How the Philippines became an Exemplar in anemia reduction

Among women of childbearing age, anemia is often a silent threat. It affects 30% of women around the world. Most prevalent in low- and middle-income countries, anemia can sap women's energy and cause preterm delivery, low-birth- weight infants, and poor cognitive development.

As part of an effort to counter this threat, Exemplars in Global Health and SickKids Centre for Global Child Health recently launched the Exemplars in Anemia Reduction among Women of Reproductive Age project to investigate how some countries have been especially successful at reducing anemia. The project is preparing to publish research on five such countries: Pakistan, Mexico, Uganda, Senegal, and the Philippines.

Ahead of the publication of the research on the Philippines, we spoke with Dr. Imelda Angeles-Agdeppa, director of the Department of Science and Technology at the Food and Nutrition Research Institute, who led the research into how her country achieved significant reductions in anemia among women of reproductive age between 2008 and 2018.

Why was the Philippines chosen as an anemia Exemplar?

Dr. Angeles-Agdeppa: It's because we recorded a very significant decline in our anemia prevalence among women of reproductive age between 2008 and 2018. The country achieved about six times the global mean compounded annual growth rate for anemia reduction during the time period, which we are very proud of. Anemia among non-pregnant women of reproductive age also declined from 27% in 2008 to 12% in 2018.

How did anemia affect women's lives and the lives of their newborns and babies?

Dr. Angeles-Agdeppa: The high prevalence of anemia prior to the study period had a tremendous effect on women's lives in terms of a lack of productivity due to reduced work capacity. It increased susceptibility to infections among these women due to compromised immunity. Among our pregnant women, we may have seen a lot of stillbirths and miscarriages and maternal mortality. For the babies or newborns of anemic women, they might have poor cognitive function and poor mental development. During their early years, they also may have more episodes of illness or infections because of their compromised immunity.

What were the most important drivers of anemia reduction among women of reproductive age?

Dr. Angeles-Agdeppa: It boils down to effective investments across health and non-health sectors. The most important drivers were from non-health sector funding, which constituted about 62% of the predicted change in our prevalence of anemia. These included poverty alleviation programs through conditional cash transfer programs and investments in women's education increased women's purchasing power and their knowledge of food choices. Also due to the government's poverty alleviation programs, women had improved housing conditions as well. There were also improvements in sanitation practices like, for example, the building of water-sealed toilets, which were actually distributed free by our government. Food security also improved during the time and maternal nutrition was better. Care-seeking behavior also improved due to women's education and the many advertisements that flooded the television and other education campaign portals.

Apart from that, about 44% of the predicted change was due to direct healthcare funding. We observed in our analysis that the Philippines increased its investments across the health sector, which may have contributed to relieving the anemia burden. Improvements in data on reproductive health, including the provision of modern family planning methods also contributed to the decline. Antenatal care visits also increased slightly, reflecting improvements in access to healthcare, counseling, and the provision or the acquisition of iron and folic acid supplements for our mothers.

At the national and local levels, there has been strong political commitment and presidential support. [we showed them] that if they don't care for their pregnant women, lactating women, and the women of reproductive age, this may result in economic downfall. Why? Because of the impact on productivity.

It seems that the largest decrease in anemia prevalence was observed in the poorest and most rural parts of the country – how did this happen?

Dr. Angeles-Agdeppa: While anemia prevalence was consistently higher among non-pregnant women living in rural areas, both rural and urban non-pregnant women experienced a net decrease in anemia prevalence over the study period. From 2008-2018, improvements were also greater among rural residents compared to urban residents. The disparities in the anemia prevalence between poor and non-poor became less over time, illustrating an improvement in absolute socioeconomic inequalities for anemia as well as between urban and rural non-pregnant women, as well as between poor and non-poor non-pregnant women.

The same pattern of anemia prevalence was noted across educational levels. Over the study period, anemia prevalence decreased across all education levels and the gaps in anemia prevalence between women’s education levels narrowed.

Previously, women had to spend money to go to a health center, which was often very far from their area. With the intensified programs on anemia reduction in the Philippines from 2008 to 2018, healthcare centers were placed in villages so people could have easier access to services. Women’s health-seeking behavior improved. There was also an increase in the number of village health and nutrition workers catering to women who were not able to visit the health center in geographically isolated and disadvantaged areas in the Philippines. The Filipino term for this is door-to-door health services. The availability of free iron-folic supplements to pregnant and lactating women and even to all women of reproductive age who go to health centers for check-ups also helped close the anemia rate reduction gap between rich and poor. All these intensive actions and initiatives are contributing factors in why anemia prevalence has declined.

What’s the current outlook for anemia reduction among women of reproductive age in the Philippines – is more progress being made?

Dr. Angeles-Agdeppa: Yes. Based on our survey, anemia prevalence is continuously declining. The Philippines has been extraordinarily successful in reducing the anemia burden on women of reproductive age through both direct and indirect nutrition programs focused on alleviating micronutrient deficiencies and poverty, and improvements in women's health and well-being. Prevention efforts should continue to focus on universal healthcare access.

Now, poverty alleviation by the government cannot do it alone. We really need some sort of an intensive campaign so families can mobilize themselves to work since income-generating projects coming from different sectors of the government are also available for them.

The finding of the anemia Exemplar study should also be widely disseminated at the local government level. Our study looked at local government units who have done well and those who have not done well. Hence, the research results must be disseminated to other local government units and those best practices must be shared.