Philippines - Population, health and nutrition : a sector review (Vol. 1 of 2) : Summary of findings, issues and recommendations

Report No. 4650-PH Population, Health and Nutrition in the Philippines: A Sector Review (In Two Volumes) Volume 1: Summary of Findings, Issues and Recommendations January 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 recipients only in the performance of their official duties Its contents may not otherwise be disclosed without World Bank authorization.  CURRENCY EQUIVALENTS IJS$1.0 = P8.5 1! 1P1.0 = US$0.1176 P1 million = US$117,647 P1 billion = US$117.65 million FISCAL YEAR Ja,nuary 1 - December 31 ABBREVIATIONS AND ACROINYMS ADB Asian Development Bank AFS Area Fertility Survey ASEAN Association of South East Asian Nations ASFR Age-Specific Fertility Rate BAEX Bureau of Agricultural Extension BAI Bureau of Anlimal Industry BHS Barangay Health Station BHW Barangay Health Worker BNS Barangay Nutrition Scholar BOHS Bureau of Health Services BOMS Bureau of Medical Services BSB Botica sa BaLran,gay BSPO Barangay Sup,ply Point Officer CBR Crude Birth Rate CDR Crude Death Rate CEB Children Ever Born COS Community Outreach Survey CPR Contraceptive Prevalence Rate DIC Disease Intelligence Center DPT Diphtheria/Pertussis/Tetanus FP Family Planning FNRI Food and Nutrition Research Institute FPOP Family Planning Organization of the Ph:Llippines FTOW Full-Time Outreach Worker GNP Gross National Product GOP Government o:f the Philippines GSIS Government Service Insurance System HEMDS Health Education. and Manpower Development Service IEC Information, Education and Communication IMCH Institute for Maternal and Child Health IMR Infant Mortality Rate 1! Annual Average Exchange Rate for FY 1982 US$1 = P8.5; Annual Average Exchange Rate for FY 1983 US$1 = Pll  - ii - IPPF International Planned Parenthood Federation IRP Integrated Reorganization Plan IUD Intra-Uterine Device KAP Knowledge, Attitude and Practice MCH Maternal and Child Health MCRA Married Couple of Reproductive Age MEP Months of Effective Protection MIS Management Information System MLGCD Ministry of Local Government and Community Development MMR Maternal Mortality Rate MOA Ministry of Agriculture MOEC Ministry of Education and Culture MOH Ministry of Health MOHS Ministry of Human Settlements MOLE Ministry of Labor and Employment MPWH Ministry of Public Works and Highways MSSD Ministry of Social Services and Development NCSO National Census and Statistics Office NDS National Demographic Survey NEDA National Economic Development Authority NFPO National Family Planning Office NMPC National Media Production Center NNC National Nutrition Council NNS National Nutrition Service NPFPOP National Population and Family Planning Outreach Project NRR Net Reproduction Rate OHEPT Office of Health Education and Personnel Training OHRD Organizational and Human Resource Development ORS Oral Rehydration Salts or Solution PCF Population Center Foundation PGR Population Growth Rate PHC Primary Health Care PHN Population, Health and. Nutrition PMA Philippines Medical Association PMCC Philippine Medical Care Commission PNP Philippines Nutrition Program POPCOM Commission on Population PUSH Panay Unified Services for Health RHCDS Restructured Health Care Delivery System RHO Regional Health Office RHU Rural Health Unit RPFS Republic of the Philippines Fertility Study RPO Regional Population Officer SCRPPP Special Committee to Review the Philippines Population Program SCRS Schistosomiasis Control and Research Service SDC Social Development Committee SSS Social Security System  - iii - TFR Total Fertility Rate TIDA Total Integrated Development Approach TMFR Total Marital Fertility Rate TWG Technical Working Group UJNDP United Nations Development Programme 'JNFPA United Nations Fund for Population Activities IJNICEF United Nations Children's Emergency Fund IJPIMC University of the Philippines Institute of Mass Communication IJPPI University of the Philippines Population Institute USAID United States Agency for International Development WDR World Development Report WFS World Fertility Survey WHO World Health Org,anization  - iv - PHILIPPINES: BASIC POPULATION, HEALTH AND MUTRITION INDICATORS (1982 data unless otherwise specified) Mid-1982 Population (in millions) 50.8 Population projected to year 2000 (in millions) 74.8 Average annual population growth rate 2.5 Population density per km2 160.0 Percentage of population aged 0-14 39.8 Percentage of population aged 65 and over 3.0 Percent urban population, 1980 37.0 Crude birth rate 32.2 Total fertility rate 4.2 Crude death rate 7.0 FMale life expectancy at birth 62.6 Female life expectancy at birth 66.1 Infant mortality rate 51.0 Male literacy rate, 1976 77.0 Female literacy rate, 1976 76.0 Percent population with safe water, estimated for 1979 43.0 Energy consumption per capita, k cals. 329.0 Per capita calorie supply as % of requirement, 1977 107.0 Annual growth in labor force, average for 1970-80 2.4 Physician to population ratio, 1977 1:2,810 Nurse to population ratio, 1977 1:3,170 Percent MWRA using contraceptives, 1980 42.0 Per capita GNP in US Dollars 790.0 FP budget as % of national budget, 1976 0.40 Sources: 1) The Population Division, Economic and Social Commission for Asia and the Pacific, Bangkok, 1983. 2) The World Bank, The World Development Report, 1982. 3) The Population Reference Bureau, World Population Data Sheet, 1982.   v PREFACE Purposes of the Review 1. Reducing population growth and improving health and nutrition in the Philippines are major concerns of the Government of the Philippines (GOP) and a number of donor agencies. Although the country still cannot fully meet the needs of its population, health and nutrition (PHN) programs, notable progress has been made during the last two decades. In recent years, however, this progress seems to have slowed, particularly in population control. Questions are also being raised about PHN program strategies and about the organization, management and financial efficiency of the agencies operating in these sectors. 2. The development of a variety of service delivery systems to address the many problems in the PHN sectors has resulted in institutional overlaps and a proliferation of administrative support structures. Field workers offer either one service or a limited package of services, often of questionable quality. Furthermore, some major studies have shown marked regiotnal disparities in the availability of PHN services.1/ The Five-Year Development Plan (1983-87) alludes to these problems and calls for more equitable access to services, particularly through strengthening Primary Health Care (PHC) efforts. 3. In light of these concerns, in 1982 the Philippine Government and the World Bank agreed to conduct a comprehensive health sector review. In the past, except for limited WHO and UNICEF assistance, most of the donor efforts (USAID, UNFPA and the Bank) had concentrated on population rather than health. In addition, not all donor efforts in population, health and nutrition were fully coordinated. 4. To improve coordination of donor inputs and complementarity of PHN activities, ADB, USAID, WHO and the Bank agreed to conduct the sector review jointly and to expand its scope to include all three sectors. A PHN sector review mission representing these four agencies visited the Philippines in March 1982. To complement this review, the Ministry of Health (MOH) conducted a health sector study and the Commission on Population (POPCOM) undertook an analysis of the implications of population growth in the Philippines. These inputs have stimulated continuing discussions between the participating GOP agencies and the donors. 1/ National Economic Development Authority, Regional Development Information, 1978, and World Bank, "Aspects of Poverty in the Philippines: A Review and Assessment," Report No.2984-PH, December 1, 1980.  - vi - Scope and Structure of the Report 5. The report consists of two volumes. Volume I presents a summary of findings, issues, and recommendations. Volume II is the Main Report consisting of four parts; the first three parts cover population, health, and nutrition respectively, since separate agencies (POPCOM, MOH, and the National Nutrition Council) are responsible for these sectors. The three sectors 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 and Dr. Y. S. Kim of WHO collaborated closely with the mission. Dr. K. Kanagaratnam (Sr. Auviser, PHN Department, World Bank) joined the mission during field trips and in its concluding discussions with senior GOP and participating donor agency officials. Consultants from the Faculty of Economics and the Institute of Public Health of the University of the Philippines contributed useful technical data. The report also benefited from the mission's discussions with numerous senior government and non-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 has led to the worsening land-man ratio. In recent years, the economic situation has deteriorated: real GNP growth fell from 7 percent a year in 1977-78 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 million persons to the Philippines population by the year 2000 -- makes it unlikely that 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 will make the attainment of the Goverment's development goals very difficult. 2. Population. At the present rate of population growth, the Philippines adds the equivalent of Australia's population every ten years. The country's population has increased dramatically, from 27 million in 1960 to 50 million in 1982, and is expected to reach about 75 million in the year 2000. Even with the reduced growth rate projected for the next 35 years (medium projection, WDR), the total population will reach the 100 million 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 fertility have resulted in a large cohort in the reproductive ages. This cohort will sustain 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 highest in the ASEAN countries (Annex 1). Family size varies from 3.6 in Metro Manila to 6.1 in Bicol, with a national average of 5.2. The contraceptive prevalence 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 percent in Bicol. The most rapid increase was in the mid-1970s, with some slowdown after 1977. However, in 1980 only 34 percent of contraceptive users employed 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 show little or no decline in fertility, and they have a higher current fertility and lower contraceptive practice. These regions still have strong socio-economic incentives for large families. The opposite is true of the richer and more urbanized regions. 5. Health. Improvements in health status over the last two decades have been considerable, and the outlook is encouraging. Life expectancy is  -2- now about 64 years, higher than t:hat of many other countries with a comparable GNP per capita. The crude death rate waS 7 per thousand in 1982. The infant mortality rate (IMR) declined from 106 per thousand to 75 between 1960 and 1970; the present low IMR of 51 probab:Ly reflects, inter alia, the relatively high level of education in the Philippines, rapid economic growth, and intensive disease control programs in the sixties and early seventies. The decline in the IMR, although clearly desirable, has exacerbated the problem of rapid population growth. The decline in infant and maternal mortality rates has apparently slowed down since the mid-7'Js. This levelling off is a cause for concern and warrants reconsideration of health programs directed toward child and maternal health. 6. Communicable diseases are still the main cause of death, but the proportion of deaths due to such diseases is slowly decreasing. The proportion of deaths due to degenerative diseases, cancers and accidents is increasing. Respiratory infections and gastroenteritis still predominatle in the national profile of morbidity, although malaria, schistosomiasis and tuberculosis are leading causes of morbidity in some regions. This morbidity profile is not expected to change in the immediate future. '7. Considerable differences in mortality and morbidity still exist among regions. Analysis of mortality data suggests that environmental improvements underlie the decline in mortality; any further decline will.. be slow and difficult and will require more elaborate improvements in the environment, 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-income groups; (b) malnutrition among the very young and among pregnant and lactating women; and (c) diet imbailance resulting in vitamin and mineral cdeficiencies. While data on nutri-tional status are fEar from complete, the results of the national weighing program and of representative sample surveys estimate the problem of pre-school malnutrit Lon at 28 percent for 1980. Although some evidence exists which indicates that overall national nutritional status is improving, the nutritional conditions of those underserved by government services and the disadvantaged social groups has not improved. There are also indications that the consumption patterns of low-income families make their diet more sensitive to changes in food prices than to changes in income. Food intake is higher in urban centers and 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 the Philippine economy and makes more difficult the task of raising living standards in the future. The past high rate of growth, which resulted from low and falling mortality and high fertility, has given rise to a s:ituation where over 40 percent of the population are aged 15 years or less. These changes in age structure have resulted in enormous demands for health and education facilities, for housing, and for public infrastruc- ture, while the rapidly growing labor force requires continuous and large-scale increases in job opporltunities. The situation is exacerbated by the increase in the proportion of women in reproductive ages, sustaining a still higher population growth momentum.  M- 3 - 10. As a result of a high population growth momentum, the Government's efforts at improving productive employment opportunities, alleviating poverty, and reducing income disDarities ha-a bFen seriouslv handicapped. Excess labor supply has contributed to a substantial real wage rate decline in agriculture between 1957-76. Of the 9 M4llion new entrants into tne labor market during the last decade, only about 2 million have found work in the non-agricultural sector. Arable land per capita fell nearly 40 percent between 1960 and 1975, with 99 percent of the arable land presently under cultivation. In another 35 years the arable land per capita will decline to less than one-twentieth of a hectare, with a substantial further decline inevitable in the next two generations, based on current projections. The worsening of the land-man ratio, combined with inheritance customs, has already resulted in a continued subdivision of land, a higher percentage of population dependent on smaller farms, higher private and social costs of bringing poor land under : Kltivation, and increased deforestaticn. The situation in all these areas is bound to deteriorate further. 11. The impact of high population growth seems distant, and it is not easy to focus attention on a situation which will arise twenty-five to fifty years hence. However, the severity of the long-term impact clearly underlies the urgency of immediate action to reduce the rate of population growth. If significant reductions in the fertility rate are made, they will begin to affect the demand for resources within five years, with a cumulative effect in later years. Expenditure on Population, Health and Nutrition 12. The Philippines population planning, health care and nutrition services suffer from scarce government financial resources, and the funds presently earmarked for them are unlikely to be sufficient for ongoing programs and the new 1983-87 Plan priorities. Central Government's 1982 appropriations for these three sectors are about P3.1 billion, or US$7.60 per capita. The total is slightly less than one percent of GNP, or 5.5 percent of the appropriation for public expenditure. On a per capita basis, $6.70 is for health, US$0.60 for population, and US$0.30 for nutrition excluding food aid. The role of external finance is small for the Ministry of Health (3 percent of expenditure), but significant for the Commission on Population (46 percent). In 1982, local government expenditure on these sectors was estimated to add only PO.3 billion or 9 percent to central government outlays, and represented only about 5 percent of total local government expenditure. This scarcity might be further aggravated by a likely decline in donor assistance for these sectors. However, it is estimated that the outlays by private households are relatively high, bringing total outlays by central government, local government and private households on population planning, healtn care and nutrition programs to approximately US$25 per capita, a figure comparable with expenditures in other middle-income cotntries. 13. Population. Between 1969 and 1982, expenditure on family planning increased from P16,4 million to P286 million; the proportion met by GOP increased from less than a third to over two-thirds. As a proportion of the Government's recurrent budget, the family planning program averaged 0.4 percent for 1977-82, which compares favorably with its  - 4 - ASEAPN neighbors. In 1982 more than 50 percent of program operating expenditure appropriately went for clinical services and outreach activities. External financing; of population actiLvities is likely to decline in the future, placing a greater burden on central and local governments. it appears unlikely that local governments will be able to assume the full cost of outreach activities, estimated at about P70 million a year (about 10 percent of the local government outlays). 14. Health. Between 1975 and 1981, expenditure by the Ministry of F.ealth (MOM) increased from P626.2 million to P1,868 million, at an average annual rate of 20 percent in nominal terms, 9 perc:ent in real terms. At the same time, the allocation of expenditure on supplies and materials, which was considered high at 45 percent, declined only marginally to 43 percent; expenditure on personnel services remained constant at about 36 p_rcent. The share of hospital services increased from 48 percent to 53 percent; field health services, from 27 percent to 29 percent. The high share of public expenditures on hospital services suggests relative neglect of the preventive and promotional activities for which there exists a strong rationale :or public subsidy. The expenditures are not equitably distributed among regions; ithe data suggest that Southern Tagalog, Western and 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 recurrent expenditure in 1978 to 8 percent in 1982. Hospita:Ls, which have a three-tier pricing structure (ac:cording to income :Level), including free services 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 -and introduction of cost recovery in rural areas in order to mobilize additional resources for health services are significant policy issues; studies indicate that demand for adult outpatient services is relatively price-inelastic in the rural areas. 16. Nutrition. Expenditure on nutrition programs, including food aid, increased 24 percent in real terms between 1978 and 1981. Much of this increase in budget is believed to be the result of reclassification of existing programs without necessarily enhancing their nutritional emphasis. About 80 percent of the nutrition budget is spent on programs of five ministries, with the Ministry of Education and Culture spending the highest amount. However, there is inadequate central control over funds, which are thinly stretched over a number of nutrition programs undertaken by various agencies. Policies 1 7. The Government's policy is to reduce the population growth ra.te from an estimated 2.7 percent in 1982 to 2.0 percent in 1985, and to attain a net reproduction rate of orie by the year 2000. But the 1983-87 Development Plan does not include a strategy for achiieving demographic goals nor does it have explicit f'amily planning performance targets, nor an explicit commitment of public resources to the popu:Lation program. The plan appears to assume that the population growth rate reduction will be  -5- mainly attained by raising living standards alone. As a result, there is much ambiguity about the nat4 onal population policoy and program. 18. In health, the basic policy objective is to increase life expectancy by continuing to improve access to and efficiency of services and by reducing morbidity and mortality due to communiicable diseases. A recent policy concern is the accelerated development of a regionally equitable, community-based system of primary health care (PHC). This developmnent is intended to be achieved in the context of a decentralized health administration, in which the provincial level assumes more responsibility and community participation is sought. An additional policy objective is to broaden the range of beneficiaries under third-party payment schemes, primarily through greater coverage of health insurance, including the extension of medicare services to all self-employed. The capacity of the health system to provide quality care and improved access to services given financial constraints needs careful examination. Moreover, the establishment of additional barangay health stations (BHSs) with extensive community participation will overstrain MOR's limited capacity to organize community activities. 19. In nutrition, Ehe policy objectives focus on (a) improving nutrition for infants, children and pregnant and lactating mothers; (b) preventing and curing malnutrition; (c) improving the nutritional status of poor families; (d) encouraging the use of indigenous nutritious foods through education; and (e) encouraging Low-cost food production and distribution. The five-year nutrition plan prepared by the National Nutrition Council (NNC) recommends subsidizing high-calorie foods for malnourished members of at-risk families and sets targets for nutritional improvement 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 has lacked continuity of leadership and has had inadequate technical capacity to direct and use operational and policy research. Policy and management decisions have been too often influenced by strong personalities and special interests represented orn the board. Most importantly, it has not been able to develop a field structure effectively linked with the clinic-based service delivery system of the MOH, while still keeping MOH accountable for family planning service delivery. POPCOM's nationwide outreach program was started in 1977 and now has more than 3,000 single-purpose full-time outreach workers (FTOWs) and 50,000 unpaid volunteers providing coverage to an estimated 60 percent of married couples in the Philippines. Sustaining the outreach program (largely funded thus far by USAID) will depend on anadditional central government subsidy, since local governments have been unable to assume the full cost of operating the outreach delivery system. 21. MOH. The services of MOH are delivered through a nationwide network of hospitals, rural health units (RHUs), and barangay health stations (BHSs). A mixture of preventive and curative services is provided by various special. programs. Despite their importance, these programs  -6- absorb only a small share of the health budget. With tightened public eKpenditiure their effectiveness may further deteriorate. Programs to control malaria, schistosomiasis, and tuberculosis require adequate funding to remain effective. iT addition, the rapid expansion nationwide of the recently adopted PHC approach has overextended MOH's management and financial resources. The future status of the special programs vis-a-vis tlhLe PHC program also remains to be clarified. 22. Although the distribution of hospitals is relatively even, almost 40 percent of public hospital beds are in the Manila region. The inclusion o:r about 1,200 private sector hospitals more than doubles the aggregate number of hospital beds to about 82,000, but private sector facilities are mostly in the richer and more urbanized areas. There are about 2,000 FRUs and 8,,000 BHSs in the country. Trhe regional distribution of these facilities is not very uneven, with a coverage of about 60-70 percent cf the population. However, distribution of these facilities within regions is often biased in favor of :Locations more accessible from the towns. At least half the RHUs and BliSs neecl repair or replacement. Health facilities in poorer regions suffer from greater problems of maintenance, equipment and 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 much greater for physicians at RHU5s, and in some regions the lack of rural physicians is acute. Substantial earning differences between public and private sectors and between domestic and foreign markets for Filipino medical manpower partially explain this situation. About two-thirds of the physicians in the Philippines work in the private sector, with more than h'alf concentrated in Manila, Southern Tagalog, and Central Luzon. The MOH has attempted to redress the regional imbalance through a program that reiquires new graduates to spend six months at a RHU, but: this short-term measure has failed to attract physicians into continued public sector employment. This raises the larger issue of government policy in regar,d to health manpower development. Although the private sector largely finances the cost of medical education, there is concern that physician training is not sufficiently responsive to emerging health program needs. Furthermore, difficulty in attracting physicians to staff RHUs suggests the importance of improved training of lower-level workers, who may remain, de facto, the service suppliers in many RHUs. 24. NNC. The national nutrition policy is well articulated, but there is inadequate central coordination of the programs of various participating agencies. Several of these programs are not properly targeted or are technically inappropriate for achieving high impact. The technical support systems of the National Nutrition Council (NNC) also need strengthening. Furthermore, the effective utilization of field workers (specifically the barangay nutrition scholars) is hampered by lack of resources and by duplication and fragmentation of effort at the local level. The nutrition workers are not assigned to any one line agency, and are accountable for multiple sectoral tasks. This multiplicity of organizational affiliations makes it difficult for them to perform their assigned 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 Less satisfactory (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 artificial contraception. Unless immediate and vigorous policy measures are taken to control fertility, there is little possibility of checkirig the rapid increase in population. Increased efforts are also needed for overcoming the 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 of the Philippines (GOP) is needed, along with strengthened implementation capacity. GOP should: (a) as a first priority, set clear demographic targets and commit public resources for a renewed emphasis on fertility reduction; (b) make MOH clearly accountable for improved service delivery in family planning; (c) improve the overall quality of health services provided, and selectively increase access to health services in underserved areas; (d) implement the primary health care program in phases, taking care that existing vertical programs are not adversely affected during the period 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 for selected programs; and (g) for all three sectors, improve central technical support functions, outreach and logistical services, community self-reliance and local government participation. Population 27. In view of the rapid population growth in recent years, its continued high momentum, and the severe economic and social implications of present trends, GOP should give the highest priority to fertility reduction. A strong population control program can have a significant demographic impact even over the medium term (see Annex 2 graphs, comparing the effects of strong, moderate, and weak population programs on annual population growth rate and size). Strong political backing and increased budgetary 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 is a need to strengthen POPCOM's ability to formulate fertility reduction policies, coordinate their implementation, conduct population impact analysis of related socio-economic policies and programs, and monitor program performance of implementing agencies. 28. In order to facilitate POPCOM's coordination of multi-agency efforts, and to strengthen the linkages between GOP's fertility reduction policies and its broader policies for socio-economic development, POPCOM's Secretariat should be more centrally located within the government  - 8 - d.ecision-making structure. GOP should review the structural and repor-:ing relationships between POPCOM's board and higher governraent authorities. In addition, 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 member cf his own interministerial board. Improvements are also needed in thte pol.icy-analysis and planning capabilities of central POPCOM staff, and more focused duties assigned to field staff. 29. To upgrade financial and operational efficiency of the populat4on planning effort, the GOP should reduce fragmentation and duplication of responsibilities assigned to various agencies. One cost effective and viable option appears to be the gradual specialization of the three agencies - MOH, POPCOM, and NNC - to perform centralized technical support functions for an integrated service delivery network at the community level. The MOH should consider, in the medium term, family planning service delivery as one of its primary responsibilities, and should be held fully accountable for it. With regard to rationalization and improvemeni' of technical services, currently the MOH, POPCOM, and NNC have their onM ionformation/educatio.n/commtnication, logistics, and mtanagement information systems, but these suffer from shortages of skilled manpower, materials, aad equipment. Changes in management systems and administrative structures are needed, and should be based on a realistic assessment of institutional capacities so that ongoing programs are not unnecessarily disrupted. 3l0. The regional diff'erences in fertility rates and contraceptive practice could be partly dtLe to unequal access to family planning and maternal and child health services, but also reflect the diversity of contraceptive methods preferred by different regions and socio-economic groujps. To assure more equitable access to services and to maintain program responsiveness to locaL demand, more intensive outreach work shoL.Ild be undertaken, and the present cafeteria approach continued. Local family p:Lanning targets should be expressed in terms of months of effective protection required to attain demographic goals, and not tied to the acceptance of specific contraceptive methods. Furthermore, since more than hallf of married couples of reproductive age (MCRA) de,iring to limit family size are still not using contraceptives, and a large number of users (abcut 64 percent) are relying on inefficient contraceptive mnethods, greater ef'forts should be made to increase protection provided by the more ef'fective methods and to improve the quality of services. The recent trend tciward sterilization should be encouraged by making this inethod more readily available. Health 31. Although the emphasis on PHC is appropriate, the future strategy to be followed for the health sector is still unclear, Priority should be given to increasing access to care in currently under.served areas (especially urban slums and remiote rural areas) and to improving the quality of services. Since the PHC programs critically depend on an efficient health service delivery system, and since the basic health infrastructure is in place, the major issue facing the GOEP is how to overcome present inefficiencies, particularly ineffective support, supervision and referral systems; inadequate health service management; low utilization of RHUs and BHSs; and insufficient outreach activities.  - 9 - 32. Implementing a decentralized PHC program requires strengthening MOR's institutional support and extension services, and developing the implementation capacity of lower-level institutions. Rather than attempting to decentralize all programs simultaneously, a phased implementation of the reorganization plan might be undertaken. In imple- menting PHC, care should be taken to ensure that the gains achieved by MOR's vertical programs and POPCOM's outreach network are not lost. To facilitate change in long-standing bureaucratic procedures, efforts should be made to improve technical and administrative support systems at the provincial level. Adequate delegation of authority, both financial and administrative, should accompany the decentralization of functions and responsibilities. 33. Three agencies (MOH, POPCOM, and NNC) support separate outreach systems, each of which suffers from inadequate resources and manpower. In view of the recent policy of tightening public expenditure and external borrowing, the GOP now has the option of either maintaining the large force of single-purpose outreach workers in each of the three sectors, or developing a unified outreach structure that will enable services to be provided at lower cost but without loss of efficiency. In this context, GOP's recent initiative in promoting community self-reliance and increased local government participation for integrated health, family planning and nutrition programs deserves careful review. An effective, nationwide, village-level, voluntary outreach service is unlikely to be sustainable or responsive to increased demands for PHC services in the absence of monetary and non-monetary incentives for the outreach workers. The MOH should therefore develop an effective support structure for all rural health workers incorporating improved incentives, inservice training, job rotation opportunities between rural health units and front line hospitals, and better support and referral linkages between the public and private health facilities. 34. The MOH and the Ministry of Education and Culture (MOEC) need to undertake a prospective study on the demand and supply for professional health manpower at all levels. Furthermore, health curricula do not adequately prepare health staff for greater roles in primary care and community medicine. Because of this and because of government policy on manpower development, shortages and maldistirbution of manpower are common in rural areas. The GOP should review the salaries and incentives (housing, additional allowances etc.) provided to trained health personnel for serving in understaffed areas. Nutrition 35. The gap between ambitious nutrition objectives and the coverage and effectiveness of existing program activities implies a need for more effective targeting, prioritizing of nutrition programs on the basis of technical and cost effectiveness, and adequate funding to make the selected programs viable. Programs should be targeted to those with the greatest need; for example, the 10 percent of municipalities most affected by malnutrition and the most severely malnourished children. Since the amount of resources actually reaching households with malnourished children is rather small at present, a careful assessment of unmet program needs could make the case for alternative or additional resources in support of well- targeted, technically effective, and high priority nutrition programs.  - 10 - 36. There is inadequate central coordination of programs and insuf.- ficient control over program resources. The nutrition committees used for program planning at the provincial and lower levels are largely ineffective. The Government should carefully examine! the central structure for coordinating the various agencies involved in nutrition programs, the field structure for planning and service delivery, arnd the role of provincial 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'L level. An alternative is to use employees of other line agencies, provided their other duties complement the activities of the nutrition program. Closer ties between the MOH and the MOEC could be useful. In addition, the feasibility of transferring the BNSs' functions to the MOH's community level PRC workers should be considered. Finance 37. Population, health care and nutrition services suffer from scarce financial resources, and the funds presently earmarked for them are like:Ly to be insufficient for ongoing programs and the new 1983-87 Plan priori- ties. This scarcity might be further aggravated by a likely decline in donor assistance for these sectors. The GOP needs to reexamine targets and biUdgets in the light of financial constraints. The financial review of all ongoing and proposed program activities should include detailed analysis of csapital and recurrent costs over the next few years. Since the PHC program is a major initiative, special car,e should be taken to establish the funds required for making it work. Reorientation of public funding toward preventive activities, for which there is a clear rationale for subsidy, is also desirable. 33. Three measures could be taken for alleviating financial short- falls. The first is to utilize available resources more efficiently by reducing functional overlaps, selectively weeding out ineffective programs, and better targeting of program efforts. Second, the GOP should adopt new policies aimed at mobilizing additional resources; in the health sector, for example, this might be accomplished by increasing the fees for services and for hospital care. Also, to encourage promotive and preventive health care, the Government should examine the replicability of pilot experiences oi 'health insurance corporations wlhich are locally owned and jointly controlled by consumers and providers. And third, increased budget a:Llocations should be provided once institutional capabilities are built up and programs with demonstrated success in achieving sectoral goals have been established.  ANNEXES Annex 1 Basic Population, Health and Nutrition Indicators: An Inter-country Comparison 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 2.5 Population projected to year 20001/ 74.8 204.5 20.6 66.1 3.0 Average annual population growth rate 2.5 1.8 2.3 2.1 1.2 Population density per km2 160.0 77.0 44.0 94.0 4,254.0 Percentage of population aged 0-14 39.8 40.0 38.1 38.7 25.6 Percentage of population aged 64 + 3.0 2.0 4.0 3.0 5.0 Percent urban population in 1980 37.0 20.0 32,0 22.0 100.0 Crude birth rate 32.2 31.7 29.4 28.6 17.3 Total fertility rate 4.2 4.0 3.8 3.6 1.7 Crude death rate 7.0 13.3 6.5 7.8 5.3 Male life expectancy at birth 62.6 50.9 64.8 60.6 68.9 Female life expectancy at birth 66.1 53.6 68.6 64.6 75.3 Infant mortality rate 51.0 109.0 41.0 59.0 11.0 Male literacy rate, 1976 77.0 72.0 77.0 89.0 87.0 Female literacy rate, 1976 76.0 49.0 54.0 75.0 66.0 Percent population with safe water2/ 43.0 12.0 62.0 22.0 100.0 Energy consumption per capita, k cals. 329.0 225.0 713.0 350.0 5,784.0 Per capita calorie supply 3/ 107.0 102.0 116.0 97.0 135.0 Annual growth in labor force4/ 2.4 2.1 3.0 2.9 2.7 Doctor to population ratio, 1977 1:2,810 1:13,670 1:2,640 1:8,220 1:1,250 Nurse to population ratio 1977 1:3,170 1:81,870 1:870 1:1,170 1:380 Percent MWRA using contraceptives, 1980 42.0 30.7 45.0 60.0 71.0 Per capita GNP in US dollars 790.0 430.0 1,620.0 770.0 4,430.0 FP 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 and Thailand, dated 1980, 1978, and 1978, respectively. 2) Data from the Population Division, Economic and Social Commission for Asia and the Pacific, Bangkok, 1983. 3) The World Development Report, 1982. 4) The Population Reference Bureau, World Population Data Sheet, 1982.   PHILIPPINES: ALTERNATIVE POPULATION PROGRAM SCENARIOS 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