Why is the Philippines an Exemplar?

Executive summary

Reducing the prevalence of anemia has been a challenge for lower- and middle-income countries (LMICs) worldwide, with global progress- leveling out or even reversing since about 2010.¹ However, a handful of LMICs have experienced significant success in countering anemia in recent years.

These positive Exemplar countries have reduced anemia among women of reproductive age—a segment of the population uniquely vulnerable to the disease—to a greater extent than might be predicted from their economic growth trajectories.

In other words, the success of these countries in reducing anemia is attributable not only to their rising affluence and increase in spending to address the condition; they are also developing and implementing smart policies that other LMICs could emulate. This is what makes these countries Exemplars.

Identifying and understanding the specific drivers and determinants of positive change in the Exemplar countries provides a framework that can be adapted and implemented by other countries with similar economic, geographic, and political profiles to achieve success in reducing their anemia burden.

One of the Exemplar countries we identified is the Philippines, which experienced a significant decline in anemia among women of reproductive age over the course of our 2008 to 2018 study period. The Philippines now has one of the lowest prevalence rates in the Association of Southeast Asian Nations region.

The Philippines' 15 percentage-point absolute reduction in anemia prevalence—from 27% in 2008 to 12% in 2018—is about six times greater than the global mean for annual rate of reduction during that time period.^2,3,4

For non-pregnant women of reproductive age in the Philippines, anemia prevalence fell by 11 percentage points during that period, declining from 23% to 12% (Figure 1).^2,3,4

Furthermore, inequities in anemia burden among different socioeconomic categories generally decreased during the study period—a representation of the Philippines' commitment to improve health outcomes across population groups, especially vulnerable and historically underserved populations. Anemia prevalence declined across all wealth quintiles, with the gap between quintiles shrinking over the course of the study period. This attests to the Philippines' strong performance in identifying vulnerable and historically underserved populations, targeting interventions at those populations, and effectively implementing policies and programs of high quality.

The Philippines is a large and geographically dispersed archipelago nation, so it is noteworthy that all of its regions experienced significant reductions in anemia burden. One way to demonstrate this is by looking at the country's three major geographic sections: the large islands of Luzon and Mindanao, and the belt of smaller islands between them, known as the Visayas. As Figure 2 shows, each of these three areas posted healthy declines in anemia prevalence during the study period.

Another highlight in the Philippines' success in bringing anemia reductions to all corners of the country is its progress across its 17 main subnational jurisdictions, known as regions. Each of these regions comprise a cluster of smaller provinces. In 2008, anemia prevalence rates in the provinces varied rather widely, and in some were quite high. The region with the highest rate was the Cagayan Valley at the northeastern tip of Luzon, at 39%. The lowest rate was in the Zamboanga Peninsula region, in western Mindanao, at 14%.²

By 2018, anemia prevalence rates were less than 15% in all regions, except for Cagayan Valley—where the rate (16%) was just slightly higher than this threshold following a concerted, community-based nutrition and health campaign. This campaign helped generate a highly significant 23 percentage-point reduction in anemia prevalence within a single decade.⁴

In short, by 2018 the Philippines had succeeded in bringing anemia levels down nationwide to levels lower than or barely above what the lowest-burden region had been experiencing just a decade before.

Improved health care access, particularly to family planning and antenatal care

Perhaps the single most important driver of progress in reducing anemia was widespread improvement in health care access for women of reproductive age, particularly in two areas—family planning and antenatal care, during which micronutrient supplementation was provided.

The progress is a direct reflection of the prioritization of a comprehensive and integrated approach to improving women's health and nutrition. This was primarily driven by the Maternal, Newborn and Child Health and Nutrition strategy, which included policies and programs that targeted core pillars of improved women's health and nutrition, such as reproductive health and micronutrient intake for women.⁵

Family planning

The importance of family planning for the reduction of anemia prevalence was a major theme emanating from of our research.

Family planning is relevant to anemia reduction because pregnancy and childbearing can create significant risks of anemia for women, as their bodies divert nutrients to support the fetus in utero. These risks are heightened in pregnancies in which the mother is very young, the interval of time since her previous pregnancy is relatively short, or the number of pregnancies brought to term over her lifetime (a measure known as parity) is relatively high (defined as 5 or greater pregnancies over a woman's lifetime).⁶

Across these and other related metrics, the Philippines has made progress toward reducing anemia risks. On the tailwind of the Maternal, Newborn, Child Health, and Nutrition strategy, the Philippines enacted the Responsible Parenthood and Reproductive Health Act of 2012, which provided women and adolescents with counseling and access to family planning services (including contraceptives) at government health centers.⁷

An important contributor to improving family planning outcomes is an increase in access and use of reproductive health commodities—specifically modern contraceptives—and counseling for family planning. Among non-pregnant women, the use of modern contraceptives, including intrauterine devices and contraceptive pills, increased from 22% in 2008 to 25% 2018 (Figure 3).^8,9

Progress was observed across family planning outcomes in the Philippines. The median birth interval increased from 33.2 months to 36.8 months between 2008 and 2018.^2,4 The total fertility rate declined from 2.0 to 1.8 births per woman over the same period, and the proportion of non-pregnant women who had two or more children declined slightly, from 49% to 47%.^2,4

Micronutrient supplementation via high-quality antenatal care

In addition to providing more women the means of preventing unintended and high-risk pregnancies, the Philippines has improved access to and the quality of antenatal care for expectant mothers. National guidelines have helped ensure the provision of high-quality antenatal care, including iron and folic acid (IFA) supplementation, deworming, and malaria treatment in all birthing centers and health facilities.

The mean number of antenatal care visits attended by mothers during their most recent pregnancy increased from 6.3 visits in 2008 to 7.0 visits in 2018, well above the international recommended minimum of four visits; the percentage of Filipino women who reached that threshold during their last pregnancy increased from 78% in 2008 to 87% in 2018 (Figure 4).^2,4

These impressive levels of antenatal care adherence led to improvements across a range of interventions relevant to anemia reduction, particularly in the crucial area of micronutrient intake via supplementation. Supplementation is a critical intervention to target nutritional anemia, which is caused when the hemoglobin content of blood is lower than normal due to deficiency in one or more essential nutrients. The primary nutritional etiology of anemia is iron deficiency anemia, which often results from inadequate intake of iron, folic acid, vitamin B12, and vitamin A. Addressing these micronutrient deficiencies through supplementation, such as iron and folic acid, is crucial for treating nutritional anemias.

Micronutrient supplementation for women and mothers in the Philippines was first established with universal micronutrient supplementation guidelines in 1993, which ensured provision of vitamin A to lactating mothers and iron tablets to all pregnant women.¹⁰ Subsequent micronutrient supplementation guideline updates ensured further improvements in dosages and population targeting—particularly in provision of IFA across women of reproductive age (including pregnant women, lactating women, adolescents).^11,12

The percentage of women consuming any IFA supplementation during their last pregnancy increased from 84% in 2008 to 93% in 2018, and that of women consuming IFA for 90 or more days during their pregnancy rose even more sharply, from 42% in 2008 to 62% in 2018 (Figure 5).^2,4

In line with the World Health Organization's multiple-micronutrient supplementation standards, the Philippines is currently exploring the provision of multiple-micronutrient supplementation — an internationally accepted and standardized formulation that contains 15 essential vitamins and minerals, including IFA — to population groups that were previously receiving IFA treatments.¹³

Advances in dietary quality

The Philippines saw a range of improvements in nutritional outcomes, particularly among women of reproductive age. Among the nationwide findings that illustrate this broad improvement in nutrition is a substantial drop in the percentage of non-pregnant women who experienced food insecurity; this proportion fell from 29% in 2008 to 14% in 2018.^2,4

Whereas the micronutrient interventions mentioned earlier are delivered primarily through the health care system, these nutrition programs reach the broader population through other means, chiefly the food system and agricultural sector.

Exemplars study interviewees frequently identified government food fortification programs as a major factor in the reduction of anemia among women of reproductive age, especially as fortified foods have become accessible even in rural areas that had formerly experienced high levels of anemia.

A watershed moment for food fortification in the Philippines was the Food Fortification Act of 2000, which provided for the addition of vitamin A to flour, sugar, and cooking oils, as well as the addition of iron to flour and rice.³ The regulatory framework developed around this act established two broad categories: processed food products and staple goods.

By 2008, 139 processed products had the Sangkap Pinoy Seal (which requires fortified products to have 1/3 of recommended daily allowance of Vitamin A, iron, iodine), 83% of which were fortified with vitamin A, 29% with iron, and 14% with iodine.¹⁴ Over time, a high proportion of the food items most commonly consumed by the general population—including processed food products such as noodles, canned goods, and dairy products—have come to be fortified with vitamin A, iron, and iodine.

In the staple goods category, the Philippines fortified cooking oil with vitamin A, and flour with vitamin A and iron. Additionally, the nation carried out a successful effort to fortify rice—one especially important dietary staple in the Philippines - with iron.

As a result of these and related initiatives, observed improvements were made in women's dietary quality and anemia outcomes. Fortification is now a standard part of food production in the Philippines, supported by national law. Food products are now commonly fortified, whether or not they carry the Sangkap Pinoy Seal or other certification.

Improved women's economic status via conditional cash transfers

The success that the Philippines has attained in reducing anemia nationwide demonstrates the importance of effectively investing across a range of domains to reduce anemia burden.

One of those domains is broad-based improvements in women's economic status via poverty alleviation. Among the most consistent findings in our interviews at the community level was the widespread observation that poverty, by itself, was a major contributing factor to malnutrition among women—and therefore to the prevalence of anemia.

Moreover, several interviewees identified the reduction of poverty in the Philippines over the study period as a primary factor in the improvement of maternal nutrition and the abatement of anemia levels.

While it may seem obvious to point out the correlation between poverty and adverse health and nutritional outcomes, it is worth considering the specific ways in which poverty exacerbates anemia prevalence. Anemia is a condition defined by the insufficiency of certain nutrients in the bloodstream, and poverty makes it more difficult for households to obtain those nutrients due to higher cost of quality, nutrient-dense foods and lower accessibility to diverse diets. It also complicates any efforts to gain access to health care.

During the study period, the Philippines made great progress in reducing adverse outcomes for women. The national government's primary social safety net program is the conditional cash transfer program known as the Pantawid Pamilyang Pilipino Program. Implemented in 2008, it provides cash assistance to households, conditioned on their attendance at health checkups.¹⁵ The program has the clear dual benefit of providing direct poverty relief and incentivizing lower-income Filipinos to get necessary health care. Since its inception, the program expanded from approximately 300,000 households in 2008 to more than 4 million today.

Partly as a result of such policies, the percentage of Filipinos living under the national poverty line fell from 26.3% in 2009 to 16.7% in 2018.¹⁶ The percentage in extreme poverty—subsisting at less than $2.15 per day (2017 purchasing power parity)—fell even more sharply during those years, from 11.3% to 3%.¹⁷

Improvements in water and sanitation

The benefits of this robust progress against poverty can be seen in rising levels of access to nutrition, health care, and education—all of which will be discussed in greater detail in the following sections. In addition to the gains identified above, the Philippines also made progress in access to clean water and sanitation. Access to improved drinking water in the Philippines rose significantly from 69.8% in 2008 to 95.0% in 2017. Sanitation also improved—the proportion of Filipinos practicing open defecation dropped from 8.4% to 4.6% between 2008 and 2017, and improved sanitation access increased from 66% to 76% during the same period. These improvements in clean water and sanitation can meaningfully influence anemia outcomes, since poor water quality and sanitation can lead to parasitic infections, diarrhea, and other gastrointestinal conditions that deplete the body of vital nutrients.

Importantly, the nation also made substantial progress in reducing the incidence of soil-transmitted helminths, intestinal worms that thrive in land contaminated by human waste and sewage—a condition associated with inadequate plumbing and high rates of open defecation, both of which have become less common in the Philippines.¹⁸