Report No. 4650-PH

Population, Health and Nutrition in the Philippines:A Sector Review(In Two Volumes)

Volume 1: Summary of Findings, Issues and RecommendationsJanuary 13, 1984

Population, Health and Nutrition Department

FOR OFFICIAL USE ONLY

X t F ts , +NE: I*,C C

Document of the World Bank

This document has a restricted distribution and may be used by recipientsonly in the performance of their official duties Its contents may not otherwisebe disclosed without World Bank authorization.

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CURRENCY EQUIVALENTS

IJS$1.0 = P8.5 1!1P1.0 = US$0.1176P1 million = US$117,647P1 billion = US$117.65 million

FISCAL YEAR

Ja,nuary 1 - December 31

ABBREVIATIONS AND ACROINYMS

ADB Asian Development BankAFS Area Fertility SurveyASEAN Association of South East Asian NationsASFR Age-Specific Fertility Rate

BAEX Bureau of Agricultural ExtensionBAI Bureau of Anlimal IndustryBHS Barangay Health StationBHW Barangay Health WorkerBNS Barangay Nutrition ScholarBOHS Bureau of Health ServicesBOMS Bureau of Medical ServicesBSB Botica sa BaLran,gayBSPO Barangay Sup,ply Point Officer

CBR Crude Birth RateCDR Crude Death RateCEB Children Ever BornCOS Community Outreach SurveyCPR Contraceptive Prevalence Rate

DIC Disease Intelligence CenterDPT Diphtheria/Pertussis/Tetanus

FP Family PlanningFNRI Food and Nutrition Research InstituteFPOP Family Planning Organization of the Ph:LlippinesFTOW Full-Time Outreach Worker

GNP Gross National ProductGOP Government o:f the PhilippinesGSIS Government Service Insurance System

HEMDS Health Education. and Manpower Development Service

IEC Information, Education and CommunicationIMCH Institute for Maternal and Child HealthIMR Infant Mortality Rate

1! Annual Average Exchange Rate for FY 1982 US$1 = P8.5; Annual AverageExchange Rate for FY 1983 US$1 = Pll

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IPPF International Planned Parenthood FederationIRP Integrated Reorganization PlanIUD Intra-Uterine Device

KAP Knowledge, Attitude and Practice

MCH Maternal and Child HealthMCRA Married Couple of Reproductive AgeMEP Months of Effective ProtectionMIS Management Information SystemMLGCD Ministry of Local Government and Community DevelopmentMMR Maternal Mortality RateMOA Ministry of AgricultureMOEC Ministry of Education and CultureMOH Ministry of HealthMOHS Ministry of Human SettlementsMOLE Ministry of Labor and EmploymentMPWH Ministry of Public Works and HighwaysMSSD Ministry of Social Services and Development

NCSO National Census and Statistics OfficeNDS National Demographic SurveyNEDA National Economic Development AuthorityNFPO National Family Planning OfficeNMPC National Media Production CenterNNC National Nutrition CouncilNNS National Nutrition ServiceNPFPOP National Population and Family Planning Outreach ProjectNRR Net Reproduction Rate

OHEPT Office of Health Education and Personnel TrainingOHRD Organizational and Human Resource DevelopmentORS Oral Rehydration Salts or Solution

PCF Population Center FoundationPGR Population Growth RatePHC Primary Health CarePHN Population, Health and. NutritionPMA Philippines Medical AssociationPMCC Philippine Medical Care CommissionPNP Philippines Nutrition ProgramPOPCOM Commission on PopulationPUSH Panay Unified Services for Health

RHCDS Restructured Health Care Delivery SystemRHO Regional Health OfficeRHU Rural Health UnitRPFS Republic of the Philippines Fertility StudyRPO Regional Population Officer

SCRPPP Special Committee to Review the Philippines Population ProgramSCRS Schistosomiasis Control and Research ServiceSDC Social Development CommitteeSSS Social Security System

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TFR Total Fertility RateTIDA Total Integrated Development ApproachTMFR Total Marital Fertility RateTWG Technical Working Group

UJNDP United Nations Development Programme'JNFPA United Nations Fund for Population ActivitiesIJNICEF United Nations Children's Emergency FundIJPIMC University of the Philippines Institute of Mass CommunicationIJPPI University of the Philippines Population InstituteUSAID United States Agency for International Development

WDR World Development ReportWFS World Fertility SurveyWHO World Health Org,anization

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PHILIPPINES: BASIC POPULATION, HEALTH AND MUTRITION INDICATORS

(1982 data unless otherwise specified)

Mid-1982 Population (in millions) 50.8Population projected to year 2000 (in millions) 74.8Average annual population growth rate 2.5Population density per km2 160.0Percentage of population aged 0-14 39.8Percentage of population aged 65 and over 3.0Percent urban population, 1980 37.0Crude birth rate 32.2Total fertility rate 4.2Crude death rate 7.0FMale life expectancy at birth 62.6Female life expectancy at birth 66.1Infant mortality rate 51.0Male literacy rate, 1976 77.0Female literacy rate, 1976 76.0Percent population with safe water, estimated for 1979 43.0Energy consumption per capita, k cals. 329.0Per capita calorie supply as % of requirement, 1977 107.0Annual growth in labor force, average for 1970-80 2.4Physician to population ratio, 1977 1:2,810Nurse to population ratio, 1977 1:3,170Percent MWRA using contraceptives, 1980 42.0Per capita GNP in US Dollars 790.0FP budget as % of national budget, 1976 0.40

Sources: 1) The Population Division, Economic and Social Commission forAsia and the Pacific, Bangkok, 1983.

2) The World Bank, The World Development Report, 1982.

3) The Population Reference Bureau, World Population DataSheet, 1982.

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PREFACE

Purposes of the Review

1. Reducing population growth and improving health and nutrition inthe Philippines are major concerns of the Government of the Philippines(GOP) and a number of donor agencies. Although the country still cannotfully meet the needs of its population, health and nutrition (PHN)programs, notable progress has been made during the last two decades. Inrecent years, however, this progress seems to have slowed, particularly inpopulation control. Questions are also being raised about PHN programstrategies and about the organization, management and financial efficiencyof the agencies operating in these sectors.

2. The development of a variety of service delivery systems toaddress the many problems in the PHN sectors has resulted in institutionaloverlaps and a proliferation of administrative support structures. Fieldworkers offer either one service or a limited package of services, often ofquestionable quality. Furthermore, some major studies have shown markedregiotnal disparities in the availability of PHN services.1 / The Five-YearDevelopment Plan (1983-87) alludes to these problems and calls for moreequitable access to services, particularly through strengthening PrimaryHealth Care (PHC) efforts.

3. In light of these concerns, in 1982 the Philippine Government andthe World Bank agreed to conduct a comprehensive health sector review. Inthe past, except for limited WHO and UNICEF assistance, most of the donorefforts (USAID, UNFPA and the Bank) had concentrated on population ratherthan health. In addition, not all donor efforts in population, health andnutrition were fully coordinated.

4. To improve coordination of donor inputs and complementarity ofPHN activities, ADB, USAID, WHO and the Bank agreed to conduct the sectorreview jointly and to expand its scope to include all three sectors. A PHNsector review mission representing these four agencies visited thePhilippines in March 1982. To complement this review, the Ministry ofHealth (MOH) conducted a health sector study and the Commission onPopulation (POPCOM) undertook an analysis of the implications of populationgrowth in the Philippines. These inputs have stimulated continuingdiscussions between the participating GOP agencies and the donors.

1/ National Economic Development Authority, Regional DevelopmentInformation, 1978, and World Bank, "Aspects of Poverty in thePhilippines: A Review and Assessment," Report No.2984-PH,December 1, 1980.

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Scope and Structure of the Report

5. The report consists of two volumes. Volume I presents a summaryof findings, issues, and recommendations. Volume II is the Main Reportconsisting of four parts; the first three parts cover population, health,and nutrition respectively, since separate agencies (POPCOM, MOH, and theNational Nutrition Council) are responsible for these sectors. The threesectors are then treated together in part 4 on Economics and Financing.Volume II also contains tables and technical annexes.

Mission Composition and Information Collection

6. The mission consisted of Mr. N. I. Khan (Nission Leader), Mr. J.Warford (Lead Adviser), and Messrs. V. Kumar, N. Prescott, R.Venkatanarayan (Consultants) from the World Bank; Dr. S. Sinding (USAID);Dr. M. Porter (ADB); and Mrs. Inciong (WHO). Mr. W. Goldman of USAID andDr. Y. S. Kim of WHO collaborated closely with the mission. Dr. K.Kanagaratnam (Sr. Auviser, PHN Department, World Bank) joined the missionduring field trips and in its concluding discussions with senior GOP andparticipating donor agency officials. Consultants from the Faculty ofEconomics and the Institute of Public Health of the University of thePhilippines contributed useful technical data. The report also benefitedfrom the mission's discussions with numerous senior government andnon-government officials, field workers and other resident staff of UNDIP,UNFPA, and UNICEF.

POPULATION, HEALTH, AND NUTRITION IN THE PHILIPPTNES: A SECTOR REVIEW

VOLUME I: SUMMARY OF FINDINGS, ISSUES AND RECOMMENDATIONS

Background

1. Despite an impressive average real GNP growth of 6.4 percent a

year in the Philippines during the postwar era, the rapid growth of

population has exacerbated problems of poverty and underemployment and hasled to the worsening land-man ratio. In recent years, the economic

situation has deteriorated: real GNP growth fell from 7 percent a year in1977-78 to 2.7 percent in 1982, a rate close to that of population growth.The high rate of population growth -- which will add about 25 millionpersons to the Philippines population by the year 2000 -- makes it unlikelythat significant improvements in real per capita incomes can be achieved in

the near future. Unless the growth of population slows down sharply, a

continued deterioration in the land-man ratio, a high dependency burden,and a 75 percent increase in the current work force by the year 2000 willmake the attainment of the Goverment's development goals very difficult.

2. Population. At the present rate of population growth, thePhilippines adds the equivalent of Australia's population every ten years.The country's population has increased dramatically, from 27 million in1960 to 50 million in 1982, and is expected to reach about 75 million inthe year 2000. Even with the reduced growth rate projected for the next 35years (medium projection, WDR), the total population will reach the 100million mark by the year 2015 before it stabilizes at 127 million in 2075.The youthful age structure of the population, the dramatic decline in

infant mortality between 1950 and 1965, and the slow decline in fertilityhave resulted in a large cohort in the reproductive ages. This cohort willsustain a very high population growth momentum.

3. The total fertility rate (TFR) declined from about 7 in the 1960s

to around 4.2 in 1982 but has prematurely plateaued and remains the highestin the ASEAN countries (Annex 1). Family size varies from 3.6 in MetroManila to 6.1 in Bicol, with a national average of 5.2. The contraceptiveprevalence rate (CPR) has increased steadily from 16 percent in 1968 to 42

percent in 1980, but varies from 62 percent in Metro Manila to 26 percentin Bicol. The most rapid increase was in the mid-1970s, with some slowdown

after 1977. However, in 1980 only 34 percent of contraceptive usersemployed the more effective methods (e.g., oral pills, IUDs, sterilization)compared with 85 percent in Thailand, which had a comparable CPR.

4. Regions that are the least developed and least urbanized showlittle or no decline in fertility, and they have a higher current fertilityand lower contraceptive practice. These regions still have strongsocio-economic incentives for large families. The opposite is true of thericher and more urbanized regions.

5. Health. Improvements in health status over the last two decadeshave been considerable, and the outlook is encouraging. Life expectancy is

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now about 64 years, higher than t:hat of many other countries with acomparable GNP per capita. The crude death rate waS 7 per thousand in1982. The infant mortality rate (IMR) declined from 106 per thousand to 75between 1960 and 1970; the present low IMR of 51 probab:Ly reflects, interalia, the relatively high level of education in the Philippines, rapideconomic growth, and intensive disease control programs in the sixties andearly seventies. The decline in the IMR, although clearly desirable, hasexacerbated the problem of rapid population growth. The decline in infantand maternal mortality rates has apparently slowed down since the mid-7'Js.This levelling off is a cause for concern and warrants reconsideration ofhealth programs directed toward child and maternal health.

6. Communicable diseases are still the main cause of death, but theproportion of deaths due to such diseases is slowly decreasing. Theproportion of deaths due to degenerative diseases, cancers and accidents isincreasing. Respiratory infections and gastroenteritis still predominatlein the national profile of morbidity, although malaria, schistosomiasis andtuberculosis are leading causes of morbidity in some regions. Thismorbidity profile is not expected to change in the immediate future.

'7. Considerable differences in mortality and morbidity still existamong regions. Analysis of mortality data suggests that environmentalimprovements underlie the decline in mortality; any further decline will.. beslow and difficult and will require more elaborate improvements in theenvironment, nutrition, and health care.

8. Nutrition. Malnutrition is primarily mani:fested in three formls:(a) the inadequacy of total calories and protein in dliets of :Low-incomegroups; (b) malnutrition among the very young and among pregnant andlactating women; and (c) diet imbailance resulting in vitamin and mineralcdeficiencies. While data on nutri-tional status are fEar from complete, theresults of the national weighing program and of representative samplesurveys estimate the problem of pre-school malnutrit Lon at 28 percent for1980. Although some evidence exists which indicates that overall nationalnutritional status is improving, the nutritional conditions of thoseunderserved by government services and the disadvantaged social groups hasnot improved. There are also indications that the consumption patterns oflow-income families make their diet more sensitive to changes in foodprices than to changes in income. Food intake is higher in urban centersand Luzon than in rural areas and on Visayan and Mindanao islands.

Economic Implications of Population Growth

95 The high rate of population growth places a heavy burden on thePhilippine economy and makes more difficult the task of raising livingstandards in the future. The past high rate of growth, which resultedfrom low and falling mortality and high fertility, has given rise to as:ituation where over 40 percent of the population are aged 15 years orless. These changes in age structure have resulted in enormous demands forhealth and education facilities, for housing, and for public infrastruc-ture, while the rapidly growing labor force requires continuous andlarge-scale increases in job opporltunities. The situation is exacerbatedby the increase in the proportion of women in reproductive ages, sustaininga still higher population growth momentum.

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10. As a result of a high population growth momentum, theGovernment's efforts at improving productive employment opportunities,alleviating poverty, and reducing income disDarities ha-a bFen seriouslvhandicapped. Excess labor supply has contributed to a substantial realwage rate decline in agriculture between 1957-76. Of the 9 M4llion newentrants into tne labor market during the last decade, only about 2 millionhave found work in the non-agricultural sector. Arable land per capitafell nearly 40 percent between 1960 and 1975, with 99 percent of the arableland presently under cultivation. In another 35 years the arable land percapita will decline to less than one-twentieth of a hectare, with asubstantial further decline inevitable in the next two generations, basedon current projections. The worsening of the land-man ratio, combined withinheritance customs, has already resulted in a continued subdivision ofland, a higher percentage of population dependent on smaller farms, higherprivate and social costs of bringing poor land under : Kltivation, andincreased deforestaticn. The situation in all these areas is bound todeteriorate further.

11. The impact of high population growth seems distant, and it is noteasy to focus attention on a situation which will arise twenty-five tofifty years hence. However, the severity of the long-term impact clearlyunderlies the urgency of immediate action to reduce the rate of populationgrowth. If significant reductions in the fertility rate are made, theywill begin to affect the demand for resources within five years, with acumulative effect in later years.

Expenditure on Population, Health and Nutrition

12. The Philippines population planning, health care and nutritionservices suffer from scarce government financial resources, and the fundspresently earmarked for them are unlikely to be sufficient for ongoingprograms and the new 1983-87 Plan priorities. Central Government's 1982appropriations for these three sectors are about P3.1 billion, or US$7.60per capita. The total is slightly less than one percent of GNP, or 5.5percent of the appropriation for public expenditure. On a per capitabasis, $6.70 is for health, US$0.60 for population, and US$0.30 fornutrition excluding food aid. The role of external finance is small forthe Ministry of Health (3 percent of expenditure), but significant for theCommission on Population (46 percent). In 1982, local governmentexpenditure on these sectors was estimated to add only PO.3 billion or 9percent to central government outlays, and represented only about 5 percentof total local government expenditure. This scarcity might be furtheraggravated by a likely decline in donor assistance for these sectors.However, it is estimated that the outlays by private households arerelatively high, bringing total outlays by central government, localgovernment and private households on population planning, healtn care andnutrition programs to approximately US$25 per capita, a figure comparablewith expenditures in other middle-income cotntries.

13. Population. Between 1969 and 1982, expenditure on familyplanning increased from P16,4 million to P286 million; the proportion metby GOP increased from less than a third to over two-thirds. As aproportion of the Government's recurrent budget, the family planningprogram averaged 0.4 percent for 1977-82, which compares favorably with its

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ASEAPN neighbors. In 1982 more than 50 percent of program operatingexpenditure appropriately went for clinical services and outreachactivities. External financing; of population actiLvities is likely todecline in the future, placing a greater burden on central and localgovernments. it appears unlikely that local governments will be able toassume the full cost of outreach activities, estimated at about P70 milliona year (about 10 percent of the local government outlays).

14. Health. Between 1975 and 1981, expenditure by the Ministry ofF.ealth (MOM) increased from P626.2 million to P1,868 million, at an averageannual rate of 20 percent in nominal terms, 9 perc:ent in real terms. Atthe same time, the allocation of expenditure on supplies and materials,which was considered high at 45 percent, declined only marginally to 43percent; expenditure on personnel services remained constant at about 36p_rcent. The share of hospital services increased from 48 percent to 53percent; field health services, from 27 percent to 29 percent. The highshare of public expenditures on hospital services suggests relative neglectof the preventive and promotional activities for which there exists astrong rationale :or public subsidy. The expenditures are not equitablydistributed among regions; ithe data suggest that Southern Tagalog, Westernand Central Visayas, and Western and Southern Mindanao are disadvantaged.

15. MOH cost recovery appears to have deteriorated in recent years,with revenues decreasing from an estimated 12 percent of recurrentexpenditure in 1978 to 8 percent in 1982. Hospita:Ls, which have athree-tier pricing structure (ac:cording to income :Level), including freeservices for indigent patients, generate about 90 percent of MOH revenues.In principle, services delivered by rural health units are free, but the`,OH has recently introduced a nominal fee for certain specific services,e.g., laboratory tests. The revision of prices for hospital services -andintroduction of cost recovery in rural areas in order to mobilizeadditional resources for health services are significant policy issues;studies indicate that demand for adult outpatient services is relativelyprice-inelastic in the rural areas.

16. Nutrition. Expenditure on nutrition programs, including foodaid, increased 24 percent in real terms between 1978 and 1981. Much ofthis increase in budget is believed to be the result of reclassification ofexisting programs without necessarily enhancing their nutritionalemphasis. About 80 percent of the nutrition budget is spent on programs offive ministries, with the Ministry of Education and Culture spending thehighest amount. However, there is inadequate central control over funds,which are thinly stretched over a number of nutrition programs undertakenby various agencies.

Policies

1 7. The Government's policy is to reduce the population growth ra.tefrom an estimated 2.7 percent in 1982 to 2.0 percent in 1985, and to attaina net reproduction rate of orie by the year 2000. But the 1983-87Development Plan does not include a strategy for achiieving demographicgoals nor does it have explicit f'amily planning performance targets, nor anexplicit commitment of public resources to the popu:Lation program. Theplan appears to assume that the population growth rate reduction will be

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mainly attained by raising living standards alone. As a result, there ismuch ambiguity about the nat4 onal population policoy and program.

18. In health, the basic policy objective is to increase lifeexpectancy by continuing to improve access to and efficiency of servicesand by reducing morbidity and mortality due to communiicable diseases. Arecent policy concern is the accelerated development of a regionallyequitable, community-based system of primary health care (PHC). Thisdevelopmnent is intended to be achieved in the context of a decentralizedhealth administration, in which the provincial level assumes moreresponsibility and community participation is sought. An additional policyobjective is to broaden the range of beneficiaries under third-partypayment schemes, primarily through greater coverage of health insurance,including the extension of medicare services to all self-employed. Thecapacity of the health system to provide quality care and improved accessto services given financial constraints needs careful examination.Moreover, the establishment of additional barangay health stations (BHSs)with extensive community participation will overstrain MOR's limitedcapacity to organize community activities.

19. In nutrition, Ehe policy objectives focus on (a) improvingnutrition for infants, children and pregnant and lactating mothers; (b)preventing and curing malnutrition; (c) improving the nutritional status ofpoor families; (d) encouraging the use of indigenous nutritious foodsthrough education; and (e) encouraging Low-cost food production anddistribution. The five-year nutrition plan prepared by the NationalNutrition Council (NNC) recommends subsidizing high-calorie foods for

malnourished members of at-risk families and sets targets for nutritionalimprovement among preschoolers, school children and the general population.

ImDlementation

20. Commission on Population (POPCOM). Since its inception in 1971,POPCOM has been a relatively well-administered organization. But it haslacked continuity of leadership and has had inadequate technical capacityto direct and use operational and policy research. Policy and managementdecisions have been too often influenced by strong personalities andspecial interests represented orn the board. Most importantly, it has notbeen able to develop a field structure effectively linked with theclinic-based service delivery system of the MOH, while still keeping MOHaccountable for family planning service delivery. POPCOM's nationwideoutreach program was started in 1977 and now has more than 3,000single-purpose full-time outreach workers (FTOWs) and 50,000 unpaidvolunteers providing coverage to an estimated 60 percent of married couplesin the Philippines. Sustaining the outreach program (largely funded thusfar by USAID) will depend on anadditional central government subsidy, sincelocal governments have been unable to assume the full cost of operating theoutreach delivery system.

21. MOH. The services of MOH are delivered through a nationwidenetwork of hospitals, rural health units (RHUs), and barangay healthstations (BHSs). A mixture of preventive and curative services is providedby various special. programs. Despite their importance, these programs

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absorb only a small share of the health budget. With tightened publiceKpenditiure their effectiveness may further deteriorate. Programs tocontrol malaria, schistosomiasis, and tuberculosis require adequate fundingto remain effective. iT addition, the rapid expansion nationwide of therecently adopted PHC approach has overextended MOH's management andfinancial resources. The future status of the special programs vis-a-vistlhLe PHC program also remains to be clarified.

22. Although the distribution of hospitals is relatively even, almost40 percent of public hospital beds are in the Manila region. The inclusiono:r about 1,200 private sector hospitals more than doubles the aggregatenumber of hospital beds to about 82,000, but private sector facilities aremostly in the richer and more urbanized areas. There are about 2,000 FRUsand 8,,000 BHSs in the country. Trhe regional distribution of thesefacilities is not very uneven, with a coverage of about 60-70 percent cfthe population. However, distribution of these facilities within regionsis often biased in favor of :Locations more accessible from the towns. Atleast half the RHUs and BliSs neecl repair or replacement. Health facilitiesin poorer regions suffer from greater problems of maintenance, equipmentand supplies, perpetuating the inequities in quality of and access to

services.

23. Nearly 20 percent of MOH positions for physicians are unfilled,with marked variations in vacancy rates by region. Vacancy rates are muchgreater for physicians at RHU5s, and in some regions the lack of ruralphysicians is acute. Substantial earning differences between public andprivate sectors and between domestic and foreign markets for Filipinomedical manpower partially explain this situation. About two-thirds of thephysicians in the Philippines work in the private sector, with more thanh'alf concentrated in Manila, Southern Tagalog, and Central Luzon. The MOHhas attempted to redress the regional imbalance through a program thatreiquires new graduates to spend six months at a RHU, but: this short-termmeasure has failed to attract physicians into continued public sectoremployment. This raises the larger issue of government policy in regar,d tohealth manpower development. Although the private sector largely financesthe cost of medical education, there is concern that physician training isnot sufficiently responsive to emerging health program needs. Furthermore,difficulty in attracting physicians to staff RHUs suggests the importanceof improved training of lower-level workers, who may remain, de facto, theservice suppliers in many RHUs.

24. NNC. The national nutrition policy is well articulated, butthere is inadequate central coordination of the programs of variousparticipating agencies. Several of these programs are not properlytargeted or are technically inappropriate for achieving high impact. Thetechnical support systems of the National Nutrition Council (NNC) also needstrengthening. Furthermore, the effective utilization of field workers(specifically the barangay nutrition scholars) is hampered by lack ofresources and by duplication and fragmentation of effort at the locallevel. The nutrition workers are not assigned to any one line agency, andare accountable for multiple sectoral tasks. This multiplicity oforganizational affiliations makes it difficult for them to perform theirassigned duties.

Issues and Recommendations

General

25. In the health sector, overall achievements are substfntial, and

compare very favorably with other countries at the same level of income.In population planning, however, accomplishments have been Lesssatisfactory (see Annex 1 for comparison with other ASEAN nations), la-gely

because of vacillating political commitment, strong socio-cultural

preferences for large families, and religious sensitivity to artificialcontraception. Unless immediate and vigorous policy measures are taken tocontrol fertility, there is little possibility of checkirig the rapidincrease in population. Increased efforts are also needed for overcomingthe high incidence of communicable diseases, maternal and infant

malnutrition, and marked regional disparities in accesc to population,health and nutrition services.

26. Greater political and financial commitment by the Government ofthe Philippines (GOP) is needed, along with strengthened implementationcapacity. GOP should: (a) as a first priority, set clear demographictargets and commit public resources for a renewed emphasis on fertilityreduction; (b) make MOH clearly accountable for improved service deliveryin family planning; (c) improve the overall quality of health servicesprovided, and selectively increase access to health services in underservedareas; (d) implement the primary health care program in phases, taking carethat existing vertical programs are not adversely affected during theperiod of transition; (e) target nutrition programs carefully to the most

vulnerable groups, weeding out inappropriate and ineffective programs; (f)better utilize available funds, and mobilize additional resources through

new cost-recovery schemes to provide increased budgetary allocations forselected programs; and (g) for all three sectors, improve central technicalsupport functions, outreach and logistical services, communityself-reliance and local government participation.

Population

27. In view of the rapid population growth in recent years, itscontinued high momentum, and the severe economic and social implications ofpresent trends, GOP should give the highest priority to fertility

reduction. A strong population control program can have a significantdemographic impact even over the medium term (see Annex 2 graphs, comparing

the effects of strong, moderate, and weak population programs on annualpopulation growth rate and size). Strong political backing and increasedbudgetary resources are needed for pursuing specific demographic goals,with performance targets set in terms of increasing the contraceptive

prevalence rate and the effectiveness of contraceptive practice. There isa need to strengthen POPCOM's ability to formulate fertility reductionpolicies, coordinate their implementation, conduct population impactanalysis of related socio-economic policies and programs, and monitorprogram performance of implementing agencies.

28. In order to facilitate POPCOM's coordination of multi-agencyefforts, and to strengthen the linkages between GOP's fertility reduction

policies and its broader policies for socio-economic development, POPCOM'sSecretariat should be more centrally located within the government

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d.ecision-making structure. GOP should review the structural and repor-:ingrelationships between POPCOM's board and higher governraent authorities. Inaddition, in order to improve POPCOM's status and ro:Le in policy formula-t:ion, GOP might consider makirtg POPCOM's Executive D:'rector a voting membercf his own interministerial board. Improvements are also needed in thtepol.icy-analysis and planning capabilities of central POPCOM staff, and morefocused duties assigned to field staff.

29. To upgrade financial and operational efficiency of the populat4onplanning effort, the GOP should reduce fragmentation and duplication ofresponsibilities assigned to various agencies. One cost effective andviable option appears to be the gradual specialization of the threeagencies - MOH, POPCOM, and NNC - to perform centralized technical supportfunctions for an integrated service delivery network at the communitylevel. The MOH should consider, in the medium term, family planningservice delivery as one of its primary responsibilities, and should be heldfully accountable for it. With regard to rationalization and improvemeni'of technical services, currently the MOH, POPCOM, and NNC have their onMionformation/educatio.n/commtnication, logistics, and mtanagement informationsystems, but these suffer from shortages of skilled manpower, materials,aad equipment. Changes in management systems and administrative structuresare needed, and should be based on a realistic assessment of institutionalcapacities so that ongoing programs are not unnecessarily disrupted.

3l0. The regional diff'erences in fertility rates and contraceptivepractice could be partly dtLe to unequal access to family planning andmaternal and child health services, but also reflect the diversity ofcontraceptive methods preferred by different regions and socio-economicgroujps. To assure more equitable access to services and to maintainprogram responsiveness to locaL demand, more intensive outreach work shoL.Ildbe undertaken, and the present cafeteria approach continued. Local familyp:Lanning targets should be expressed in terms of months of effectiveprotection required to attain demographic goals, and not tied to theacceptance of specific contraceptive methods. Furthermore, since more thanhallf of married couples of reproductive age (MCRA) de,iring to limit familysize are still not using contraceptives, and a large number of users (abcut64 percent) are relying on inefficient contraceptive mnethods, greateref'forts should be made to increase protection provided by the moreef'fective methods and to improve the quality of services. The recent trendtciward sterilization should be encouraged by making this inethod morereadily available.

Health

31. Although the emphasis on PHC is appropriate, the future strategyto be followed for the health sector is still unclear, Priority should begiven to increasing access to care in currently under.served areas(especially urban slums and remiote rural areas) and to improving thequality of services. Since the PHC programs critically depend on anefficient health service delivery system, and since the basic healthinfrastructure is in place, the major issue facing the GOEP is how toovercome present inefficiencies, particularly ineffective support,supervision and referral systems; inadequate health service management; lowutilization of RHUs and BHSs; and insufficient outreach activities.

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32. Implementing a decentralized PHC program requires strengtheningMOR's institutional support and extension services, and developing theimplementation capacity of lower-level institutions. Rather thanattempting to decentralize all programs simultaneously, a phasedimplementation of the reorganization plan might be undertaken. In imple-menting PHC, care should be taken to ensure that the gains achieved byMOR's vertical programs and POPCOM's outreach network are not lost. Tofacilitate change in long-standing bureaucratic procedures, efforts shouldbe made to improve technical and administrative support systems at theprovincial level. Adequate delegation of authority, both financial andadministrative, should accompany the decentralization of functions andresponsibilities.

33. Three agencies (MOH, POPCOM, and NNC) support separate outreachsystems, each of which suffers from inadequate resources and manpower. Inview of the recent policy of tightening public expenditure and externalborrowing, the GOP now has the option of either maintaining the large forceof single-purpose outreach workers in each of the three sectors, ordeveloping a unified outreach structure that will enable services to beprovided at lower cost but without loss of efficiency. In this context,GOP's recent initiative in promoting community self-reliance and increasedlocal government participation for integrated health, family planning andnutrition programs deserves careful review. An effective, nationwide,village-level, voluntary outreach service is unlikely to be sustainable orresponsive to increased demands for PHC services in the absence of monetaryand non-monetary incentives for the outreach workers. The MOH shouldtherefore develop an effective support structure for all rural healthworkers incorporating improved incentives, inservice training, job rotationopportunities between rural health units and front line hospitals, andbetter support and referral linkages between the public and private healthfacilities.

34. The MOH and the Ministry of Education and Culture (MOEC) need toundertake a prospective study on the demand and supply for professionalhealth manpower at all levels. Furthermore, health curricula do notadequately prepare health staff for greater roles in primary care andcommunity medicine. Because of this and because of government policy onmanpower development, shortages and maldistirbution of manpower are commonin rural areas. The GOP should review the salaries and incentives(housing, additional allowances etc.) provided to trained health personnelfor serving in understaffed areas.

Nutrition

35. The gap between ambitious nutrition objectives and the coverageand effectiveness of existing program activities implies a need for moreeffective targeting, prioritizing of nutrition programs on the basis oftechnical and cost effectiveness, and adequate funding to make the selectedprograms viable. Programs should be targeted to those with the greatestneed; for example, the 10 percent of municipalities most affected bymalnutrition and the most severely malnourished children. Since the amountof resources actually reaching households with malnourished children israther small at present, a careful assessment of unmet program needs couldmake the case for alternative or additional resources in support of well-targeted, technically effective, and high priority nutrition programs.

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36. There is inadequate central coordination of programs and insuf.-ficient control over program resources. The nutrition committees used forprogram planning at the provincial and lower levels are largelyineffective. The Government should carefully examine! the central structurefor coordinating the various agencies involved in nutrition programs, thefield structure for planning and service delivery, arnd the role ofprovincial and municipal action officers and barangay nutrition scholars(BNSs). Furthermore, reliance on informal cooperation is unlikely to work,especially since there are no paid nutrition officials below the regiona'Llevel. An alternative is to use employees of other line agencies, providedtheir other duties complement the activities of the nutrition program.Closer ties between the MOH and the MOEC could be useful. In addition, thefeasibility of transferring the BNSs' functions to the MOH's communitylevel PRC workers should be considered.

Finance

37. Population, health care and nutrition services suffer from scarcefinancial resources, and the funds presently earmarked for them are like:Lyto be insufficient for ongoing programs and the new 1983-87 Plan priori-ties. This scarcity might be further aggravated by a likely decline indonor assistance for these sectors. The GOP needs to reexamine targets andbiUdgets in the light of financial constraints. The financial review of allongoing and proposed program activities should include detailed analysis ofcsapital and recurrent costs over the next few years. Since the PHC programis a major initiative, special car,e should be taken to establish the fundsrequired for making it work. Reorientation of public funding towardpreventive activities, for which there is a clear rationale for subsidy, isalso desirable.

33. Three measures could be taken for alleviating financial short-falls. The first is to utilize available resources more efficiently byreducing functional overlaps, selectively weeding out ineffective programs,and better targeting of program efforts. Second, the GOP should adopt newpolicies aimed at mobilizing additional resources; in the health sector,for example, this might be accomplished by increasing the fees for servicesand for hospital care. Also, to encourage promotive and preventive healthcare, the Government should examine the replicability of pilot experiencesoi 'health insurance corporations wlhich are locally owned and jointlycontrolled by consumers and providers. And third, increased budgeta:Llocations should be provided once institutional capabilities are built upand programs with demonstrated success in achieving sectoral goals havebeen established.

ANNEXES

Annex 1

Basic Population, Health and Nutrition Indicators: An Inter-countryComparison

Annex 2.

Philippines: Alternative Population Program Scenarios and Their

Demographic Implications

ANNEXI

Basic Population, Health and Nutrition Indicators:An Inter-Country Comparison

(1982 data unless otherwise specified)

ASEAN Countries

Indicators Philippines Indonesia Malaysia Thailand Singapore

Mid-1982 population (in millions) 50.8 156.4 14.5 48.6 2.5Population projected to year 20001/ 74.8 204.5 20.6 66.1 3.0Average annual population growth rate 2.5 1.8 2.3 2.1 1.2Population density per km2 160.0 77.0 44.0 94.0 4,254.0Percentage of population aged 0-14 39.8 40.0 38.1 38.7 25.6Percentage of population aged 64 + 3.0 2.0 4.0 3.0 5.0Percent urban population in 1980 37.0 20.0 32,0 22.0 100.0Crude birth rate 32.2 31.7 29.4 28.6 17.3Total fertility rate 4.2 4.0 3.8 3.6 1.7Crude death rate 7.0 13.3 6.5 7.8 5.3Male life expectancy at birth 62.6 50.9 64.8 60.6 68.9Female life expectancy at birth 66.1 53.6 68.6 64.6 75.3Infant mortality rate 51.0 109.0 41.0 59.0 11.0Male literacy rate, 1976 77.0 72.0 77.0 89.0 87.0Female literacy rate, 1976 76.0 49.0 54.0 75.0 66.0Percent population with safe water2/ 43.0 12.0 62.0 22.0 100.0Energy consumption per capita, k cals. 329.0 225.0 713.0 350.0 5,784.0Per capita calorie supply 3/ 107.0 102.0 116.0 97.0 135.0Annual growth in labor force4/ 2.4 2.1 3.0 2.9 2.7Doctor to population ratio, 1977 1:2,810 1:13,670 1:2,640 1:8,220 1:1,250Nurse to population ratio 1977 1:3,170 1:81,870 1:870 1:1,170 1:380Percent MWRA using contraceptives, 1980 42.0 30.7 45.0 60.0 71.0Per capita GNP in US dollars 790.0 430.0 1,620.0 770.0 4,430.0FP budget as % of natl. budget,1976 0.40 0.20 0.11 0.04 0.10

1/ Population in millions.2/ Estimated for 1979.3/ Per capita calorie supply as % of requirement in 1977.4/ Average % growth during 1970-80.

Sources: 1) World Bank Staff Appraisal Reports of Population Projects in Indonesia, Malaysia andThailand, dated 1980, 1978, and 1978, respectively.

2) Data from the Population Division, Economic and Social Commission for Asia and thePacific, Bangkok, 1983.

3) The World Development Report, 1982.

4) The Population Reference Bureau, World Population Data Sheet, 1982.

PHILIPPINES: ALTERNATIVE POPULATION PROGRAMSCENARIOS AND THEIR DEMOGRAPHIC IMPLICATIONS

POPULATION GRO WTH RAT E IN PERCENT PER ANNUM

2.5-

z _ 2.22

20

I- 1 .71

1.12

9 979 11984 1983 as -9S 87e. a89$ 12914. 1993 J-095 1997 1999

POPULATION SIZE, IN MILLIONS

80

! | ~~~~~~~~~~~~~~~~~76.8

73.7

19 9 i81 1983 1985 1Sa isx57s j89 19iQ 1Qs1 199

_WEAK PROGRAM _STRONG PROGRAM