percent in 1987, to 58 percent in 1995, and 61 percent in 1998 (POEA, 2000). These figures point to a continuing trend of feminization of overseas employment. OFWs are classified by the Philippine Overseas Employment Administration as either land-based or sea-based. Occupations in the land-based categories are broader and cover almost all skill areas, from domestic helper to managers. Sea-based work pertains mostly to ship operations like navigation; engineering, and maintenance. There are also Filipino workers in large passenger vessels and they fulfill a variety of jobs, from kitchen staff to onboard entertainers. Prior to 1976, deployed sea-based OFWs outnumbered their land-based counterparts by a 2:1 ratio. This changed starting 1977 when land-based OFWs began to significantly outnumber sea-based OFWs. In the late 1980s and 1990s, more than 90 percent of OFW deployment went exclusively to two regions, Asia and the Middle East. In 1987, 71.2 percent of OFWs went to the Middle East while 23.7 percent went to Asia. During the same year, seven Middle East countries figured in the list of top 10 host countries of deployed OFWs. Nearly 200,000 OFWs went to the Kingdom of Saudi Arabia, the nation with largest share of OFWs in the

26

world. The Middle East region became the primary destination for OFWs because of the "construction boom" spurred by the surge of millions of petro-dollars in the late 1970s and early 1980s. In the 1990s, six of the top 10 host countries were from East and Southeast Asia (POEA, 2000). Surveys have detected a selectivity taking place in the labor migration process. Based on data cited by various studies (Ogena, 2000; Cario, 1993) migration seems to be dominated by persons in their prime ages. Close to 60 percent of migrant workers are in their early 20s and 30s. In terms of sex characteristics, an overwhelming majority (75 %) of the OFWs up to the early 1980s were males, a phenomenon that can easily be attributed to the demands of the construction sector in the Middle East (POEA, 1983). However, in recent years, there has been an increasing feminization of migrant labor streams particularly to the countries in Asia (Japan, Hong Kong, Singapore) where the demand for domestic helper, nurses, entertainers, and other types of service workers is high (Cario, 1993 and Go, 1991). International migration has been the anchor of trafficking, not only for labor, but for sex as well. Although it is difficult to ascertain how many women have been trafficked, it is easy to see how both undocumented and documented migrant women are especially vulnerable to the sex trade. The reported complicity of some government officials and agencies has made trafficking easier and monitoring more difficult (ADMU and WEDPRO, 1999; Beltran and de Dios, 1992) About one-third of the country's entire population is directly or indirectly benefiting from remittances sent by family members and relatives abroad. In 1999, the remittance of Filipino international labor migrants amounted to US$6.8 billion (POEA, 2000). Not included in this figure are remittance coursed through informal channels. There is no doubt that OFW remittances have made labor export the single biggest dollar earner of the country. In the first quarter of 1999, these remittances amounted to 21 percent of gross national product (GNP=P224.8 billion) (POEA, 2000). A large proportion of this money comes from women migrant workers who now comprise the majority of OFWs. It is not surprising that government has begun to refer to overseas worker as modern-day heroes. The profiles of documented women migrant workers from the Philippines, based on data collected by the National Commission on the Role of Filipino Women (NCRFW) show them to be (Guerrero et al., 2001):

Young mainly in the 20-29 age group (women are generally younger than their male counterparts who are likely to be 25-39 years old);

27

Unmarried (56 percent were unmarried in 1992 and 1993, in contrast to most male migrant workers, 72 percent of whom were married in 1992 and 1993; among domestic women workers, the proportion of unmarried ran as high as 80 percent) (DOLE, 1995 as cited in Asis, 1994);

About half of women migrant workers have completed some college education (onefourth have college degrees, although more male migrant workers are college educated); and,

Most women migrant workers come from Luzon, also the region that contributes the most number of migrant men.
TABLE 4-4. OFW FOREIGN EXCHANGE REMITTANCES BY YEAR: 1990-2000 Year Remittances (In Million US$) Percentage Growth 1990 1,181.07 21.38 1991 1,500.29 27.03 1992 2,202.38 46.80 1993 2,229.58 1.24 1994 2,940.27 31.88 1995 3,868.38 31.57 1996 4,306.64 11.33 1997 5,741.81 33.32 1998 4,925.98 -14.20 TOTAL 29,869.42 Average 20.39

Source: Fast Facts on Filipino Labor Migration, Kanlungan Center Foundation Inc.

Behind the numbers are many stories of courage, survival, and the continuing struggle of migrant workers for recognition and protection. The large number of undocumented workers, unprotected by social and labor laws, has raised important social questions in host countries over issues of workers' welfare and human rights. Filipino labor migration affects a wide range of actors and agents, including the migrants, their families and communities, recruitment agencies and intermediaries, employers, Philippine and foreign government bodies in the Philippines and abroad, social service providers, and advocacy groups (Yukawa, 1998). IMPACT OF PUBLIC POLICIES To date, Republic Act 7279, otherwise known as the Urban Development and Housing Act of 1992 (UDHA), is the most significant migration-sensitive policy instrument in the country. This act provides for a "comprehensive and continuing urban development and

28

housing program"

It explicitly provides inter-agency coordination among the National

Economic and Development Authority, the National Statistics Office, and the Commission on Population in monitoring population movements and providing population projections in aid of planning. In collaboration with local governments, POPCOM has helped establish migration information centers to assist cities manage their migration-related problems. These Migration Information and Assistance Centers are now being piloted by the city governments of Tagbilaran, Antipolo, Mandaluyong, and Muntinlupa (POPCOM, 2000a). The Centers facilitate the formation of migrant "mental maps" of possible destinations once the decision to migrate is reached. The 1974 Labor Code affirmed the government's explicit policy on overseas employment. It created the Overseas Employment Development Board (OEDB) and the National Seaman's Board (NSB), which are the precursors of the POEA. Their mandate was to undertake a systematic program for overseas employment, which included the banning of direct hiring and the mandatory remittance of overseas worker's earnings. The mission of the present POEA is to ensure quality employment opportunities for OFWs. The Overseas Workers Welfare Administration (OWWA) was created to protect the interest and well being of OFWs and their families and dependents. From funds derived from employer contributions, OWWA finances an array of programs and services for migrant workers and their families. These include legal, livelihood, welfare, enterprise, career development and skills upgrading assistance, and benefits. Republic Act 8042 or the Migrant Workers and Overseas Filipinos Act of 1995 spells out the benefits of overseas employment through the provision of a mechanism for full protection to migrant workers even while still in the Philippines. More important, the law contains provisions on protecting OFWs in the host countries, where they are more susceptible to abuse and exploitation. Through the years, legislative and policy measures promoting the welfare and protection of migrants have been pursued actively by both the executive and legislative branches of government. Some of these are as follows:

Imposition of a minimum age requirement for those wanting to work abroad as domestic helpers, to ensure that they are sufficiently mature and emotionally and psychologically ready to face the risks of overseas work.

Enactment of Republic Act 6955, which forbids the operation of marriage bureaus and pen pal clubs matching Filipino women with foreigners for marriage. It also prohibits the

29

advertisement, publication, printing and distribution of literature promoting mail-order brides.

The issuance by the Department of Foreign Affairs of Department Order No. 15-89, which requires all Filipinos who are fiances or spouses of foreign nationals to attend guidance and counseling sessions at the Commission on Filipinos Overseas prior to acquiring a passport.

CHALLENGES AND FUTURE DIRECTIONS

Fostering a more balanced spatial distribution of the population by promoting populationsensitive development policies and strategies, and enhanced mechanisms to monitor population movements and manage urban growth through resource-conscious planning.

Redirect development efforts from the more populated urban centers to both secondary (or alternative) urban centers and the countryside.

Strengthen agricultural modernization and rural development programs to reduce ruralurban disparities and lower urban-ward migration.

Comply with the country's international commitments at the Istanbul and the Habitat conferences.

Support the setting up of information networks at the places of origin so that those who plan and decide to leave will have adequate information that could help them maximize the gains from their migration through higher-paying employment.

Support policies and programs aimed at encouraging alternative urban concentrations in different parts of the country.

Strengthen advocacy among national and local officials to enhance understanding and consciousness on the impact of population on human settlements.

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Address the lack of policy and legislation toward a comprehensive and rational urban and city development strategy.

Address the lack of an appropriate urban and city development plan by launching an effective multi-sectoral and interdisciplinary effort that balances national, local, and sectoral concerns.

Conduct a national migration survey every five years to encourage more research that will analyze the changing population and development condition and aid in the improvement of methodologies on migration and urbanization.

Strengthen local database information systems on migration and systematic analyses of local population and development situations.

Provide information and technical assistance to LGUs in planning and managing urban settlements.

Develop programs to reintegrate returning OFWs into the domestic economy. Protect the welfare of OFWs, particularly the undocumented. Take steps to consciously integrate Migration/Urbanization into Regional and Local Population Plans.

Establish a standard Migration Monitoring System

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S E C T I O N

POPULATIONAGEING

This section describes the current situation of older persons in the Philippines (defined as those 60 years old and over) and the policies and programs affecting them. The current challenges related to the slow pace of ageing in the country is analyzed with a view to identifying future prospects for improving the welfare of this growing population sub-group. SITUATIONER As in many countries in Asia, the Philippines has not yet experienced a significant ageing of its population. In 1995, the older persons population comprised 5.5 percent (3.7 million) of the country's population. The size of the older persons population is expected to expand dramatically in the coming years because of sustained fertility declines and mortality improvements. Since the 1970s, the older persons sector has been growing at a faster rate than that of the general population. Among the older persons, females outnumbered males in 1995, with 100 females for every 87 males (NSO, 1995). This increasing feminization of older persons could be explained partly by the higher life expectancies of females, who outlive males by 5 years on average. Women who reach the age of 60 are also expected to live for another 18.5 years compared with 16.5 years for males (UN Population Division, 2000). Results of the 1996 Philippine Elderly and Near Elderly Survey (PES) reveal significant differences between male and female older persons in terms of their marital status. About 4 of every 5 older persons males in the country are currently married. The corresponding figure is about half (49.2 %) among females. To a certain extent, this can be explained by men's greater tendency to remarry. On the economic participation of older persons, the same survey revealed that 38.2 percent were working, 48.4 percent used to work but were looking for a new job, and 13.4 percent never worked at all (Cabigon, 1996)). This empirical evidence debunks the common notion that older persons people are idle, tired, and retired (Cabigon, 1996). A larger proportion of older males was working (52.3 %) compared with females (28.1 %). Only 1.7 percent of older persons men have never worked for a living, compared with 21.7 percent of

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women. This could be due to the Filipino practice of forcing women to stay at home to keep the house and take care of the children. The living arrangements of older Filipinos reflect the traditional role of the family as a provider of support for its older members. Results of the 1996 PES showed co-residence with a child, with or without the presence of the spouse or other kin as the older persons' most common living arrangement (Natividad and Cruz, 1997). The norm in Philippine society of taking care of their kin is reflected in the low proportion of older persons who live alone (5.5 %). Regarding the geographic mobility of older persons, about 50 percent of elderly Filipinos have migrated at least once (Ogena and Williams, 1996). Women are more prone to urbanward migration with 82.1 percent of them having migrated to Metro Manila, compared with 73.1 percent of men. This could be due to the higher demand for female labor in urban centers (Ogena and Williams, 1996). Through self-reporting of their health status, older men appear to be more optimistic about their health than women (Cruz; 1996). However, their perception is at odds with actual health-related behavior. More men than women smoke tobacco and drink alcohol, habits that place them at greater risk of contracting diseases such as tuberculosis. In the 1996 PES, 16.4 percent of male older persons were reported as having contracted lung diseases, compared with 11.3 percent of females (Natividad, 1996). POLICIES The 1987 Constitution recognizes the significant role that elderly citizens play in society. It reaffirms the duty of the family to provide care and support for their older persons. Two Philippine laws concern this sector: Republic Acts (RA) 7432 and 7876. Passed in 1992, RA 7432 is known as the "Act Maximizing the Contribution of Senior Citizens, Granting Benefits and Special Privileges and for Other Purposes". An important provision of this law is the 20 percent discount it gives to senior citizens when purchasing medicines and patronizing public transport, restaurants, recreational facilities, lodgings, and places of culture. It also gives free medical and dental services in government hospitals anywhere in the country. The other law, RA 7876, was enacted in 1995 and is known as an "Act Establishing a Senior Citizens' Center in All Cities and Municipalities of the Philippines and Appropriating Funds Therefore." The Center is a place where senior citizens can get together to meet their mutual needs. There are concerns regarding the implementation of these laws. Foremost is the inability of older persons to avail of the benefits and privileges provided in RA 7432. This is probably due to the incorrect interpretation of the law, the presence of too many requirements 33

before the older persons can get their senior citizen's ID cards, and in many cases, noncompliance. For instance in Zamboanga City, only Mercury Drugstores comply with the provision of giving 20 percent discounts to senior citizens. With respect to RA 7876, many local governments (particularly 5th and 6th class municipalities) reportedly do not have enough resources, including sites, to set up Senior Citizens' Centers. Under the Philippine Plan of Action for Older Persons (PPAOP) 1999-2004, the Department of Social Welfare and Development (DSWD) has conducted an evaluation of the effectiveness of policies, legislative reforms, and information campaigns with the end in view of resolving these gaps in implementation. In general, the two laws are considered inadequate in addressing older persons concerns. At present, there are advocacy efforts to promulgate a Magna Carta for Older Persons. This was among the actions mentioned by DSWD Secretary Corazon JulianoSoliman at the Second World Assembly on Ageing held in Madrid, Spain, in April 2002. The Magna Carta will formulate a national comprehensive plan and delineate the socio-economic and political rights of senior citizens. PROGRAMS AND INITIATIVES With the Vienna Plan of Action on Ageing and the Macao Plan of Action on Ageing for Asia and the Pacific as guides, the DSWD spearheaded the preparation of the Philippine Plan of Action for Older Persons (PPAOP) in 1999. This addresses the following:

Older Persons and the Family Social Position of Older Persons Health and Nutrition Housing, Transportation and Built Environment Income Security, Maintenance and Employment Social Services and the Community Continuing Education and Learning Older Persons and the Market. The implementation of the PPAOP by various agencies, sectors and organizations is

ongoing. following:

These include the activities for the older persons of local government units, Local activities include the

nongovernment organizations, and people's organizations.

Senior Citizens' Centers Livelihood development 34

Advocacy and IEC campaign for the full implementation of PPAOP, RAs 7432 and 7876 Multi-purpose cooperatives for older persons Health and nutrition programs Databank on the older persons Provision of education, information, and gender sensitivity training Capability building Resource augmentation. A notable local initiative is the establishment of the Geriacare Physical Therapy and

Rehabilitation Center (GPTRC) in Butuan City, in Mindanao. Opened two years ago, the Center has successfully provided health services and physical therapy treatments to an average of 11 older persons patients per day. Other activities are in the areas of livelihood development, self-enhancement, substitute family care, after care, and follow-up to older persons, among others. An example is the program of the DSWD that has set up neighborhood support services for older persons in 17 municipalities and cities. The program taps the capabilities of potential caregivers from the community, especially young girls, to assist frail and bed-ridden older persons. Another example is the Coalition of Services for the Elderly (COSE) in San Antonio, Quezon province. Ten street children from the National Capital Region were moved to live with elderly couples to form surrogate families. The older persons supply the affection these street children need and the children provide older persons care assistance (Cabigon, 2002). ISSUES AND CHALLENGES The Philippines is currently experiencing a modest decline in fertility. There is an expectation of population ageing although this will be at a slow pace in the short term. The NSO estimates that the Filipino older persons population will reach 13.5 percent or 14.5 million in 2030 (NSO, 1999). Given limited resources coupled with the demands coming from other sectors, the government will be confronted with the burden of responding to the special needs of older persons. These special needs include health facilities, geriatric clinics (especially in urban centers where the older persons population is rapidly increasing), and homes for the abandoned older persons, well-trained caregivers, social security provisions, and recreational facilities. The tradition of care giving for the older persons is being threatened. Younger women, who are the traditional providers of older persons care, have been joining the labor force in greater numbers, both in the country and abroad. This points to a decreasing number of

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caregivers for older persons and children, and a greater need for older persons, especially women, to substitute for their "absent daughters." There are age and gender differences in the well being of older persons, which means that they have differences in needs. Existing policies and initiatives should be reviewed for age and gender specificity. The age categories proposed by the United Nations are as follows: Near Old (55-69); Young Old (65-79); and Oldest Old (75+ or sometimes 80+; also called the frail older persons). Each group has a specific set of needs that call for relevant policies and initiatives. In addition, the older persons sector needs to be further segmented in order to understand particular needs. Specific target groups include older persons in the informal sector, poor older persons (especially those without family), older women, rural older persons, older persons belonging to indigenous groups, and older persons displaced by internal conflicts and economic displacement. Traditionally, reaching old age in the Philippines has been viewed positively. However, some recent studies show that an increase in longevity does not necessarily lead to a healthier life (Cruz, 1996). The health and medical expenditures of older persons are higher compared with the that of younger people. This suggests that medical and hospital costs consume a significant proportion of the savings of the older persons. Moreover, as older persons age further, there is a decline in employment opportunities, which results in meager incomes. The older persons are at greater risk of being poor. Another challenge is to organize the public and private agencies servicing the older persons so that they can help formulate meaningful policies and provide more cohesive and coordinated services. There is a need to establish an inter-agency task force that will devise a comprehensive and detailed monitoring scheme for the effective implementation of existing policies and initiatives for the older persons. Finally, attention should be given to preparing the citizenry for the gradual ageing of the Philippine population in the short-term. (Cabigon, 2002). Lifelong programs that foster an optimistic perception of and positive behavior toward the ageing process need to be carried out

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S E C T I O N

FROM FAM ILY PLANNINGTO REPRODUCTIVE EALTH: H A PARADIGMSHIFT IN POLICIESAND PROGRAM S

The International Conference on Population and Development or ICPD (1994) and the Bali Declaration (1992) recognized the need to broaden family planning programs through the adoption of a reproductive health approach. This approach calls for universal access to a full range of safe and reliable family planning methods and the provision of related reproductive and sexual health services. This section reviews projects initiated by the Government of the Philippines in response to both ICPD and Bali. It then gives a brief situationer, followed by a discussion of issues and future prospects of RH/FP in the Philippines. PROGRAMS AND INITIATIVES The reformulated Philippine Population Management Program (PPMP) for the period 2000-2004 gives emphasis to meeting the high unmet need for family planning of Filipino couples, especially those from the poor and disadvantaged groups. Specifically, the PPMP aims to achieve the following objectives:

Help couples and individuals to achieve their desired family size within the context of responsible parenthood and sustainable development;

Improve the reproductive health of individuals and contribute to further reduction of infant mortality, maternal mortality, early child mortality; and,

Reduce the incidences of teenage pregnancy, early marriage, and other reproductive health problems. The Department of Health's Philippine Family Planning Strategy for the period 1996-

2000 recognized the increasing demand among Filipinos for family planning commodities and services, particularly in cases of high-risk births among women with reproductive health problems. The program was implemented within a reproductive health framework and quality of care approach. The RH care package includes 10 core service elements. They are:

37

Family planning Maternal health care Prevention of abortion and management of its complications Prevention and treatment of reproductive tract infections including STDs, HIV and AIDS; Prevention and appropriate treatment of infertility and sexual disorders Prevention and treatment of breast cancers, cancers of the reproductive system, and other adverse gynecological conditions Counseling and education on sexuality and sexual health Adolescent reproductive health Male reproductive health Prevention and management of violence against women. Another major program introduced in 1999 by the DOH is the Women's Health and

Development Program.

This aims to ensure women's health and development through

participatory strategies that enable women to have control over their health and their lives. The government's RH program is further improved by the adoption of the Health Sector Reform Agenda (HSRA). The Agenda integrates all existing and emerging health programs, including reproductive health. The HSRA has two basic principles. The first is health regulatory reform. This includes quality assurance for health services, to be achieved by strengthening the licensing and regulatory functions of the DOH, and implementing a recognition and certification program ("Sentrong Sigla Movement") for public and, eventually, for private health facilities. The second HSRA principle is health operation reform. The core concept is "making devolution work" or putting "health in the hands of the people." work. The 1991 Local Government Code directed the Philippine government to shift governance from the central to the lower levels of government. This entailed the transfer of many basic services to local governments, including such health services as family planning. The DOH has since been working to reinforce and support the devolution of family planning and reproductive health programs. In 1996, the DOH issued Executive Order 307 which instructed local governments to provide family planning information services, including Natural Family Planning (NFP), in their respective health facilities. The most recent DOH policy direction was in June 2002, when the Department issued Administrative Order 125. Reforms include strengthening preventive and promotive strategies, reform of government hospitals, and reestablishment of the district health system and two-way referral

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This provided for policies, standards, strategies, and activities needed to mainstream NFP methods within the PFPP for the period 2002-2006. STATE OF REPRODUCTIVE HEALTH Family Planning. Unmet need for family planning remains high and the number of unplanned or unwanted births was up in the five years before the 1998 NDHS. Notwithstanding the relatively low contraceptive prevalence rate (CPR) among married couples of reproductive age, the availability of family planning methods donated mainly by the United States Agency for International Development (USAID) has helped to sustain a gradual decline in fertility since the late 1960s. However, USAID which donates 80 percent of contraceptives in the country has informed Philippine health officials that it will phaseout its contraceptive donations within the next two years. With stock-outs expected to begin in the last quarter of 2004, the government foresees problems related to accessibility and affordability of various contraceptives and other RH services by the poor who are completely dependent on the free services and supplies provided by public health facilities. It is not clear whether the government has the resources to purchase contraceptive supplies, given that health accounted for only 2.08 percent of total government expenditure in year 2001 (Department of Budget and Management, PSY 2001, Table 15.4). Prevention of Abortion and Management of its Complications. One estimate places the number of abortions in the Philippines at 400,000 cases annually, with teenagers accounting for 17 percent of these cases, (Perez et al., 1997). Based on DOH records, 12 percent of all maternal deaths in 1994 were due to complications related to abortion, making it the fourth leading cause of maternal deaths in the country. The most vulnerable women, whether married or unmarried, are the poor. Among the top three reasons cited for terminating pregnancies is economic difficulty (POPCOM, 2001). Violence Against Women (VAW). There have been gains in the country's efforts to respond to gender-related issues, including relevant laws passed by Congress and gender responsive programs and initiatives. Domestic violence is now recognized as a major social concern that particularly affects women. According to the 1993 Safe Motherhood Survey (SMS), 1 woman out of 10 experiences physical abuse even while pregnant. Other common forms of VAW are rape and act of lasciviousness. About 3 percent of SMS survey respondents said they were physically forced to have sex with a man. Of these, more than 60 percent did not seek help, and most were women in younger age groups (POPCOM 2001a). Men's reproductive health. The RH program also focuses on the needs of men. The leading cause of cancer deaths in men 20-35 years old is testicular cancer. The incidence is 35 times higher among men with undescended testes (Philippine Statistics, 1990-1995). The 39

second most common cancer in men is cancer of the prostate.

Its incidence has been

increasing from 12.5 per 100,000 male population in the period 1980-1982, to 19.6 per 100,000 male population in 1993-1995. Other male RH concerns are sexual dysfunctions such as impotence, pre-mature ejaculation, and erection dysfunctions. RH programs for men also deal with their participation in household responsibilities and in women's health projects. In a review of 177 women's health projects in five cities, it was found that 47 percent of the projects involved men in the areas of RH, domestic violence, and STD/HIV-AIDS, although male participation in RH was peripheral (Lee, 1996). Other surveys show that men are beginning to share somewhat in household chores, such as caring for sick members of the family, shopping for food, and preparing household budgets (POPCOM, 2001a). Prevention and treatment of infertility and sexual disorders. Data on infertility reveals that 10 percent to 15 percent of couples are not able to conceive after a year of unprotected, adequately-timed intercourse (WHO, 1986). There has been little or no service available to infertile couples in the country probably because only 2 percent of women are considered infecund (1998 NDHS and 1993 NSMS as cited in POPCOM, 2001a). There is no data at all for infertile men and services for infertility are provided only by a few training hospitals in the country. Infertile couples, particularly in rural areas, resort to traditional rituals and use of herbal medicines. OPERATIONALIZING RH PROGRAMS In the early years of devolution, many local governments found it difficult to perform their new responsibilities in the area of local health service delivery because they did not have adequate capabilities and financial resources. To help local governments, USAID provided funding and technical assistance to two DOH programs known as the Local Performance Program (LPP) and the Matching Grants Program (MGP) designed to augment the capability of local governments in the delivery of health services, with a special focus on FP, maternal and child health, and nutrition. Both the LPP and MGP were expected to contribute to a reduction in the total fertility rate and maternal and child mortality rates by helping to increase the contraceptive prevalence rate, immunization coverage for children and pregnant mothers, and feeding programs. In an assessment, the LPP was found excellent in developing local capabilities in manageing and delivering FP-MCH-nutrition. However, its implementation was found to be still highly centralized and its current structure as unsustainable. It should be noted though that these weaknesses were established from benchmarks and performance measurements

40

since the assessment was not completely based on actual accomplishments (Reynolds et al., 1998). In recent years, efforts to adopt the RH approach were evident in policy and program reformulation. Government also worked to raise awareness about the RH concept through various IEC and advocacy activities, and to enhance the capability in RH care of service providers through training. The United Nations Fund for Population Activities (UNFPA) has been a firm supporter of the country's reproductive health programs. In its Fourth Country Programme (1995-1999), UNFPA assisted a pilot project to integrate the four core RH elements (i.e., gender-sensitive quality RH services for family planning; maternal and child health; prevention and treatment of reproductive tract infections; and, STD/HIV/AIDS and sexuality education) in the public health services of selected municipalities of Nueva Vizcaya Province. This pilot project sought to improve access to RH services and increase knowledge and awareness on RH. Access to services was improved by raising the capability of service providers (through upgrading of facilities, training, and technical assistance), promoting the development and adoption of quality of care standards for already available services such as family planning and maternal care, facilitating the development of new services such as management of violence against women and adolescent reproductive health, and targeting services to specific groups with large unmet needs. Knowledge and awareness on RH matters were improved by national and local IEC campaigns, training of service providers on interpersonal communication skills, and propagation of a large number and wide variety of IEC materials. The UNFPA Fifth Country Programme integrates the 10 RH elements in all public health services of Nueva Vizcaya and expands the coverage to selected municipalities in eight other provinces. The Programme seeks to consolidate different compartmentalized local health services under the unifying umbrella of RH. It adopts an incremental, public health approach that addresses the various health needs of an individual throughout his or her lifespan. The Programme emphasizes the need to create viable referral systems and promotes the concept of a constellation of services that operate on many levels from the primary level of health care to the highest tertiary referral health facility. The Programme also gives priority to establishing strong linkages with other organizations within and outside of the health sector, including local and foreign donor agencies. Over the period 1995-1999, major donors that included the World Bank, Asian Development Bank, Australia Agency for International Development, the European Commission, and Kreditanstalt fur Wiederanfpan (KfW) gave substantial support to the Women's Health and Safe Motherhood Project. This project enhances the quality and range 41

of women's health and safe motherhood services by upgrading the service delivery capacity of local governments and enhancing the ability of the DOH to provide policy, technical, financial, and logistical support. It also employs mechanisms to raise the participation of NGOs and communities. The project includes family planning, and the treatment of RTIs, STDs, and cervical cancer; it covers 40 provinces for maternal care activities, 10 provinces for RTIs/STDs, and 15 provinces for cervical cancer care. The World Bank and AusAID also have supported the Urban Health and Nutrition Project (1994-1998). This project addressed health and nutrition problems in Metro Manila, Metro Cebu, and Cagayan de Oro City. The project focused on MCH, family planning, nutrition, sexually transmitted diseases, and diarrheal diseases. AusAID also has supported the Expansion of FP/MCH/Safe Motherhood and Women Enhancement Program in selected urban communities. The Japan International Cooperation Agency and the Japanese Organization for International Cooperation in Family Planning also have supported FP/RH projects in the country. The initiatives of national and local governments and NGOs are considered milestones in the effort to respond to the population's RH needs. The Philippine Health Insurance Program covers sterilization services. As an offshoot of the UNFPA Sub-Programme on Reproductive Health, pilot municipalities in Cagayan Province (Region 2), initiated community-based Birthing Centers. These Centers expanded and improved on the quality of FP/RH services offered by Rural Health Units. They are located within barangays and managed by trained volunteer health workers with the help of traditional birth attendants ("hilots"). The goal is to achieve zero maternal morbidity and mortality. The pilot municipalities also are experimenting with a Pre-paid Pre-natal Services Project. In this project, pregnant women ensure that they will get pre-natal services by agreeing to pay a minimum of 1,000 pesos in advance (hence, "pre-paid"), which they can pay in installments within the duration of their pregnancy. The project develops self-reliance and a sense of solidarity among pregnant mothers. They become a support group at the time of delivery. Another initiative by the pilot municipalities is the Botika sa Birthing Home (Birthing Home Drugstore), which aims to make affordable and quality essential drugs and emergency medicines available at all times in the community. In the workplace, the Trade Union Congress of the Philippines has a Family Welfare and Family Planning Program that addresses the health needs of union members, including their family members. This is done in coordination with government agencies like the DOH, Department of Labor and Employment, and POPCOM. The Program works through company policies and Collective Bargaining Agreements between labor and management. It applies to participating companies with at least 200 employees and currently works to 42

improve the provision of the 10 key RH elements within the existing health programs of the companies. Other notable efforts to promote reproductive health care include:

A pilot project by public hospitals in Pangasinan Province (Region 1) on prevention of abortion and management its complications; Mobilizing community participation in RH services in partnership with local governments, seen in the projects of NGOs like the Family Planning Organization of the Philippines in Catbalogan and Samar (Region 8), and the LIKHAAN project in Pasay and Malabon in the National Capital Region, and Bulacan (Region 3);

The over 200 Well-Family Midwife Clinics operating in the country through the technical assistance of USAID and the John Snow International-Research and Training Institute; Projects that involve men as FP and RH motivators in selected towns in Bataan Province, Zamboanga Province, and the National Capital Region; Research in RH, such the one on men's involvement in RH projects by the Task Force on Reproductive Health of De La Salle University, and the qualitative research by LIKHAAN on "Instigating Responses to Obstetric Complications and Barriers to Emergency Obstetric Care Among Urban Poor Women," which investigated socioeconomic and cultural barriers to obstetrical care;

Efforts to involve the religious sector, such as the initiative taken by the Province of Pangasinan to develop a partnership with the Catholic Church for the promotion of Natural Family Planning;

The continuing use of mass media by a number of stakeholders to generate awareness on RH; and the RH advocacy activities of interdisciplinary groups coordinated by private academic institutions, including Ford Foundation-funded groups in Luzon, Visayas, and Mindanao, which sponsor seminars on RH issues, manage resource centers, and conduct trainings; and the various community-based and capability building projects of NGOs in the areas of adolescent reproductive health and HIV/AIDS supported by the David and Lucile Packard Foundation.

CHALLENGES

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The RH approach to health care can be mainstreamed only through a broad multisector network of national and local partners. The common ground of this network should be a unified understanding of reproductive health. There is a need to concretize a concept of reproductive health that is based on the culture and complex value systems of the Filipino and on the universal rights to reproductive health of all men and women.

The government needs to improve access, especially by the poor, to quality RH and FP services, through appropriate budget support for contraceptive supplies and related RH/FP programs.

Many local governments still need help in strengthening their capability to plan, implement, and manage local RH/FP programs.

There remains a need to establish a strong partnership of all stakeholders (NGO, GO, LGU, Private and commercial sectors, civil society) in the formulation, implementation, and monitoring and evaluation of RH/FP strategies.

There is a need to address the RH needs not only of women and children but also underserved groups such as men and adolescents, and even the older persons.

There is a need to strengthen male involvement in reproductive health.

There is a need to create an environment for more open discussion about emerging RH issues, such as abortion and emergency contraception and abortion.

There is a need to fill in the RH data gaps for all 10 key elements.

PROSPECTS AND DIRECTIONS

With the expected phase-out of USAID contraceptive donations, the Philippine government will turn to the private sector NGOs, private health service facilities, businesses, people's organizations, and grassroots groups to provide contraceptive supplies to married couples of reproductive age, particularly those with unmet FP needs.

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The recently formulated Strategic Operational Plan of the Philippine Population Management Program will pursue its commitment to ensure the reproductive health and well being of the most deprived sectors of the Philippine population.

It is anticipated that continued foreign assistance, such as that from UNFPA, USAID, World Bank, and AusAID, will continue to play a significant role in sustaining the gains in FP/RH care delivery.

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S E C T I O N

ADOLESCENTREPRODUCTIVE EALTH H

Among the recommendations of the 1994 International Conference on Population Development (ICPD) in Cairo was the protection and development of adolescents and youth.2 The ICPD Programme of Action emphasized the need to:

Promote to the fullest the health, well being, and potential of all children and youth; Meet the social, economic, political, educational, health, and other special needs of adolescents and youth, particularly young women; and, Encourage them, especially young women, to continue their education, avoid early marriages and high-risk pregnancies, and reduce associated risks of mortality and morbidity (United Nations, 1994). These objectives were echoed by the action programs of subsequent international

gatherings, including the World Program of Action for the Youth in the Year 2000 and Beyond (1995) and the 1998 Lisbon Declaration on Youth Policies and Programs. Other international agreements that strengthen the promotion of youth welfare are the United Nations Convention on the Rights of Children and the Convention on the Elimination of All Forms of Discrimination. SOCIO-ECONOMIC PROFILE Demographics. According to the World Health Organization, there are 1.2 billion adolescents worldwide, meaning 1 of every 5 people on the planet is an adolescent. More than 50 percent of the world's population is below 25 years, and 85 percent of them live in developing countries. Based on the 1995 census, 38 percent or nearly 22 million of the population of the Philippines are below 15 years old. About 23 percent represent the adolescent group and 20 percent represent the age group 15-24 years old. The number of Filipinos ages 15-24 stood at 12 million in 1990, up from almost 4 million at mid-century. This number will continue to grow because of slow fertility decline and likely will reach 20 million by mid-2000. The Philippines is in the midst of a "youth bulge," a transitory but an important demographic expansion (Xenos and Raymundo, 1999). The country's population is expected to continue growing rapidly because of the high
2 The World Health Organization defines "adolescents" as those in the age group 10 to 19 years, "youth" as those in the age group 10 to 24 years, and, "young people" as those in the age group 10 to 31 years.

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proportion of the young entering childbearing age. This has important consequences on the social, economic, political, and health conditions of the country. Education. Education is generally considered a gender-fair socioeconomic variable. In 1994, 75 percent of 15-24 year olds reached at least high school level. This increased to 85 percent in 2002 (Raymundo, 2002). School enrolment rose dramatically during the last half of the last century and this trend continued despite economic downturns in the past decade. Young females have consistently shown better educational attainment than their male counterparts (NYC 1998). Based on the Young Adolescent Fertility and Sexuality Survey II (YAFSS II), 13 percent of college-educated females ages 15-24 were already mothers, in contrast with 32 percent among the elementary-educated (NSO and Macro International, 1994). Education evidently deters early marriage and childbearing probably because it opens other opportunities to women. Work participation. In general, increased school enrolment is associated with a corresponding decline in work participation. There are about 12 million youth who are either employed or actively looking for employment (NYC, 1998). In 1995, 60 percent of males ages 20-24 were in the labor force, compared with 40 percent among young females. These figures represent an 18 percent decline among males between 1970-1995 and 33 percent increase among the females (Xenos and Raymundo, 1999). The declining trend in youth employment has continued into the new millennium as they are the most vulnerable group in the work force. The role of employment in marriage and family formation was highlighted in a qualitative study conducted by the Health Action Information Network (HAIN), which found that to many low income Filipino youth, marriage occurs soon after they start working no matter how meager their income (Tan, 2001). Religion. Eighty-seven percent of Filipino youth are Roman Catholics, with 84 percent among them regularly attending religious services. A small but not negligible 6.5 percent of young people have changed their religion at birth, with no gender differences (Xenos and Raymundo, 1999). Religion appears to have varying influences on the sexual behavior of young males and females. Catholic males tend to engage more in premarital sex. Females, on the other hand, say that participation in religious ceremonies serves to protect them from early premarital sex (Raymundo and Lusterio, 1997).

HEALTH SITUATION

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Today in the Philippines, females are reaching menarche at increasingly younger ages, and males are attaining sexual maturation much earlier. Menarche usually occurs between ages 10 to 12. Early sexual maturity coupled with delayed age of marriage exposes the young to unplanned sexual activities earlier and longer, and under conditions of risk from all kinds of potentially adverse consequences from STDs, to HIV/AIDS, to unplanned pregnancies (UNFPA, 1999). In the Philippines, age at menarche has declined from 16.2 years old in the 1950s to 13.2 in the 1990s (Raymundo, 1994). YAFSS II data show a fairly high incidence of reproductive health problems and sexual activity among the young, with a low incidence of treatment and utilization of medical and family planning services (Cruz and Berja, 1999). For instance, 50 percent of young people have experienced at least one reproductive health problem but only 5 percent ever utilized related health services. More females are experiencing reproductive health problems (73.6 %) than males (40.6 %) (Cruz and Berja, 1999). However, the reproductive health problems experienced by females are not considered serious (dysmenorrhea, diminished desire for sex, irregular menstruation). In contrast, those experienced by males are serious ones and the most common is painful urination followed by diminished desire for sex and itching in the genital area, a sign of bacterial infection. Less than a third have not experienced any reproductive health problem and have not engaged in premarital sex. One aspect of the problem is the historical lack of attention to the health needs of this segment of the population. Adolescent medicine is only starting in the Philippines. Another aspect is the poor health-seeking behavior of the adolescents themselves. ADOLESCENT HEALTH RISK BEHAVIORS The health of adolescents and the youth is at risk because they generally lack accurate and appropriate information and an incomplete understanding of the many aspects of sexual behavior, reproductive health, and their sexuality. Some of these risky behaviors and practices have resulted in illness, and even death, and include the following: Early sexual activity. The timing of first sexual intercourse marks the initiation to sexual activities, which when done unprotected can lead to adverse consequences. Sexual activity begins during adolescence in many countries in the Asia-Pacific region. In Thailand, the average age of first sex for males is 16.6 years old, and for females, 17.6 years. In the Philippines, YAFSS II show that, on average, boys and girls have their sexual encounter at the age of 18 and 18.3, respectively. Some 2.5 million or 18 percent of the youth (1.8 million boys and 670,000 girls) already had premarital sex and around 80 percent were not using any method of protection. There were also indications that about 10 percent of girls with sex experience were forced into sexual relations by their partners and that many young people 48

engaged in premarital sex without adequate knowledge about how to avoid pregnancy or STDs. Thirty-seven percent of those who admitted being sexually active are at risk for a variety of reasons, including having multiple partners, engageing in commercial sex, and using intravenous drug users. There are, however, some factors that tend to delay the first sexual encounter, including the following: being employed (for boys); staying longer in school (both boys and girls); receiving population education in school (both); living with parents (girls); and, having a liberal-minded father (girls) (Raymundo and Lusterio, 1997). YAFSS II data further reveal that about 48 percent of sexually active youth (38 percent, males and 72 percent females) engage in repeated sexual intercourse with the same partner after the first time. Young males are more likely to have a repeat of sexual activity not only with the same partner but also with others. The pattern observed is that once a young person gets initiated into premarital sex, a "repeat" either with the same partner or with another, is likely. The "buntog" phenomenon, which is a ritual exchange of sex within a youth peer group and seen as either a result of seeking acceptance among peers or in reaction to family breakdown and stress, has led girls in cities like Davao and Cebu into exchanging sex for money, shelter, and food (Varga, 2001; Cabigon, 2002). Forming union or early marriage. Delayed age at marriage is characteristic of Filipino males and females. In 1995, 80 percent of all youths in the Philippines were single; 20 percent were either married, widowed, or separated/divorced. The percentage of youth who are single has moved upward in the last few decades. Between 1960-1990, for ages 20-24, single males increased from 66 percent to 73 percent, and females from 44 percent to 56 percent (Xenos and Raymundo, 1999). In 1994, 13 percent of young Filipinas were already married by age 18; 43 percent by age 21 and 60 percent by age 24 (Balk and Raymundo, 1999), a level higher than in most other Asian countries. Among adolescents who have married or formed unions, the rate of dissolution is higher than the adult rate (0.23 percent among married adolescents versus 0.17 percent among adults). More than half of those who married before they were 25 years old said they were forced into marriage by circumstances, usually related to their sexual encounters and family problems, with no significant gender differences. Early childbearing/teenage pregnancy. The number of teenagers who have begun childbearing is increasing, although still below 10 percent of all women of reproductive age based on the 1993 NDS and 1998 NDHS (Cabigon, 2002). Teenage childbearing is much higher among rural and low educated females. Fertility among adolescent women declined by about 8 percent in the five years before the 1998 NDHS. More women today delay 49

childbearing past their teen years compared to a generation ago. The reverse is true among less-educated women. Young women today generally want smaller families. According to YAFSS II, 33 percent of young women between 20-24 years old already gave birth to their first child before reaching their 21st birthday. Of the total 1.8 million young women who already had sex, 94 percent said they were unwilling and unprepared to become parents. Young pregnancies account 12 percent of normal deliveries, 6 percent of spontaneous abortions, 3 out of 4 maternal deaths, 10 percent of forced first sexual relations, 30 percent of births to females in reproductive ages, 30 percent of marriages below 20 years old among those aged 15-24, and 74 percent of illegitimate births (JOICFP, 1998). Some 21 percent of these illegitimate births were among the 15-19 age group and 53 percent among the 20-24 age group. Young pregnancies account for 17 percent of induced abortion cases. Teenagers who have unprotected sex or unwanted pregnancies are more likely to resort to abortion. The largest proportion (28 %) of women who had induced abortion complications belonged to the 20-24 age group (Raymundo et al., 2001). Restricted access to contraceptive supplies and RH services, plus social pressure of shame and guilt, influence the relatively high rates of abortion among young women (Cabigon, 2002 ). Sexually transmitted diseases including HIV/AIDS. The prevalence of HIV/AIDS in the Philippines is still low, although patterns of sexual behavior and several sociocultural conditions could precipitate an AIDS epidemic. As of May 2001, the HIV/AIDS registry of the country confirmed 766 cases of HIV seropositive children and youth with 6 percent belonging to the 10-19 age group and 90 percent in the 20-29 bracket. The Advocates for Youth place the 1999 HIV prevalence to be a low 0.04 percent among young women and 0.01 percent among young men. In the Philippines, 95 percent of adolescents and youth have heard about HIV/AIDS, although there is only a fair level of knowledge on the correct transmission mode. About 70 percent of young people believe they are not likely to contract HIV. Among young people, STDs are most frequent in the age group 15 to 24 years. The risk of exposure to STDs is greater for young people who become sexually active early and, therefore, more likely to change sexual partners (UPPI, 1994). Condom use among the young is still very low; intercourse with commercial sex workers is on the rise (Raymundo, 2002). POLICY AND PROGRAM RESPONSES Consistent with its commitment to the 1994 ICPD Programme of Action, the Philippine government has taken steps to create an enabling environment to protect adolescent and youth sexual reproductive health and rights. 50

One population policy objective is to reduce the incidence of teenage pregnancy, early marriage, and other adolescent reproductive health problems. To achieve this objective the AHYDP has been adopted as a major component of the Philippine Population Management Program Directional Plan (PPMP-DP) for 2001-2004 to provide for appropriate (scientific and policy-consistent) information, knowledge, education, and services on population and reproductive health for adolescents and the youth. Similar directions are found in the 1999-2004 Philippine Medium Term National Youth Development Plan (PMTYDP) and in the Compendium of Philippine Youth Programs or the "Youth Doors" of the National Youth Commission (NYC). The NYC serves as the official policy-making and coordinating body of all youth programs and projects of the Philippine government. The PMTYDP provides a clear policy for developing responsible reproductive health behavior among adolescents through an integrated and comprehensive package of preventive and curative health care services for the youth at all levels of health care. The task of providing RH services to young people belongs to the Department of Health (DOH). The DOH carries out an Adolescent and Youth Health and Development Program (AYHD), done in close cooperation with local governments. With UNFPA assistance, the DOH is currently developing an adolescent reproductive health framework in consultation with POPCOM and other institutions. INITIATIVES AND BEST PRACTICES The AHYDP of the PPMP is implemented by various agencies at the national and local governments, NGOs and private sector. Following are the projects and initiatives: National level projects. In 1995, POPCOM worked closely with a network of national government agencies, NGOs and local governments on this program. Participating local governments implemented 18 innovative projects to reach the young. These consisted of media outreach, skills training and enhancement, peer counseling, and support to other programs and projects. The program launched a nationwide IEC campaign called "Hearts and Minds" to reach young Filipinos with messages about preparing themselves for adulthood and parental responsibilities. Training modules on "Sexuality, Health and Personally Effective Adolescents (SHAPE)" for peer helpers and parents were produced and widely utilized. POPCOM with funding assitance from UNFPA produced the SPPR 2002 which has ARH as its main theme. SPPR 2002 presents comprehensive account of the trends and issues about the sexuality, health and fertility of Filipino adolescents and youth. It is meant to serve as an instrument for promoting policy dialogue and influencing policy decisions at both national and sub-national levels, with decision-makers as the primary audience.

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The DOH developed an AYHD program which aimed to institutionalize the provision of information, counseling and clinical services to adolescents and youth, including reproductive and sexual health issues and concerns. The DOH also developed a training module and facilitator's guide for the Training Programme on Adolescents, for Health and Non-Health Service Providers. The University of the Philippines Population Institute (UPPI) implements YAFSS III with funding support from The David and Lucile Packard Foundation. YAFSS III is a major effort to update information about the sexuality-related values, knowledge, attitudes, and behavior of adolescents. YAFSS III covers a wider range of sexual, non-sexual, and health risk behaviors of young people. Like its predecessors, YAFSS III is a useful source of policyand program-relevant information. School based initiatives. The Population Education Program (POPED) has been implemented by the Department of Education (DepEd) since the 1970s. One in-school initiative is the the Strengthening and Revitalizing the Population Education Program implemented by the DepEd. The objective of this program is to enrich POPED in schools by enlisting the Commission on Higher Education (CHED) at the tertiary level and the Technical Education and Skills Development Authority (TESDA) at the vocational level to participate in the program and adopt the POPED curriculum. This has resulted in further improving concepts and learning competence. The project evaluates POPED and constantly introduces improvements in program content. From focusing largely on population and development, family life, and responsible parenthood, the project has introduced new areas of concern such as gender equality, HIV/AIDS, sexuality, and reproductive health. Along the same lines, the Philippine Center for Population and Development in collaboration with the Bureau of Secondary Education implemented a project to institutionalize a Revitalized Home Guidance in 12 regions of the country. Students gained new skills in becoming more assertive and in improving their relationships with the opposite sex. They also acquired new knowledge on STDs, HIV/AIDS, courtship, friendships, dating, and other aspects of adolescent personal development. IEC materials on value formation of young people toward becoming responsible adults also were developed and produced. The project also set up a Teen Health Center inside an industrial park. The Foundation for Adolescent Development, an NGO that focuses on young people's health and sexuality needs, carries out SEXTERS, a classroom program to nurture socially, emotionally, and sexually responsible teenagers. This program trains peers to provide The program information, counseling, and referrals on adolescent health and sexuality.

assigns a trained peer counselor in campus. School administrators support the program because they recognize that their students can benefit from the information and counsel 52

provided by enlightened peers. The project has produced a Trainers Guide for training potential peer educators. Capability building for youth leaders and organizations in colleges and universities on adolescent health sexuality and development has also been provided. In 1994, the DepEd and Kimberly Clarke Philippines, Inc. started a program called Feminine Hygiene Education Program (FHEP) for elementary and secondary school students. Under this program, school nurses of the regions are trained and mobilized to counsel and lecture on the physiological and biological changes experienced by boys and girls, good grooming, personality development, and clarification of myths and fallacies about menstruation and feminine hygiene. The positive impact of the program has been noted in the improved perception of the target group on feminine hygiene. The DepEd is also deeply involved in a School-Based Women's Health Project in partnership with Johnson and Johnson, and the ASEAN Consumer Group of Companies in the promotion of reproductive and adolescent health. Inter-sectoral and community-based initiatives. A nationwide training program by the Department of Social Welfare and Development (DSWD) for Municipal and City Social Welfare and Development Officers was undertaken to enhance their understanding of and effectiveness in providing technical assistance and capability building to LGU workers and other service providers in the implementation of the Unlad Kabataan Program. This program develops new approaches and strategies to address the emerging needs of the out-of-school (OSY) youth and help them become more actively involved in community activities. Several projects are geared to establishing places where teenagers can interact. These come in the form of teen "healthquarters", youth and drop-in centers, ARH Corners and "Tambayans." Teenagers use these centers to get information, counseling, and referrals for health services. There are also projects that provide telephone counseling (e.g., "Dial a Friend" and "Friends in Line"), counseling through the Internet (www.teenfad.ph and "E-Mail a Friend"), and counseling on air services on adolescent development, sexuality and health issues. The performing arts have been employed effectively in influencing youth values related to sexuality and reproductive health. For example, the Foundation for Adolescent Development has produced Enter-Educate videos that provide youth audiences with behavioral modeling on relevant health and sexuality issues. Likewise, the CAR Dev Theatre in the Cordillera Administrative Region and Zamboanga Zarzuela in Zamboanga City use folk theater performances to deliver RH messages. Some initiatives provide useful ARH information at the local level and in the workplace. For example, members of the Sorsogon City Advocacy for Responsible Team of Youth (SCARTY) composed of Sangguniang Kabataan officers act as lead persons in ARH programs and activities. The province of Leyte has two youth projects. 53 The first is the

Movement for Young 'Rurban' Women wherein single young women serve as advocates to other young urban and rural women on their reproductive rights and about access to reproductive health services. They also campaign against illegal recruitment of domestic helpers, the treatment of women as commodities, and acts of violence against women. The other Leyte project is called Youth for Human and Ecological Security (YHES). This trains youth leaders in adolescent and youth development, environmental protection, livelihood, gender awareness, and the theatre arts. CHALLENGES The reproductive health needs of adolescents and the youth have been neglected for many years by the public health system. Few services address the specific health concerns of this segment of the population (NYDP, 1994) and most are provided by NGOs. There is a problem of coverage and, therefore, of accessibility and availability. Efforts must continue to mainstream adolescent reproductive health by putting in place culturally sensitive, high quality, accessible, and user-friendly services. Moreover, these services must respect the right of adolescents and the youth to privacy, confidentiality, and informed consent. ARH care providers need to be specially trained and oriented so that they are competent and sympathetic in how they relate to adolescents seeking RH-related preventive and curative care services. In sum, the major challenges confronting ARH are the following:

Adolescents and the youth have limited access to RH services that meet accepted standards of quality of care and that are user-friendly and culture-sensitive. There is low ARH service coverage; there are still too few adolescent and youth centers to adequately fill the need of the sector. Most adolescents and the youth are not aware of existing ARH programs and services. There is a lack of clear and sufficient policies and guidelines on the provision of medical reproductive health services for adolescents and the youth. Many health service providers are inadequately trained and are suspicious, judgmental, and hostile to adolescents who ask for RH information or medical services. There is a continuing need to build the life skills of adolescents and the youth to help them deal more effectively with the demands of everyday life and avoid high-risk behaviors.

Despite their powerful influence on adolescents and the youth, most parents and guardians still do not fully understand the situation of the young, have inadequate communication skills, and, therefore, are limited in their ability to give meaningful RH counseling.

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Program and service delivery planning is hampered by the absence of a comprehensive ARH database that should include data on the composition, size, behavior, and practices of adolescents and the youth.

FUTURE DIRECTIONS AND PROSPECTS

Provision of adolescent friendly-clinics in strategic places. Strengthening the ARH system to make services more available, acceptable, accessible, and affordable to adolescents and youth. Strengthening the skills and reorienting service providers and youth serving professionals. Active involvement of parents and other stakeholders on sexuality and other ARH concerns. Intensive IEC and advocacy on human sexuality and ARH issues and concerns. Inclusion of ARH in the school curriculum and promotion of value education through the media. Establishment of a "Youth Development Center" in every municipality. Review of existing laws that affect ARH and the formulation of new legislation to close the gaps in adolescent health and development (new laws need to address issues of population and development, adolescent general health and reproductive health, enhancing known protective factors for adolescent RH, reducing the effects of known risk factors for ARH, and so on).

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S E C T I O N

ECONOM ICAND SOCIAL IM PACTOF HIV/AIDS

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STATUS AND TRENDS Around 40 million people in the world live with HIV/AIDS today. In the Asian region, 7.1 million people now have HIV/AIDS. The prediction is that Asia will surpass Africa in the number of HIV infections in the first decade of the 21st century (UNAIDS, 2002). In the Philippines, the first AIDS case was recorded in 1984. Since then, the HIV/AIDS Registry has recorded 1,611 HIV Ab seropositive cases, as of December 2001. Health authorities suspect that many more cases are unreported. Various Philippine epidemiologists estimate the actual number of HIV cases at a low of 5,000 to a high of 13,000 (NEDA, 2002) Of the recorded 1,611 cases, 61 percent are men and 39 percent are women. The 30-39 age group has the highest number of infected men, while the 19-29 age group has the highest number of infected women. Of these cases, 28 percent are overseas Filipino workers The primary mode of transmission is sexual (OFWs), 38 percent of them seafarers.

intercourse (Millennium Development Goals, 2002). International experts characterize the Philippine HIV/AIDS situation as a "nascent epidemic." This means that the number of confirmed cases of HIV/AIDS is low and the rate of increase in the number of cases is slow. Factors contributing to the low prevalence of HIV infection in the Philippines include the following (Synergy, 2001):

Female sex workers have relatively few sexual partners; Filipino males have a relatively low exposure rate to female sex workers; Injecting drug use is not as common as in other East Asian countries; There is low prevalence of ulcerative sexually transmitted infections (STIs); and Most Filipinos have few sexual partners. The "low and slow" signifies that the number of infections has not reached critical level.

However, an epidemic still could take off because of the following reasons:

Surveillance is not comprehensive since it focuses only on registered commercial sex workers, men having sex with men, and injecting drug users; Preference for private physicians to ensure confidentiality; High awareness of HIV/AIDS not translated to protective action (e.g., condom use); and, Inability of the DOH to provide for free (as in other countries) exorbitantly priced antiretroviral drugs, which could prevent transplancental transmission.

POLICIES AND PROGRAMS The ICPD recommends that governments should ensure that at least 90 percent of young men and women, aged 15-24, should have access by 2005 to preventive methods - such as female and male condoms, voluntary testing, counseling, and follow up, and at least 95 percent by 2010. In response, the Philippines has intensified its programs on responsible 56

parenthood and reproductive health. These programs advocate for the increased availability and accessibility of reproductive health information and services aimed at reducing the risk of HIV/AIDS infection. The initial national governmental response to HIV/AIDS was in 1989 through orders issued by the Secretary of Health. This became the basis for a 1992 Executive Order that, today, embodies the national HIV/AIDS policy. Later, this was legislated into law as the Philippine AIDS Prevention and Control Act of 1998.

The Act serves as a model for

HIV/AIDS-related human rights legislation and has the following important provisions: Prohibition of compulsory testing for HIV; Respect for human rights, including the privacy of HIV infected individuals; Integration of HIV/AIDS education from intermediate to tertiary levels of schooling; Provision of basic health and social services for individuals with HIV; Promotion of safety precautions in practices where there is a risk of HIV transmission; and

Prohibition of discrimination against persons living with HIV/AIDS in the workplace, schools, hospitals, and in insurance services. The Philippine National AIDS Council (PNAC) is the legally established body to

coordinate and direct the nationwide implementation of the Act. The PNAC is a multisectoral body composed of government and nongovernment institutions. The Secretariat, headed by a director and a full-time staff provided by the DOH, serves as the key support staff of the PNAC. Committees on local responses, science and research, education, and advocacy, have recently been organized to focus on various aspects of the national effort. Other HIV/AIDSrelated policies include:

A government policy on the use of condoms; A policy on regular (bi-annual) serelogical testing among high risk groups, such as commercial sex workers; Provision of basic health services not only for HIV positives but also for high risk individuals; and, Non-discrimination of HIV/AIDS persons.

BEST PRACTICES Nationwide activities. Some examples of important ongoing nationwide activities include the following:

Pilot research and development work of academic institutions, government agencies, and NGOs;

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Ongoing serological and behavioral surveillance, including annual dissemination of surveillance results; Efforts to incorporate knowledge of HIV/AIDS in the educational programs of the formal and non-formal education system; Continuing assessment of vulnerability to HIV infection of various areas and regions of the country; Efforts to incorporate HIV/AIDS knowledge in the pre-departure orientation of overseas Filipino workers; Efforts to reach all workers in their workplaces with basic information and knowledge about HIV/AIDS; Social marketing efforts to promote condom availability and sale as well as facilitate dispensing and use of standard full-course treatment packs for the syndromic treatment of STDs;

Development and printing of AIDS educational modules for integration in appropriate learning areas; Conduct of national and regional surveys on the knowledge, attitudes, and practices (KAP) of students on HIV/AIDS;

Adaptation of the etiological reporting of STDs to improve surveillance.

Local activities. Some examples of notable local responses include:

Passing of local ordinances to improve the quality and expand the operation of social hygiene clinics for better prevention and control of STDs; Local government efforts to absorb the operating costs of HIV/AIDS surveillance activities (for example, in Cebu, the Municipality of Balamban has set up an STI Clinic through a municipal resolution; also in Cebu, the Cebu Medical Society established a Center for Infectious Diseases, and a laboratory for HIV and STI testing; in Region 2, there are surveillance and monitoring activities through serologic testing of so-called "guest relations offices" (night club hostesses) and volunteer clients at social hygiene clinics);

Establishment of local AIDS councils to coordinate multi-sectoral work in the localities; Community outreach and preventive education activities of several NGOs targeted to various groups such as commercial sex workers, minors in the sex trade, men who have sex with men, and adolescents;

Adoption of local ordinances that mandate 100-percent condom use policies in registered entertainment enterprises; and, HIV/AIDS counseling and establishment of telephone hotlines and information centers.

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There are indications that the current national effort is making progress. There is greater availability of reliable scientific and research-based information about the current levels of HIV infection and the actual risks for spreading the infection. Awareness of HIV/AIDS issues is now higher among leaders and opinion makers; there is more vigorous response among many stakeholders to forestall an HIV/AIDS epidemic. Condoms, STD treatment packs, HIV testing services, preventive counseling and education services, and proper clinical care and support of AIDS patients are now more available and accessible.. ISSUES AND CHALLENGES According to UNAIDS (2002), the Philippine AIDS Law and the National Medium Term Plan on HIV/AIDS still have not been fully implemented. The budget allocated by the government for HIV/AIDS has steadily decreased over the years, moving from 20 million pesos (US$400,000) at the start of the program to 9 million pesos today (US$180,000) (UNAIDS, 2002). In addition, the HIV/AIDS program faces these other challenges (Synergy, 2001; POPCOM, 2002):

Fully implementing the new national strategic plan for the prevention and control of HIV/AIDS; Raising levels of condom use while taking into account the objection of some religious groups opposition; Providing HIV/AIDS education to a large overseas migrant worker population; Coping with the illicit and mostly unregulated commercial sex industry; Reducing high STI prevalence and resistance to STI drugs; Reducing the tuberculosis rate, which is among the highest in the world; Reaching more effectively out to men having sex with men; Establishing a practical system to register 'freelance' commercial sex workers; Setting up HIV/AIDS telephone hotlines and information centers; Establishing "teen centers"; Organizing an HIV/AIDS core group; Improving social hygiene clinic facilities nationwide and conducting regular social hygiene classes; Intensifying condom promotion among qualified condom users; Making STD drugs and testing reagents widely available; Organizing Visitation Task Forces; Identifying high-risk groups for possible HIV/AIDS testing; and, Carrying out a comprehensive information drive on RH services including HIV/AIDS among overseas Filipino workers. 59

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S E C T I O N

GENDER EQUALITYAND DEVELOPM ENT

POLICIES, PLANS AND PROGRAMS The Philippine government was among the first to promote gender equality and women empowerment, following the international conferences in Bali (1992), Cairo (1994) and Beijing (1995). In 1992, the Philippine Congress passed Republic Act 7192, "An Act Promoting the Integration of Women as Full and Equal Partners of Men in Development and National Building." This law is the legal basis for long-term plans to address gender issues. It directs all government agencies to institute measures that would eliminate gender biases in government policies, programs, and projects and ensure women's complete participation in development and nation building. The Philippine Plan for Gender Responsive Development (PPGRD) for 1995-2025 is the result of a participative process conducted at the national and sub-national levels. The PPGRD provides the framework to guide policies, programs, and projects in making men and women equal participants and beneficiaries of development. The plan also identifies prevailing gender issues in all the sectors (trade, education, credit, reproductive health, etc.) and addresses these issues through a collaborative effort among government and the civil society. The National Commission on the Role of Filipino Women (NCRFW) is responsible for manageing the PPGRD. The NCRFW has the mandate to monitor and coordinate gender mainstreaming. However, the agency's capacity for monitoring and coordination with The NCRFW depends on departments and other government bodies remains weak.

monitoring reports from other government agencies as the basis for its policy and program advocacy. The problem lies with the timeliness, regularity, and specificity of the reports. For instance, monitoring reports are simply listings of nominal information, such as indicators and activities, often bereft of impact assessment. Complementing the implementation of PPGRD is the institutionalization of financial support for Gender and Development (GAD) activities, which is provided for in the General Appropriations Act. The "GAD Budget" has been incorporated in the Philippine Annual budget since 1995. All agencies are mandated to set aside a minimum of 5 percent of their total budget for gender-related activities.

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Monitoring compliance with the 5-percent GAD budget requirement remains weak. Many government agencies are not effectively guided on what outputs and outcomes are expected. Given the small staff of the NCRFW, it cannot review all GAD budget proposals, much less analyze the other 95 percent in terms of potential impact on women and men. The government also has adopted a gender-responsive population program framework to improve current population planning and policy development. Gender equality and women empowerment cuts across all the four major components of the Philippine Population Management Program or PPMP. One tool is the "Framework for Analyzing Gender Responsive Population Policies with the RH Perspective," which PPMP managers use to ensure that effects and benefits of policies and projects are shared equitably between men and women. Using the Framework, policies may be viewed from a 3-dimensional perspective social and institutional levels of development, the development factors affected by, affecting them, and crosscutting issues of gender and reproductive health. The country has made significant gains in mainstreaming gender and development. This can be seen in the sizeable number of legislative measures, training programs, research activities, and advocacy campaigns. Important legislation that empower women include: the New Family Code, which eliminates discriminating provisions in the previous law; the AntiSexual Harassment Law, which declares sexual harassment unlawful in employment, education, and training institutions; Republic Act 7610, which protects children against abuse, exploitation, discrimination, prostitution, and trafficking; the Anti-Rape Law, which classifies rape as a crime against persons rather than a crime against chastity; and, Republic Act 8505, which strengthens the government mechanism to respond to violence against women through the establishment of women's crisis center in every province. THE STATE OF GENDER EQUALITY AND EQUITY Education. The Millennium Development Goals include the elimination of gender disparities in primary and secondary education by 2005 and in all levels of education before 2015. The Philippines has made solid progress to achieve this. It is indeed in education that women and men have attained almost equal status. Simple literacy of the population 10 years and above is nearly universal for both females and males (94 percent for women and 93.7 percent for men in 1994). The functional literacy of the female population 10-64 years (85.9 %) in 1994 is 4.2 percentage points higher compared with men. In the 1995 Census of Population, about 21 percent of females compared with 19 percent of males had a postsecondary or higher education, although more women than men did not complete any education in 1990 and 1995 (NSO, 1999).

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Employment. Access to productive resources such as land, technology, infrastructure support, natural resources, and labor defines the scope by which women and men participate in economic activities that produce value. Men have better access to land and other agricultural services. They also dominate agricultural work. According to the 1997 Integrated Survey of Households (NSO, 2001), there were more women (23.3 million) than men (22.8 million) in the labor force. However, the labor force participation rate of women (48.9 %) was almost half that of men (82.4 %). For the period 1990 to 1999 (NSO, 2001), the labor force participation rate of women ages 25-54 (considered the peak childbearing or child-rearing period) was only half that of men. Men consistently dominate agricultural and production, while women dominate the sales, community services, and personal services. More women than men do unpaid family work in the Philippines, although the number of male unpaid family workers increased by 41 percentage points from 1989-1999, compared with the 29-percentage point increase among female unpaid family workers (NSCB, 2000). While women have lower participation rates than men in local employment, the reverse is the case in overseas employment. At ages 20-29, there were nearly two women OFWs for every one male OFW (NSO, Survey of Overseas Filipinos 2001). One explanation offered for this is that women have a need for paid work in order to contribute to family income. Disparities are obvious in the kind of work they do, which parallels the situation in the local job market. Women overseas workers also have lower wages than men, as seen in the amounts they send home (NSO, Survey of Overseas Filipinos 2001). Health and Nutrition. Women seem healthier than men. Women live about 5 years more than men, on average (NCSB, Phil. Statistical Yearbook 2001). Infant mortality rates in 1998 were higher for boys than girls at 39 percent and 32 percent, respectively (NDHS, 1998). On the other hand, child mortality rates for girls are higher than boys at 21 percent versus 18 percent (NDHS, 1998). However, women are more likely to suffer from nutritional problems than men. About 16 percent of women were undernourished compared with 12 percent for men in 1993. Women also have a higher incidence of obesity at 3.4 percent versus 1.7 percent for men (NDS, 1993). Women are particularly vulnerable to malnutrition because of their special nutritional needs during pregnancy. Only about 40 percent of pregnant women had two or more doses of tetanus toxoid injections, while 30.7 percent had only one dose and 0.3 percent did not have any during their pregnancy. Three in every four women (74.6 %) received iron tablets during pregnancy, while one in every two (56.6 %) of the pregnant women received iodine capsules. (NDS, 1993)

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Personal Security. Women are more vulnerable to acts of violence, while men are more often the perpetrators of violence. Based on January-to-September 2001 data from the Philippine National Police (PNP) Women's and Children's Desk, the most reported cases of violence against women were physical injuries and wife battering (55.1 %), followed by rape (10.1 %), and acts of lasciviousness (6.9 %). Political Participation and Voice. Men continue to dominate political participation and decision-making in society, although women have improved their participation over the years. In the 1998 elections, voter turnout among women was slightly higher than among men (87.0 percent for women versus 85.7 percent for men), probably because there were more registered female voters. However, there has been a decrease in the proportion of women running for elective posts from 1998 to 2001 (COMELEC, 1998 and 2001). In the bureaucracy, women comprise more than half of government personnel, outnumbering men at national agencies. However, more men are employed in local In terms of positions held in They are government units and government-owned corporations.

government, women dominate second-level positions with 71.9 percent. outnumbered in the first-level and third-level positions (WAGI, 2002).

As of June 2001, 21 percent of judges in Philippine courts are women. During the 1993-1998 period, the Supreme Court, which has 15 members, had only one woman member. In the Municipal Trial Courts, the proportion is more equitable, with 28 women judges out of a total 55 judges (WAGI, 2002). Feminization of Poverty. UNIFEM estimates that about 70 percent of the world's 1.3 billion poor are women. Over the last two decades, the number of rural women worldwide living in absolute poverty has risen by 50 percent, compared with 30 percent for men (WAGI, 2002). Are Filipino women poorer than men? This is not easy to establish since national data on income and expenditures does not make a distinction in the gender of the household head. The feminization of poverty is rooted in the claim that women are more vulnerable to chronic poverty because of gender biases in the distribution of income, in the access to productive inputs (such as credit and technology), in command over property or control over earned income, and in the preferences of the labor market (Cagatay, 2001). In addition, gender relations perpetuate women's poverty by "restricting women's rights both to entitlements and to the enhancement and unfettered exercise of their capabilities" (Banaria and Bisnatch, 1996).

CURRENT INITIATIVES 64

The Philippine government has continuously implemented activities to strengthen institutional mechanisms to advance the adoption of the PPGRD. These activities include the following:

Organization of GAD Focal Points in national and sub-national agencies and LGUs. At present there are more than 70 GAD Focal Points organized in more than 20 line agencies (NCRFW, 1996).

Development and dissemination of a standard guide entitled "Gender Mainstreaming: A Handbook for Local Development Workers." Installation of a monitoring system for GAD mainstreaming to facilitate coordination between NCRFW and other government agencies, and systematize the assessment of the GAD-related accomplishments of different agencies.

Conduct of gender development advocacy activities and various gender sensitivity training seminars on gender planning and budgeting. At the sub-national level, various projects and activities have been undertaken.

Sensitivity to the generation and utilization of sex-disaggregated data and statistics for planning, programming, and project development continues to be advocated. Gender and Development Indicator Systems are being installed in local-level government offices to institutionalize the incorporation of gender in regional development plans. The series, Women and Men: 2000 Statistical Handbooks, has been developed and produced for Regions 1, 2, 3, 4 and 5. Training on statistics for gender planning has also been done for local development planners. To operationalize the provision of RA 7192, GAD focal points at agency and LGU levels were organized nationwide. The GAD Regional Core Group (sometimes called Regional GAD advocates or GAD Local Councils) has been established in Region 1 and Region 5. This Core Group currently engages in mobilization activities to mainstream gender in the plans and projects of line agencies and local governments. GAD Coordinating Committees under the Regional Development Councils were established to monitor and evaluate GAD projects. Similarly, grassroots women's organization and groups have been tapped for gender issues advocacy and information dissemination. Local government units at the city and municipal level have been very active in establishing Women's Desks to attend to victims of VAW. The DSWD is currently piloting a National Family Violence Prevention Program in four barangays in Region 5. So far, the program has recruited and built the capability of volunteers in the barangays to counsel and assist victims of violence. CHALLENGES 65

Notwithstanding the gains achieved thus far, much remains to be done to mainstream gender in the programs of various government agencies, both at the national and the local levels. The main challenges are summarized as follows:

Results of the requirement to allocate 5 percent of total budgets to GAD activities are generally considered to be below expectations. This is mainly due to different ways of interpreting GAD guidelines. More technical assistance (especially to local governments) is required to build gender-capability.

A GAD database with sex-disaggregated data needs to be maintained to help develop better laws, policies, and programs. There is a need for greater information and advocacy on GAD. The need for sustained advocacy on gender equality and reproductive rights needs emphasis because large segments in the bureaucracy, in industry, and in the grassroots have low awareness of gender issues.

Monitoring and evaluation should be strengthened. Efforts must be sustained to assess the impact of GAD-related programs in minimizing or eliminating discrimination against women.

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S E C T I O N

1 0

IEC, A DVOCACYAND ICT

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IEC FOR BEHAVIORAL CHANGE Through the years, communication to change behavior and influence policy has been an integral part of the Philippine government's population, reproductive health, and family planning programs. The information, education, and communication (IEC) campaigns of the Department of Health (DOH) carry various messages that focus on proper spacing of births and reflect a shift from number of children to quality of life. The current slogan used nationwide is "Kung sila'y mahal n'yo, magplano" (If you love them, plan your family). A number of nongovernment organizations complement the DOH efforts. For example, DKT International has launched multi-media campaigns that promote use of condoms and pills under its HIV/AIDS Prevention and Control Project and Family Planning Project. ReachOut Foundation, with its reproductive health campaigns, has actively promoted the use of various modern FP methods, including emergency contraception. Other private sector groups, including women's groups, also have carried out similar information drives to attract more FP acceptors. The most important indicator of the effectiveness of these campaigns is the increasing contraceptive prevalence rate (CPR), which is currently pegged at 49 percent of all married couples of reproductive age (1999 Family Planning Survey). This is low compared with a neighboring country like Thailand, which had a 1998 CPR of 74 percent. ADVOCACY AND IEC FOR A SUPPORTIVE POLICY ENVIRONMENT POPCOM has developed a four-year (2001-2004) Advocacy Plan and Framework which aims to contribute to the improvement of the policy environment for a more effective implementation of the population, reproductive health and responsible parenthood/family planning programs. The advocacy plan and framework serves as the blueprint for the efficient and effective coordination and implementation of the PPMP advocacy at all levels. One of the significant accomplishments is a more heightened awareness among planners, legislators, and government executives of the need to integrate population perspectives into development activities. Advocacy efforts have also helped to produce legislation supportive of the population program. The province of Agusan del Sur is one local government that has generated policies following intensive population advocacy activities by the program. The local legislations include an executive order that encourages all local chief executives to create a municipal population management office. Agusan has also issued a 67

resolution endorsing the establishment of an Adolescent Health and Youth Development Center; and another resolution increasing funding support for RH and population projects (e.g., repair and construction of barangay health stations, funding support for IEC and advocacy activities on RH and population, establishment of youth and VAW centers). In Negros Occidental province, the Ilijan Upland Development Organization decided to integrate population concerns in its economic and environmental protection programs for upland communities. Based on the strategies of the Advocacy Framework, following are the countrys notable advocacy activities and initiatives: Capability-building. In the 1980s and early part of the 1990s, POPCOM conducted combination Workshops-Writeshops on Local Population Planning; Information, Education and Communication (IC) Prototype Development Skills Training; and Values Orientation Workshop; and Interpersonal Communication Skills Training. With the assistance of the Japan International Cooperation Agency (JICA), POPCOM organized an in-country training program in the early 1980s on Gender and Development Toward Improvement of Women's Health and Family Welfare wherein individual action plans were formulated on mainstreaming gender into various organizations and projects. From 1996 onwards POPCOM also trained various regional offices and local government units on Basic Demographic Concepts and the use of the RAPID software with support from USAID and UNFPA. During the latter part of the 1990s to the present, POPCOM conducted Monitoring and Evaluation Training; Training on Gender and Sensitivity and Reproductive Health; seminars on Program Awareness and Team Building; Advocacy Campaign Management and Media Relations; Advocacy Plan Development; Power Communications; Occupational Safety and Health (OSH); and, Male Involvement in Reproductive Health. As support to the more recent training activities conducted, POPCOM, with assistance from the UNFPA developed the Practical Guide on Advocacy for Reproductive Health, Broadcasters Manual as well as various curriculum on advocacy. Broadening of partnership and advocacy network and establishment of new, and maintenance of existing advocacy groups. The creation of local advocacy teams is a major strategy employed by POPCOM in generating support and commitment from local governments. Members of these advocacy teams include development officers, health officers, local legislators and department heads, NGOs, media, women's and youth groups, and religious groups. These local advocacy teams coordinate and harmonize advocacy efforts in their locality and serve as the prime movers of the advocacy campaign. They are

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responsible for developing and implementing local advocacy campaigns. Central to this strategy is the capability and capacity building of the members in planning, advocacy skills, crafting of core messages, and materials development. As an example of the impact of these advocacy teams, in Region 6, local advocacy teams succeeded in establishing solid partnerships with the academe on ARH concerns and even became instrumental in setting up school-based youth centers. POPCOM, in close cooperation with the Philippine NGO Council, the Philippine Legislator's Committee on Population and Development, and selected local government units also spearheaded a Local Advocacy Project (LAP) with assistance from USAID and the Policy Project-The Futures Group International. A sequel to the LAP is the Provincial Advocacy Network to be implemented by POPCOM in selected areas, also with help from USAID and the Policy Project-The Futures Group International. The networks will consist of civil society groups working alongside government. Another advocacy activity is the Policy Champions Project, a concept of the Population Council that is being implemented by POPCOM with funding support from the Philippine Center for Population and Development. This project promotes population research findings in formulating population policies. NGOs have actively contributed to creating community-based advocacy networks. In CARAGA, the Women's Health and Safe Motherhood Project established community-based advocacy groups in 14 municipalities of the region. They include women and auxiliary groups of husbands, the youth, and children. The project has succeeded in empowering women in the community through capability building and livelihood support. Advocacy work has also targeted various religious groups. The most recent along this line is the creation of a pool of advocates composed of Muslim religious leaders through the ULAMA and ALIMA project of Mindanao. Development, production and dissemination of advocacy materials. POPCOM, with assistance from various donor agencies, particularly UNFPA and USAID, has developed many advocacy materials and references, including:

The State of the Philippine Population Report Local Governments and Filipino Families and Partners for Peace and Progress Hearts and Minds for ARH The RAPID Model POPCOM has also conducted various communication campaigns in coordination with

the media. The major themes include "Tao Para sa Mundo, Mundo Para sa Tao" (People for the Earth, Earth for the People) and "Pamilyang Nakaplano, Panalo" (A well-planned Family is a Winner). This involved the development of press releases, audio-visual presentation, and other IEC activities to raise program awareness and support. 69

Special population events. POPCOM has organized various institutional activities to get the support of stakeholders. Foremost of these is the annual celebration of Population and Development Week. Major activities include a regional and national Population Quiz Show, Local Government Unit Awards, Regional and National Population Congress, and the Rafael M. Salas Population and Development Awards. contributions to the population program. The Salas Awards publicly recognize outstanding individuals, groups, and local government units that have made significant In 2000, POPCOM coordinated the Philippine hosting of the Global Media Awards for Excellence in Population Reporting. Among UNFPA-assisted countries, the Philippines was one of a handful that commemorated the symbolic day (October 12, 1999) when world population reached the sixbillion mark. On this date, POPCOM and UNFPA selected baby girl Lorrize Mae Guevarra, born at the government-owned J. Fabella Hospital, as the Filipino counterpart of the world's six billionth baby. As the representative of her generation, Lorrize was also chosen as the Symbolic Child 21 model for the Philippine National Strategic Framework for Plan Development for Children (2000-2025). The Council for the Welfare of Children will be monitoring Lorrize until she reaches 25 years old to find out whether Filipino children are receiving the necessary services to enable them to live healthy lives. In 2001, POPCOM also spearheaded launches in various parts of the country of the State of the World Population Report and the Philippine Population Report. Other special population related events by various government organizations include, among others, National Family Planning Day and AIDS Awareness Month by the Department of Health, and the Women's Month by NCRFW. Aside from these national events, Regional Population Offices also conduct their own special events to promote and gain more support for the program. Among these are the Search for Model Family, the Women's Health Arts Festival, Outstanding Population Workers and Volunteers, and various loyalty and recognition awards. Strengthening national and local population information centers. various networking strategies were adapted. When POPCOM assumed the direct administration of the Philippine Population Information Center (PPIC), "Population Information" or POPIN satellite The PPIC performs library centers were established in all regional population offices. development of corporate publications such as POPINEWS. The PPIC serves as the link to regional population information centers and international information centers to enable the sharing and acquisition of information on population and related issues that can be used in policy and advocacy work. Regional Population Information Centers and Satellite Centers have expanded network links with school libraries on the 70

management, which includes gathering, documentation, and circulation; referral services; and,

provision and acquisition of population information and materials. So far, the PPIC has not yet reached its full potential. Information Communication Technology (ICT) is being introduced to further expand its reach. STRENGTHENING IEC AND ADVOCACY EFFORTS THROUGH ICT The utilization of information and communication technology or ICT in the IEC and advocacy efforts of the program is gaining ground and has opened opportunities for institutions that have adopted the technology. Notable improvements can be seen in the fast exchange and gathering of relevant information among stakeholders through the Internet, email, mobile telephony, and the text messaging (Short Message Service) features of cellular phone networks. These have also proven useful in networking with national and international advocates as well as in recruiting more supporters for the program. The Internet and the World Wide Web have also been the venue for advocates to discuss pertinent RH and FP issues. More sophisticated IEC and advocacy materials have been developed with the aid of new software. This has paved the way for creating databases, such as the National Population and Development Information System (NPDIS) developed by POPCOM with support from the UNFPA. The NPDIS will be made available on-line to respond to information queries within POPCOM (internal) and from various agencies and sectors (external). Aside from NPDIS, POPCOM is also developing the Communications and Advocacy Information System (CAIS) to support POPCOM's role of managing population related information. The system will contain the bibliographic database of all types of IEC and advocacy materials developed in support of the population program. It will be capable of storing IEC and advocacy materials in digital form for easy retrieval and access via POPCOM's website. To be considered in the development of this information system is the existing CDS-ISIS and POPLINE library information system. At the local level, matching grant programs from USAID have helped local governments in Region 6 to adopt the Community Based Management Information System (CBMIS) in determining unmet FP need and other maternal and child health indicators.

PROSPECTS AND FUTURE DIRECTIONS

Strengthen IEC/advocacy efforts to reach out to industry based managers and workers. Improve monitoring and evaluation mechanisms of advocacy campaigns.

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Scout, target, and recruit potential advocates from among politicians at all levels, NGOs, and other civil society organizations (Lacson, 2002). At the national level of advocacy, a policy of strategic alliance with concerned stakeholders should be initiated to overcome the continuing problem of policy ambivalence (Lacson, 2002).

There is a need to expand advocacy work to other religious sects aside from Muslim and Catholic religions (Lacson, 2002). IEC activities at the community level have to be research-based and be planned based on theory-driven strategies. They should be professionally implemented, monitored, and evaluated.

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S E C T I O N

11

DATA, RESEARCHAND TRAINING

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PHILIPPINE POPULATION DATABASE INFORMATION SYSTEM On the 12th of July 2000, the Philippine government adopted a plan for computerizing the information of key frontline and common government services to enhance overall efficiency and effectiveness of the bureaucracy. The government also approved the setting up of RPWEB, which would serve as the country's gateway to the Internet. Expectations were that this would promote information exchange among government, academe, industry, and business. In line with these moves, POPCOM is developing a Philippine Population Database Information System (PPIS) to be available on-line. The information in this database will be quantitative (statistical and financial), qualitative (textual and descriptive), and geographic (graphical and illustrative). Conceived in 2001, the PPIS contains two major information systems, namely, the National Population Database Information System (NPDIS), which has five sub-systems, and the Administrative and Fiscal Support System, which has three subsystems. The NPDIS is designed to be the portal or central source of data for policy and plan formulation. It also will be a tool of the PPMP for monitoring and evaluating the country's commitment to the ICPD Programme of Action, following the Asia-Pacific Population Information Network (POPIN) framework. The Asia-Pacific POPIN has two objectives. First, it is designed to promote awareness of emerging issues in population and sustainable development with emphasis on priority areas identified at the ICPD. Second, it is meant to promote and encourage the use of population data in formulating and implementing national population and development policies, plans, and programs. The five NPDIS sub-systems currently being developed are:

Demographic and Socio-Economic Indicators System. This contains timely and relevant statistics disaggregated by gender, main age groups, and geographic coverage among others. It also contains sectoral data on demography, health, economy, education, environment, and agriculture.

Plans and Program Monitoring and Evaluation. This is designed to monitor the progress and accomplishments of PPMP projects. Budgets and expenditures will form part of this sub-system.

Policy Development. This contains policy instruments that support the PPMP issued at the national, regional, or local level.

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Communication and Advocacy. This contains a bibliographic database of all types of information, education, and communication (IEC) and advocacy materials that support PPMP.

Research and Evaluation. This is a database of abstracts of all research outputs relevant to the population management program areas. It also has research studies that evaluate the impact of programs and projects. In addition to the five major sub-systems described above, there is also an

Administrative and Fiscal Support System that contains basic data internal to POPCOM, i.e., human resource management, fiscal support, and property and supplies management. These sub-systems will guide and direct operational decisions so that support services are strategically positioned and synchronized with program activities. At present the PIS is lodged at the POPCOM Management Information System Unit. It is available through the local area network (LAN) of POPCOM Central Office. It will be linked by wide area network (WAN) to 15 regional population offices and will be made accessible on-line through the Internet. POPULATION AND DEVELOPMENT (POPDEV) INDICATORS AND DATABASES The National Statistics Coordinating Board (NSCB) recently approved 27 POPDEV indicators that will be collected and updated periodically by various national agencies and institutions through surveys and statistical reports. These 27 indicators are categorized into four groups and are as follows:

Population Processes indicators: 1) Crude Birth Rate 2) Crude Death Rate 3) Total Fertility Rate 4) Maternal Mortality Rate (MMR)

Population Outcome indicators: 5) Annual Population Growth Rate 6) Percentage Population by Five-Year Age Group and by Sex 7) Percentage of Urban Population by Sex

Development Processes indicators: 8) Percentage Distribution of Local Government Expenditures by Specific Activities 9) Labor Force Participation Rate by Sex, (LFPRS 10) 11) Length of Local Government Roads by Surface Type Elementary and Secondary Cohort Survival Rates 74

12) 13) 14) 15) 16) Occupied 17) 18) Being Used 19) 20) 21) Sex

Doctor-Population Ratio Hospital Bed-Population Ratio Percent of Births Attended by Health Personnel Contraceptive Prevalence Rate (CPR) Percentage Distribution of Households by Type of Housing Unit Percentage Distribution by Main Source of Water Supply Percentage Distribution of Households by Type of Toilet Facilities Percentage distribution by type of Garbage Disposal Crime Rate Percentage Distribution of DSWD Clientele Served by Type and by

Development Outcomes Indicators:

22) Unemployment Rate, Total and by Sex 23) Average Family Income 24) Literacy Rate by Sex 25) Percentage of Malnourished 7-10 Year Old Children 26) Percentage of Infants with Low Birth Weights 27) Morbidity Rates of Leading Causes. When completed, the POPDEV indicators will be used for local policy formulation, planning, and monitoring. They will also be used in determining the level of development in the local governments. Local governments will be encouraged to make available the POPDEV indicators databases down to the community level to complement official statistics, which usually provide provincial data only. The databases will then become part of the NPDIS Demographic and Socio-Economic Indicators System database. POPDEV indicators will be linked to other existing government databases. The most important of these is the Minimum Basic Needs or MBN approach of the DSWD. This consists of 33 socio-economic indicators of family welfare. The MBN is the main database used by the Philippine government's anti-poverty program. Another database that the PPMP links to is REPROWATCH, which contains gender and reproductive health information. It is maintained by the Institute for Social Studies and Action. UNICEF Philippines keeps a database on the health and economic status of Filipino children. Some local governments have local databases on the characteristics and needs of migrants. SOURCES OF DATA 75

The usual sources of population and development data are reports, surveys, and research studies conducted by various agencies and institutions. Since 2000, POPCOM has been producing an annual State of Philippine Population Report, which contains the most recent studies on the pressing population issues in the country. The first issue focused on unmet need for family planning. The second was on adolescent sexuality, fertility, and health. The NSO through its Vital Statistics Report provides data on crude birth rate, crude death rate, and total fertility rate annually. Data on the country's population growth, sex, and age distribution including data on household facilities down to the municipal level are derived through the census of population and housing conducted by NSO every ten years. The highlights of the 2000 census are available through the NSO's website. The DepEd's Statistical Bulletin or Basic Education Statistics provides annual data on elementary and secondary cohort survival rates down to municipal level. The DOH has its Philippine Health Statistics, which gives data on doctor and hospital bed-population ratio, percent of births attended by health personnel, and of leading causes of morbidity. Among the national surveys conducted regularly is the National Demographic and Health Survey (NDHS) by the NSO. The latest NDHS was for 1998. Also by the NSO is the Family Planning Survey, an annual survey that is the source of determining contraceptive prevalence rate. The Integrated Survey of Households and the Labor Force Survey of the Department of Labor and Employment are two surveys used to estimate labor force participation and unemployment rates by sex every quarter. The NSO's Family Income and Expenditures Survey is the basis for estimating average family income and is conducted every three years (the last was in 2000). The Food and Nutrition Research Institute makes an update of the nutritional status of Filipino children every two years through its Updating of Nutritional Status of Filipino Children Survey. Poverty incidence is established through the NSO's Annual Poverty Indicator Survey (APIS), which provides data on poverty incidence level down to the regional level. The University of the Philippines Population Institute has conducted a Young Adult Fertility Survey (YAFS) in 1982 and 1994, and is doing a 2002 update. The survey covers knowledge, attitudes, and practices of the youth related to sexuality and reproductive health. It helps to provide policy-and program-specific information directed at improving adolescent fertility and sex education programs. Several agencies in Southern Mindanao and the National Capital Region are engaged in a study on Enhancing Male Involvement in RH. The National Economic and Development Authority or NEDA is currently doing a study on the Population Poverty Nexus in Rural Areas. This gives simulated data on poverty in the rural areas. POPCOM has initiated other researches, including a Policy Evaluation Research of the

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PPMP, Proposed Operational Definition of Urban Areas in the Philippines, and Estimation and Institutionalization of PPMP Expenditures. The PPMP has local information systems which complement the national databases. Included here are the Contraceptive Delivery and Logistics Management Information System (CDLMIS), which gives an annual data on the delivery and use of contraceptives in every community; the Field Health Service Information System (FHIS) on the health status of the community; the Reproductive Health Management Information System (RHMIS) on the overall RH situation of the communities in Nueva Vizcaya in particular; the CAVANET, a more effective sharing of information among government and privates sectors in Cagayan Valley in Northern Luzon; the Community-based Management Information System (CBMIS) on the socio-economic-demographic profile of the community including the movement of people; and the Community-based Demographic Information System (CSDIS) on POPDEV indicators being pilot tested in Eastern Visayas. TRAINING ON DATA AND INFORMATION MANAGEMENT Basic data and information management training has been given to POPCOM staff and program workers of other agencies. The range of training topics cover basic computation, analysis, interpretation, and presentation of data through the SPECTRUM computer systems models developed by the USAID. Specific training modules include DemProj or the Demographic Projection model; FamPlan or Family Planning model; CostBen or the Cost Benefit analysis model; RAPID or the Resources for the Awareness of Population Impact on Development model; and PES or Policy Environment Survey model. Since all these modules require computer skills, POPCOM staff and program workers of other agencies have undergone in-house training on computer skills, particularly with MS Office applications, Local Area Network administration, and Internet access. ISSUES AND CHALLENGES

Insufficiency of timely, accurate, and official data at the national and local levels, including census data (local planners need more updated and localized data on such demographic events as births, deaths, and migration; the census is done at 10-year intervals and it does not disaggregate data to the city and municipal level).

There are logistical problems related to: upgrading computer software, hardware, and required skills; physical network layouts so that even regional population offices can be upgraded; and frequent electrical power interruptions, which make it difficult to local/wide area networks and the Internet.

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Need for continuous training in the areas of database management, systems testing, data sourcing, validation, standards and analysis, profiling and/or analysis of data users.

FUTURE PROSPECTS AND DIRECTIONS To fully adopt the GSIP and the Asia-Pacific POPIN framework, the PPIS has to continue to enhance its website, fully develop its NPDIS, and facilitate and ensure their availability and accessibility through a variety of channels. These include hard-copy reports, local area networks, wide area networks, the Internet, and possibly CD-ROM.

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S E C T I O N

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PARTNERSHIPS RESOURCES AND

This section discusses partnerships among national government agencies, local governments, legislative leaders (i.e., "Parliamentarians"), the private sector, NGOs, and religious groups. It then presents the investments made by the government and its key partners on population and development programs. Finally, the section discusses resource mobilization for important issues, including steps needed to attain sustainability. PARTNERSHIPS Multi-sector Partnerships. Good governance promotes cooperation among government, civil society, and the private sector in improving the quality of life of all Filipinos, especially the poor. It builds on the principles of strategic partnership and critical collaboration. The 1990s saw more collaboration between government and civil society as a result of the 1994 ICPD and the country's commitments to the ICPD Program of Action. The environment favored the nurturing of effective partnerships in policy-making, planning, implementation, and monitoring. Leading the government side in these partnerships were the National Economic and Development Authority, Department of Health, and the Commission on Population. The partnership made it possible to position population management as an important strategy for comprehensive human development and protection of vulnerable groups in the Medium Term Development Plan 2001- 2004. DOH Partnerships with Local Governments. governments. The 1991 Local Government Code transferred the responsibility of providing health care services from the DOH to the local To meet their new responsibilities, many local governments asked for additional resources and technical guidance. With funding assistance from USAID from 1995-2000, the DOH responded through the Local Performance Program or LPP. This provided both financial and technical assistance to local governments in planning and implementing comprehensive population, family planning, and child survival programs. Assistance included logistics management, training, IEC, program monitoring, operations research, advocacy, networking, and program management. The adoption of a community based-monitoring information system through the LPP strengthened the partnership.

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Partnership between Government and NGOs. NGOs have been collaborating actively with government either directly as individual NGOs or through umbrella organizations like the Philippine NGO Council on Population, Health and Welfare, Inc. NGOs provide RH services by providing innovative and holistic approaches to quality health care, reaching out to under-served segments of the population through community-based RH programs, creating livelihood schemes and opportunities, and conducting wide ranging advocacy and IEC activities to increase modern contraceptive use. In addition to RH and family planning, NGOs provide supplementary health care services. These include: laboratory work, pap smears, pregnancy tests and other diagnostic services, surgical services and lying-in facilities for deliveries, family health care, women's rights, youth development, education and livelihood support for indigenous peoples, poverty alleviation, environmental concerns, and others. The DOH and POPCOM recognize NGO expertise in reproductive health and tap them for national-level training, IEC, advocacy, and research projects. Some of the NGOs engaged in these projects are the Women's Health Care Foundation, the Institute for Social Services and Action, Family Planning Organization of the Philippines, Institute of Maternal and Child Health, Institute of Maternal and Child Care Services and Development, Foundation for Adolescent Development, Inc., and FriendlyCare Foundation. At the local level, NGOs have been active in helping to organize stakeholder groups to address RH concerns. In Region 11, for example, there are several outstanding cases of local NGOs working closely and effectively with local governments to mobilize people's organizations. In February 2000, the NGO umbrella group PNGOC was able to successfully host the first Asia-Pacific Conference on Reproductive Health in Manila. Some 1,300 delegates from 37 countries attended this gathering. Among the results of this conference was the formation of the Asia-Pacific Alliance for Reproductive Health, a network of individuals and organizations working in the field of RH. The Philippine Center for Population and Development is another long time major NGO partner. Since 2000, the Center has shifted its social development role from being an implementing agency to a grant-giving institution. Its grants are mainly in the areas of population and development and development of policy research. Grants also are given to promote community-based projects and responsible parenthood in the industrial sector. Examples of the last are the grants the Center has provided to a number of industrial establishments providing RH services in the Cordillera Administrative Region. Twenty-three institutions representing RH service delivery organizations, women's groups, and advocacy organizations have united to form the Reproductive Health Advocacy Network or RHAN. Their common vision is to pursue RH rights and quality RH care for all. 80

The RHAN has a lawyer's group that conducts studies of the constitutional and legal basis of population and RH programs. This lawyer's group helped to file House Bill 4110 in Congress on December 19, 2001. The bill seeks to establish an integrated national policy and program on RH, which recognizes women's reproductive rights, gender equality, and universal access to RH services, information, and education. The Trade Union Congress of the Philippines (TUCP), the largest trade union confederation in the country with an estimated 1.25 million worker-members, has pioneered in integrating RH and FP in collective bargaining agreements in Cebu, Bacolod, and Davao. It has an ongoing project to institutionalize RH/FP programs in the workplace. The TUCP has adopted coalition building as one of its major strategies in five of the country's regions. These coalitions are made up of partners from government, NGOs, trade unions, employers' groups, and the academe. Partnerships between GOs and the Private Sector. The private sector is involved in social marketing programs that make low priced contraceptives available through commercial channels. The sector also is engaged in providing RH information, education, and counseling services for employees and local communities. Private groups collaborate with government, multilateral organizations, and international NGOs to minimize barriers and facilitate cost reductions so that RH services, including contraceptive commodities, can be made more accessible and affordable. The private sector also provides RH and family planning services to their employees. A number of business enterprises practice corporate social responsibility through their nonprofit foundations. These corporate foundations undertake programs that help alleviate the plight of underprivileged youth, women, and other sectors. Several professional organizations are involved in promoting a conducive environment for policy reforms to achieve the country's population goals. They include, among others, the Philippine Medical Association, Philippine Obstetrical and Gynecological Society, Philippine Academy of Family Physicians, Integrated Midwives Association of the Philippines, and Philippine League of Government Midwives, and the Philippine Nurses Association. The Unique Role of Parliamentarians. Parliamentarians play an important role in population and development programs. The essential groups are the Philippine Legislators' Committee on Population and Development, the House Committee on Population and Family Relations, the Senate Committee on Health and Demography, and the Presidential Legislative and Liaison Office. The vision of the Philippine Legislators' Committee on Population and Development is to improve quality of life through population and human development legislation. PLCPD works with legislative bodies at all levels, from national to the local, to introduce substantive changes in population legislation. It builds networks with NGOs, government agencies such 81

as POPCOM and the DOH, the academe, the church, business, and citizen's groups. PLCPD advocates for the integration of population and economic issues. The House Committee on Health and Family Relations is responsible for reviewing and processing population and family related bills at the Lower House. The Senate Committee on Health and Demography is its Upper House counterpart. Government agencies, NGOs, people's organizations, and grassroots groups liaison with these two committees to support bills on women, children and youth, family welfare, and AIDS protection. Working alongside these two committees is the Presidential Legislative and Liaison Office. This is an office under the Office of the President and its main role is to review all House and Senate bills to determine those proposed bills that the executive branch will consider urgent and high priority. Enlightened legislation has resulted from the partnership between parliamentarians, national government agencies, local governments, and civil society. These new laws focus on human development, greater protection of youth and children, women empowerment, family welfare, sexual harassment, and AIDS protection, among others (still to be enacted, however, is the population bill). At the city and municipal level, some local legislators have passed ordinances on adolescent health, youth development, and gender. Some of the ordinances call for setting up a system of collecting data on local migration. Forging Partnerships with the Religious Sector. The population program has always endeavored to maintain dialogues with Catholic, Muslim and inter-faith groups. At the local level, POPCOM has been working closely with the Catholic Church in promoting responsible parenthood and natural family planning (NFP). This can be seen in Region 1, where the Regional Population Office, the Archdiocese of Lingayen and Dagupan, and the Provincial Government of Pangasinan have forged a viable partnership on responsible parenthood and NFP. There are similar collaborations in Region 5 and Region 9. In other regions, POPCOM is exploring joint programs involving parent education in adolescent reproductive health and sexuality, and the establishment of a migration information center. With UNFPA support, POPCOM is mobilizing Muslim religious leaders to promote RH in seven provinces and four cities in Muslim Mindanao. The religious leaders have received technical assistance and resources in order to build their capability to be advocates of reproductive health and responsible parenthood in ways consistent with the Qur'an and the Sunnah of Prophet Muhammad. The Iglesia ni Kristo (INK) is a long time program partner in the provision of family planning and related services. The INK works with the Family Planning Organization of the Philippines and the United Christian Churches of the Philippines (UCCP) on a project to implement an RH program for INK and UCCP members. 82

Strengthening Effective Partnerships.

POPCOM central office and its 15 regional

population offices have established coordinating mechanisms at the national and regional levels. At the national level, the involvement of the private sector in policy-making is ensured through the participation of three NGO commissioners in the POPCOM Board. A private sector desk within POPCOM provides support to the NGO commissioners. The NGO representatives also sit in various inter-agency bodies in the formulation and updating of medium term population program plans. NGOs, the pharmaceutical/commercial sector, and the leagues of cities and municipalities are represented in an inter-agency body working to ensure self-sustainability in contraceptive supplies. At the regional level, NGOs and local governments are represented in the Regional Population Executive Board, the Regional Population and Development Coordinating Committee, and the Regional Population Committees. Other active inter-agency coordinating bodies that build partnerships are the POPDEV committees, Population, Health and Nutrition committees, Gender and Development committees, and the RH Task Force. At the local level, the 1991 Local Government Code has institutionalized the participation of NGOs in local affairs by giving them the right of access and representation in the decision-making process. By law, provincial, city, and municipal development councils and local health boards must have NGO representatives. The population executives of various local governments nationwide have incorporated themselves into the League of Population Officers in the Philippines or LEPOPHIL. LEPOPHIL has been working closely with POPCOM in supporting the PPMP and the passage of the population bill. RESOURCES Since 1994, the total funding for the program has reached P1.0 billion, 58 percent of which was provided by foreign sources (Table 12-1). During the 1994-1998 period, the Philippine government contribution grew by 15.4 percent a year, on average. However, increased domestic funding in the future is likely to be modest given the current economic crisis and the huge government deficit.

TABLE 12-1. FUNDING OF THE PPMP, Year GOP 1994 58.5 (11.88%) 1995 73.5 (79.03%) 1996 85.4 (70.64%)

1994-1998 (IN MILLION PESOS). Foreign Total 434 (88.12%) 492.5 19.5 (20.97%) 93.0 35.5 (29.36%) 120.9

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1997 1998 Grand Total

106.7(62.40%) 101.0 (75.49%) 425.1 (42.04%)

64.3 (37.60%) 32.8 (24.51%) 586.1(57.96)

171.0 133.8 1011.2

Source: Commission on Population, 1999.

Local government units also provide financial support to the program mostly by absorbing staff salaries, maintenance costs, and other operating expenses. however. Foreign donor agencies that have supported the program include USAID, UNFPA, World Bank, UNICEF, AusAID, ADB, JICA, KfW, GTZ, Ford Foundation, and the David and Lucile Packard Foundation. Foreign funding has been declining both in absolute amounts and in terms of share in total program costs. In 1996, external funding for population amounted to P599.5 million (UNFPA, 1999). The DOH has allocated budgets for the purchase of contraceptives in year 2000 (P63 million), in 2001 (P86 million), and in 2002 (P76 Million). Funds for this, however, have been realigned to purchase family health supplies and upgrade government hospitals. The Speaker of the House of Representatives has allocated P50 million from the congressional budget to promote NFP nationwide. Senator Juan Flavier has allocated P36 million from his countrywide development fund to increase contraceptive supplies and support health promotion activities, especially voluntary surgical contraception. So far, the funds allocated have not yet been released. USAID recently announced that it would phase-out its contraceptive support to the Philippines by the end of 2003. USAID has contributed about 80 percent of the total commodity requirements of the national family planning program since 1990. There will be no more condom shipments by September 2003. Pill orders will be reduced by 3.4 million cycles, which is one third of the total requirements of current users in the public sector. The big challenge is, even if USAID maintains its current US$3 million grant to the country beyond 2003, the Philippines will still need to mobilize resources for the program's long-term sustainability. Since priority concerns and emerging issues are urgent, efforts have been undertaken to mobilize resources for the programs long term sustainability. Formulation of Population Investment Plan (PIP) for 2001 2004. The PIP listed projects and activities of the PPMP, determined appropriate levels of expenditures, and mapped them out over a four-year period. It is an effective tool for budget analysis and Lack of documentation makes it difficult to determine the total value of their financial assistance,

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advocacy for funding support from national and local governments as well as external official sources. Formulation of 10-Year RH Investment Plan. The 10-year RH plan of DOH spelled out major strategies and activities and the required budget from 2001 to 2010. The plan estimated the commodity requirements of the national family planning program based on trend of contraceptive method use and population program goals. With declining donor support, the share of the Philippine government (GOP) and the Philippine Health Insurance Corporation (PHIC) is expected to increase. The desired sharing scheme by 2010 is set at: GOP = 30 percent; donor support = 10 percent; PHIC = 20 percent; and, NGO/Private Sector = 40 percent. The guiding principle is those who can pay should pay for contraceptives. This way, the resources of both government and donor agencies can be used to subsidize the needs of the very poor. Contraceptive Interdependence Initiative (CII). CII is the government's strategic response to the need of sustaining the country's family planning program. Through the CII, the government, NGOs, and the private commercial sector can converge toward the common agenda of securing the country's contraceptive supply to meet the family planning needs of couples. The action agenda includes, among others, a study on alternative schemes for the procurement of contraceptives, conduct of advocacy at national and local levels to support CII, capability building, and maintenance of institutional mechanisms for coordinating CII efforts. Estimation and Institutionalization of PPMP Expenditures. This is an ongoing project of POPCOM and the Philippine Institute for Development Studies. It aims to develop and maintain the PPMP accounts in order to determine comprehensively how much resources have really been allocated by government, NGOs, the private sector, and international and local donors to the PPMP. Started in 2001, the project is due for completion in 2003. Implementing Allocations for Women In Development (WID), Gender and Development (GAD) and Human and Ecological Security (HES). Republic Act 7192 or the "Women in Development and Nation Building Act" provides that a portion of Official Development Assistance funds should support WID programs. The General Appropriations Act of l995 (Section 27) and of 1998 (Section 28) instructed all national government agencies and all local government units to set aside a portion of their budgets to GAD projects. In response to a directive from then President Fidel Ramos, the Department of the Interior and Local Government issued an order in 1997 directing local governments to allocate a certain percentage of their Local Development Funds to HES programs. The 1997, 2000, and 2002 editions of the General Appropriations Act contain provisions that require all national

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government agencies to set aside an amount from their budgets for HES programs. The implementing guidelines for HES is now being developed. Mobilization of the National Health Insurance Program (NHIP). The NHIP of 1995 offered important opportunities for more efficient, equitable, and potentially larger sources for financing health services. The NHIP is a means for mobilizing health insurance financing for family planning and reproductive health services. However, NHIP coverage is limited and currently covers surgical contraception only. Philippine 20/20 Initiative. The Philippine 20/20 initiative: A Comprehensive Action Agenda (CAA) for the 21st Century outlines the framework and strategies to meet the goals and action to fulfill the commitments made in the World Summit on Social Development. The Philippine Government commits to allocate 20 percent of its national budget for basic social services such as primary health care including RH, basic nutrition, basic education, early child care, basic social welfare, low cost water supply and sanitation. Mobilization of Local Funds. POPCOM continues to advocate for increased spending by local governments on population and RH programs, POPDEV activities, productivity skills training and capability building for women and youth, and the establishment of local population offices. Formulation of Strategic Operational Plan (SOP) for PPMP for 2002-2004. Recently, POPCOM formulated a strategic operational plan for 2002 to 2004. This SOP focuses on the limited resources of government and available foreign funding to address unmet family planning need in the country, particularly for poor families. WHAT NEEDS TO BE DONE There is still a need to expand the participation of NGOs and the private sector in the provision of RH/FP information and services. The 1998 National Demographic and Health Survey reported that only 29 percent of family planning users get their services from the private sector. Clearly, the need is to increase the NGO and private sector share of family planning service delivery. To do this, it is necessary to: assess the operational drawbacks and limitations of NGOs and private sector providers; identify strategic areas for NGO and private sector interventions; and, tap and mobilize community based private associations (e.g., midwives and other paramedical personnel). For their part, local governments at the municipal level should expand their health services to include comprehensive RH services, particularly family planning. Local governments should coordinate with NGOs and the private sector to come up with area coverage schemes for paying and non-paying clients. This will help to ensure that both public and private resources are maximized and that quality standards will not suffer. 86

At national and local levels, parliamentarians should support the passage of the population bill. The current version of the bill is more responsive to population and RH issues. It also is more consistent with the vision of ICPD for a client-centered and rightsbased population program. In terms of improving the resource base of the population program, the following should be considered: Strengthen Revenue Base and Expenditure Focus of Local Governments.

A new formula for computing the internal revenue allotment (IRA) share of local governments should be developed. Population size as a factor in determining the IRA should be minimized. Financial and income generating capabilities, socio-economic conditions, and human development status, among others, must be considered in determining IRA share. The new scheme must also adjust revenue share to reflect the unjust distribution of the cost burden of devolved functions among local governments. The present scheme favors cities and barangays while insufficiently providing for provinces and municipalities. There should be inducements for local governments to generate revenues from local economic activities, recognize different levels of historical advantages and disadvantages among localities, and reward local development efforts.

POPCOM and the DOH should continue to encourage local governments to commit more funds to support essential population and RH programs by offering and extending national government support in return. Various approaches for mixing and matching national and local government funding to achieve common purposes could be developed and tried.

Local government spending for population and RH should be monitored effectively and in a timely fashion.

Periodic utilization reviews should be done at the national and local levels to ensure that funds available for population and RH programs are maximized.

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Contraceptive Interdependence Initiative.

The activities and projects included in the CII action agenda should be implemented and monitored vigorously. Priority should be accorded to the study of various alternatives on how to procure contraceptives.

The national government through the DOH should be required to purchase contraceptives using government funds.

Other donor agencies should be tapped for funding assistance. A strong advocacy campaign using mass media should be conducted to help enhance the sustainability of the family planning program.

National Health Insurance Program.

The coverage of the NHIP should be expanded to include outpatient services so that all RH services including family planning can be financed as benefits. This will ensure that not only surgical contraception but also contraceptive dispensing, counseling, and inpatient education will become part of program benefits.

The Philippine Health Insurance Corporation should be encouraged to accelerate its Indigent Program and the general expansion of its membership coverage. It should target first the cities and metropolitan areas where local governments have more available resources to finance their counterpart premium subsidies to the poor.

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SUM M ARYAND CONCLUSION

Since the 1980s, reducing poverty has been the stated priority of successive Philippine governments. What continues to hamper anti-poverty efforts is the absence of legislation that addresses the intimate relationship between poverty, development, and population notwithstanding the country's high fertility rate, consequent rapid population growth, and the socio-economic pressures that these exert on national resources. This is why the Philippine Population Management Program (PPMP) continues to be a strong advocate for the enactment of a comprehensive population bill. The PPMP is a component of the Philippine Medium Term Development Plan under the National Economic and Development Authority. Managed by the Commission on Population in partnership with many government and civil society groups, the PPMP vision is improved reproductive health of women, men and adolescents and ensure that poor couples are guaranteed access to family planning information and services (POPCOM, 2001a). This vision is consistent with the The goals of various international agreements on reproductive health and population. Bali Declaration, the ICPD Program of Action, and the Millennium Development Goals. Overall, the country has achieved modest gains in reducing fertility, infant and under five mortality; empowering women; responding to unmet need for family planning; putting in place measures to keep HIV/AIDS at its "low and slow" infection stage; and improving the policy environment for population and gender equity through IEC, advocacy and information communication technology. Serious issues and challenges, however, still remain. From the viewpoint of the PPMP, the most crucial is the lack of a firm approach to the country's high fertility and rapid population growth situation. Some related issues include inadequate response to the desire among the majority of Filipino couples for fewer children, the increasing size of the youth population and consequent impact of this on RH/FP services and employment, and the relatively weak enforcement of existing population-related laws. Following are recommendations both in terms of policy measures and program actions that could address these and other issues:

Philippines subscribes to these goals through the PPMP. These include the goals set in the

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Work strategically toward multi-stakeholder collaboration approaches to ensure continuous access to family planning goods and services by the majority of the population, especially poor households, in order to achieve the desired fertility rate of 2.7 children and, ultimately, replacement fertility of 2.1 by 2015;

Provide measures that will ensure the availability and accessibility of RH/FP supplies and services, in view of the diminishing and eventual phase-out of USAID contraceptive donations, to help Filipino couples space pregnancies and have only the number of children that they want;

Work in partnership with civil society to significantly reduce maternal mortality, infant mortality, and child mortality;

Foster a more balanced spatial distribution of the population by promoting populationsensitive development policies and strategies, and installing mechanisms to monitor population movements;

Enact laws and implement programs that will benefit the older persons, including: the development of a database on older persons; establishment of gerontology centers to provide much needed research and training; legislation of a Magna Carta for older persons; and, strengthening the advocacy capabilities of organizations involved in ageing;

Pursue the recently formulated Strategic Operational Plan of the PPMP that will address the unmet needs for FP among poor couples and sexuality and fertility information needs of adolescents/youths especially among those who are poor;

Formulate clear, fearless, and appropriate policies on the provision of adolescent RH information and services that will guide the action programs of the national government;

Enforce the Philippine AIDS Law and sustain the HIV/AIDS-related activities of both NGOs and local governments, to help prevent an HIV/AIDS epidemic in the country;

Sustain advocacy efforts to mainstream gender equality and reproductive rights in government agencies, industry, private corporations, and the grassroots;

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Assess the impact of Gender and Development or GAD-related programs and projects in minimizing or eliminating discriminatory policies and practices against women;

Generate a GAD database with sex-disaggregated data to support the development of more effective and responsive laws and programs;

Initiate a strategic alliance with concerned stakeholders to overcome the continuing problem of policy ambivalence on the issue of population; and,

Strengthen IEC and advocacy efforts to reach industry-based managers and workers.

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