Uneven performance among local government units under devolution
The Philippines made extraordinary gains against anemia in women of reproductive age over the course of our study period. Yet, as many interviewees pointed out, the nation also faces some significant challenges in building upon this progress.
Our respondents mentioned several such challenges, but one standout challenge was the unevenness of performance and commitment to addressing anemia prevalence across local government units (LGUs).
That variability has limited the effectiveness of implementation efforts in some parts of the country. While the Philippines has undertaken ambitious efforts to make health care and coverage universal across the archipelago, the devolution of health policy that began in the early 1990s has placed a great deal of practical responsibility for service delivery in the hands of local health officials.
As noted elsewhere in this report, devolution has brought considerable benefits, with many LGUs rising to the occasion and improving health and nutrition services for their communities.
Devolution has given LGUs responsibility and autonomy to manage local health services — including effective promotion and delivery of preventive care and maternal care, and national stakeholders have acknowledged general success in improving access to essential healthcare and quality nutrition across LGUs. However, some LGUs have achieved greater success than others.
Study respondents pointed to this as a primary factor for continued disparities in maternal health and nutrition service delivery across the country, which is still a pressing issue despite some meaningful equity gains.
"Basically, it's the same from one region to another: the trends are decreasing, but there are really areas that are higher in prevalence of anemia", said a representative of an international organization. "In some areas, there [is] higher prevalence of anemia [among WRA] —this is especially in the geographically isolated and disadvantaged areas. . . . Although even in those areas, it's still decreasing."
Several respondents said that the devolved structure of health care services is a major reason that the prevalence of anemia in some places has not fallen at the same rate as the national level, even as the overall nationwide trend is toward lower prevalence rates. Devolution inherently heightens the influence of local leaders. When those leaders are unsupportive of the health and nutrition policies that can curb anemia, the areas they govern can fall behind.
According to some respondents, this has already happened in some parts of the country. "At the national level, there is no problem in terms of policies. But at the local level, the translation of the many policies and programs is the problem," said an official from a community nongovernmental organization.
Among the most practical ways in which the variability of LGU support manifests itself is in local and regional budgeting. Insufficient local funding, particularly for nutrition, was mentioned by respondents as an obstacle to further gains against anemia—as reflected, for example, in some local shortages of micronutrients such as ferrous sulfate.
Shortfalls in monitoring and evaluation of programs, particularly related to dietary intake
A challenge closely related to inconsistent LGU performance is the inadequacy of monitoring and implementation of programs. Interviewees noted that the monitoring and evaluation of programs were often lacking—and that this led, in turn, to weak implementation.
"They will implement the program and then that's it, they won't even go to see whether it is working or not, what needs to be improved", said a respondent from an international organization. "Those are the gaps, larger gaps [that explain] why these programs and policies may not work or may not be working."
For example, observers said there was no monitoring of fortified foods to ensure manufacturer compliance with national guidelines. "Regular monitoring of fortified food products to ensure that all manufacturers complied with the mandatory food fortification is not conducted by the Food and Drug Administration," said an interviewee from a local nongovernmental organization (NGO). "The NCP [Nutrition Center of the Philippines] studies showed that cooking oil in the groceries are compliant, while unbranded cooking oil are not fortified with vitamin A or there is zero content."
The Philippines also faces a need to improve the monitoring of program outcomes—for example, through better collection of household- and individual-level dietary data—and to link such indicators more directly to specific programs and policies. With more robust data, national and local officials can more clearly assess the impact of food fortification programs and other interventions intended to improve women's health and nutrition, and refine programs as needed to effectively target and reach populations in need.
We need to have good monitoring of nutrition programs, said one interviewee from an international organization. "We have to be more vigilant in monitoring and evaluating these policies and programs."
Continued gaps in the provision of clean water and sanitation
As mentioned in this report, the reduction of overall poverty and the elevation of living standards—including expanded access to improved water, sanitation, and hygiene, an especially relevant marker of progress against anemia and other digestion—related health disorders-have been prominent contributors to the Philippines' success against anemia.
However, these improvements are not comprehensive, and parts of the country still must contend with water, sanitation, and hygiene deficiencies that can compromise further gains against anemia. Interviewees said that while the government has worked to improve access to safe water in rural areas, this remains an unfinished task, particularly in geographically isolated and disadvantaged areas.
While most study participants said they had sufficient water supply for household use, some participants from rural areas mentioned that they experienced shortages, particularly in the summer or during dry seasons.
"In our barangay, there is water supply four times a week", said a woman from Benguet. "But during summertime, the water supply is only once a week. So, you really need to save water to have enough supply for the household."
The water that finally emerges from the pipes may be undrinkable for a time. "When [the] water supply comes back after a water interruption, it is dirty and rusty, and it will take about eight hours before the water becomes clean again," said a woman from Makati City.
Access to functional sewage also remains an issue in some areas, despite the government's efforts to increase the number of toilet facilities. This lack of toilets is a consequence of other problems besetting some areas, including deficiencies in sewage infrastructure, household crowding, and water shortages.
Such circumstances raise the risks of parasitic infections, which can lead to nutritional deficiencies that cause anemia. Exemplars interviewees said they have seen this cycle in some areas, especially lower-income communities. The problem becomes worse during cyclones and heavy rains, which can cause flooding that overburdens inadequate sewage facilities.
Vulnerability to climate change
The Context section of this report discusses the Philippines' high level of vulnerability to a range of natural disasters, including earthquakes and volcanic eruptions. Many of the hazards confronting the archipelago are compounded by accelerating climate change. Cyclones, floods, landslides, extreme heat, droughts, and rising sea levels are becoming more common as temperatures continue to exceed normal historic levels.
Several interviewees from national government agencies and NGOs identified climate change as a major driver of food insecurity and nutritional deficiency, which in turn place women of reproductive age and their children at higher risk of anemia.
One direct way that climate disruptions affect food availability is through damage to property, infrastructure, crops, and agricultural land-impeding the cultivation and delivery of food, as well as the livelihoods of agriculture—dependent households and communities.
"Before, the typhoons and droughts [were] seasonal. Now, typhoons and droughts occur often; thus [there is] less time for the food systems to recover", said an NGO representative. "The severity of the weather has doubled, as well as the regular implications of La Niña and El Niño. Seasonal rains already have no regular patterns, impacting dams, which affects other industries that depend on these dams for agriculture use."
Another NGO official said, "It's hard to plant nowadays because of the extreme heat, especially in areas where irrigation is difficult. So it's really hard for farmers to do food production."
For example, some interviewees pointed out that rising temperatures are increasing the risk of zoonotic diseases. Increased disease risk amongst pigs, cows, or poultry birds could also reduce the accessibility and affordability of animal protein sources and thereby reduce iron consumption.
"When the price of pork increased due to African swine fever . . . people opted not to eat pork, which is a primary source of protein for a lot of families", said an NGO respondent. "Chicken acquiring diseases also impacted food access and the capacity of the household to buy their food."
The ramifications of climate change for anemia prevalence—and across a broad gamut of public health issues—are complex and varied.