How did the Philippines implement?

Sustained political commitment to women’s health and nutrition

The first key to the Philippines’ successful implementation of anemia reduction programs is the nation’s strong and sustained political commitment to women’s health and nutrition.

Interviewees called attention to the strength of this political support and said it was reflected in everything from presidential policies to the everyday actions of local officials. Guidelines and provisions contributing to the reduction of anemia’s prevalence were embedded in a range of national and regional health measures. Over time, these developed into a comprehensive framework for shrinking the burden of anemia among women of reproductive age. This commitment manifested itself through a multisectoral, systems-minded approach to policies and programs that targeted both the causes and the consequences of nutritional inadequacy and other factors that had driven the nation’s historically high anemia rates.

One important catalyst of this political support was the Millennium Development Goals (MDGs), which arose from the United Nations Millennium Declaration of 2000 and set social and economic targets to be achieved by 2015. The Philippines showed a deep commitment to the MDGs from an early stage, especially the benchmarks relating to maternal and neonatal health.

Several important examples of legislation and policy emerged from this heightened level of commitment and expenditures. For example, the Philippine Department of Health (DOH) implemented the Maternal, Newborn and Child Health and Nutrition (MNCHN) strategy nationwide in 2008, at the start of our study period; its effects are reflected in many of the improvements that occurred over the following years. One of the notable aspects of the MNCHN strategy was its emphasis on close coordination across governmental departments, including those outside of normal health policy channels.¹

One particularly strong indicator of the government’s willingness to apply public resources toward the MDGs was the steadfast support for PhilHealth and its maternal health and nutrition programs, including such interventions as the provision of free iron and folic acid to pregnant women, as well as the coverage of pregnancy-related complications for all expectant mothers.

Interviewees pointed out that this support from other government agencies (incl., Education, Social Welfare & Development, Agriculture) allowed for more sophisticated intersectoral planning—for example, in the area of adolescent health, where coordination with officials in such areas as education could generate better outcomes than a less systemic and collaborative process might produce. One Department of Education official cited the development of “teen hubs” in public schools, where adolescents could get reliable information on such health topics as sexually transmitted diseases, early pregnancy, and mental illness.

Another example of how ambitious government action and intersectoral collaboration helped generate meaningful progress against anemia was the development of joint promotional campaigns between the DOH and the Philippine Commission on Population and Development. POPCOM, as the commission is known, is the government agency responsible for the coordination and monitoring of policies related to population management. The two entities collaborated on campaigns to provide messaging on pregnancy and child spacing. Both also contributed to the implementation of the POPCOM-led Responsible Parenthood and Family Planning program, which advanced family planning as a primary means of improving maternal health outcomes.²

While the Philippines fell short of achieving the maternal mortality targets of the MDGs, the investments and collaborations put in place to progress towards those goals helped generate significant improvements in anemia reduction, as well as in such related areas as nutrition supplementation, facility-based childbirth, and antenatal and postnatal care.

Investments in systemic policies and programs

A few of the highlighted programs in the previous section demonstrate a broader commitment to policies and programs focused on system-based improvements to women’s health, nutrition, and economic empowerment.

That commitment was expressed in many ways, including through investment in systems-based improvements. Some of these were general social welfare and antipoverty measures, but many of them focused on expanding access to the health care system. These systemic reforms to the delivery of health services placed a heavy emphasis on helping traditionally underserved populations nationwide to obtain essential health services and critical interventions.

Over the past two decades, reforms were embedded in a broad range of health policies and programs. The PhilHealth universal health coverage program led to strengthened health systems in rural areas.³ National antenatal care guidelines ensured the provision of iron and folic acid supplementation, deworming, and malaria treatment in all birthing centers and health facilities. Micronutrient guidelines ensured free supplementation to mothers during both antenatal care and postnatal care sessions—including in rural and barangay clinics, and even in patients’ homes.

These and similar policies mandated that such nationwide programs be rolled out at the local level. As a result, over time, local chief executives (i.e., elected officers of local government units, or LGUs) began to pay more attention to the problem of anemia and to the necessity of safeguarding maternal health and nutrition within their jurisdictions.

But they were not the only local champions of such policies. Community health workers in rural health units played an important part in advancing government health programs, particularly integrated women’s health and safe-motherhood services. They provided nutrition counseling, offered family planning guidance, and performed prenatal checkups.

In addition to these health reforms, another kind of system-based governmental policy that merits attention for its contribution to anemia reduction is the broad-based “social safety net” program that provides essential services to those who would not otherwise be able to afford them.

Such programs are often difficult to develop and sustain even in affluent nations, but the Philippines has shown a commitment to safety net initiatives that have made a material difference in addressing anemia and other public health challenges.

One of those initiatives, as discussed at various points in this narrative, is the 4Ps. The 4Ps initiative is a powerful example of the government's ability to deploy system-minded, multisectoral strategies toward the improvement of maternal and child health. Led by the Department of Social Welfare and Development, the 4Ps implementation also relied heavily upon other national agencies—including the DOH—as well as local entities. In other words, it is systemic and intersectoral to its core.

“The 4Ps is one of the priorities of the national government and local government units,” said a national official. “[A]nd for the program to be successful, in terms of achieving the outcome or goals, then collaboration between stakeholders is important in addressing the problem in maternal and child care, anemia, [and] mortality.”

This collaborative approach has generated the country’s flagship safety net program. As a conditional cash transfer program, the 4Ps program’s viability and effectiveness depend on an assiduous monitoring and evaluation system to ensure that recipients undertake the necessary steps to receive the funds.

Those steps include attendance at medical checkups as well as a monthly appointment known as the Family Development Session, which is a required seminar for pregnant women - a core high-priority population group in the Philippines’ health policy. This seminar focuses on improving the health of mothers and young children through increased utilization of preventive health care services and better health-seeking behaviors. The Family Development Session instructs households in topics directly relevant to anemia prevention, such as nutrition and water, sanitation, and hygiene. An important component of these classes is “learning by doing,” with lessons related to quality nutrition and improved dietary diversity and intake that could be readily applied in the home as part of the nation’s broader MNCHN strategy.

The checkups required under the 4Ps also expose women of reproductive age to instruction in such crucial areas as family planning, prenatal care, and skilled birth attendance—all of which are linked to reduced anemia prevalence.

In addition to the 4Ps program, in 2010 the DOH also built upon its universal health care efforts by inaugurating a multisectoral campaign to pursue universal membership in PhilHealth.³ In this effort, the DOH collaborated with the Department of Social Welfare and Development to identify the poorest families and to make certain those households had PhilHealth coverage—including for vital maternal care services. Increased coverage through PhilHealth was identified by our study respondents as a major enabler to the improvement of maternal care use nationwide.

The DOH and Department of Social Welfare and Development extended this collaboration to LGUs through a National PhilHealth Registration Day, in which LGUs were encouraged to enroll their low-income residents—an initiative that led to the enrollment of 5.2 million poor families into the program.⁴

Effective program targeting and implementation through cross-sector coordination

A crucial aspect of the Philippines’ implementation of its anemia policy was the nation’s focus on expanding services to vulnerable and historically underserved populations. This was supported by the diffusion of both responsibilities and services, which has enabled the Philippines to deliver resources more efficiently across its expansive geography.

This devolution, which was an important factor in the improved targeting of anemia programs, was codified in the 1991 Local Government Code. This measure devolved the delivery of most health services from the DOH to the LGUs, with improved service for underserved communities as one of the leading motivations for the policy.

The health system remained under DOH auspices, so the DOH continued to coordinate nationwide policies, standards, and regulations; it also had a predominant role in providing tertiary care. However, the devolution gave LGUs main responsibility for primary and secondary health facilities, which would be especially important to the delivery of care in remote areas far from major hospitals.

Over subsequent years, significant variations across localities in the performance of health care facilities and health workers became increasingly obvious. The nation’s geographically isolated and disadvantaged areas, known as GIDAs, showed especially high morbidity and mortality rates and a striking lack of sufficient health care facilities and personnel.⁵

To address these issues, the DOH instituted the Health Facilities Enhancement Program in 2008. This program focused on the construction or upgrading of health centers, with a particular emphasis on emergency obstetric and neonatal care in areas with especially high maternal mortality rates, as well as the development of facilities across 20 provinces with approved plans to reorganize their health systems.⁶

While devolution has created some new problems to overcome, it has also benefited the campaign against anemia in some important ways, notably by helping to ensure better outcomes for underserved populations. As mentioned earlier, it has compelled local officials to better understand anemia and to adequately prioritize maternal health and nutrition across the socioeconomic spectrum. Maternal health has consequently risen to the top of many LGU policy agendas, as demonstrated through the various policies, regulations, and maternal health programs implemented at this level. In addition, the strengthening of local health functions has enabled—and necessitated—multisectoral collaboration among officials at different levels of government.

An important result of this collaboration has been the implementation of targeted programs to address the particular needs of vulnerable or historically underserved populations, including indigenous peoples, the elderly, and residents of GIDAs.⁵

Several interviewees attested to this broadening of access among long-underserved communities and populations. “There were a lot of improvements in the delivery of services,” said one national official. “I was in a GIDA, and I see why women, especially the pregnant and lactating, become anemic because of inaccessibility of services. It’s either because they cannot access it or there are no services available. But over the years, it has been improving, especially the delivery of health services for women.”