Improving early childhood development : an integrated program for the Philippines

DIRECTIONS IN DEVELOPMENT lmproving Early Childhood Development An Integrated Program for the Philippines RICHARD A. HEAVER JOSEPH M. HUNT .1~~A , ji - q. A collaborative report by Lhe World Bank and the Asian Deelopmenr Bank for the ~ Goverrnent of the Republic of the Philippine   Improving Early Childhood Development An Integrated Program for the Philippines  IBRD 27407 Administrative Regions: I llocus PHILIPPINES CAR Cordillera Adm,inistrative Regio r Natio l capital 11 Ciagayan Valley / I -- Region boundaries III Central Lu.zon '1CAR NCR National Capital Region j ) .E. ____- a IV ..o.thernmlagalog ( ,} V icol B / VI Western Visayas VII Centr,l Visaya,s Vil Eastern Visava.s NCRttMani IX Western Mindana- / X Northern Mfiodanao / IV v XI Southern Mindanao XII Central Mii3danao I K ARMM tAutonomous Region .o A uslim Mindan-o / - / ,I___ / \ Vll|Vill / VII xx~~~~~ . _ _ _ _ _ _ -AtI IP I E \_ f f ARMM \ARMM ARMMNv *1A ARMM\ KK,, , 1 TE:, ,.,S ...... ,,,./,.., ,,t: m,, .,t 1,h , ve1................... 1 lf3Sr; to., ;'-) I'na~rZ S-N'l 1 Il'n I.sd, ,5hil  DIRECTIONS IN DEVELOPMENT Improving Early Childhood Development An Integrated Program for the Philippines Richard A. Heaver Joseph M. Hunt A collaborative report by the World Bank and the Asian Development Bankfor the Governmenit of the Republic of the Philippines The World Bank Washington, D.C.  C 1995 The International Bank for Reconstruction and Development / THE WORLD BANK and the Asian Development Bank All rights reserved Manufactured in the United States of America First printing November 1995 The findings, interpretations, and conclusions expressed in this study are entirely those of the authors and should not be attributed in any manner to the World Bank or the Asian Development Bank, to their affiliated organizations, or to members of their Boards of Executive Directors or the countries they represent. Cover photograph by Curt Carnemark. ISBN 0-8213-3350-X  Contents Foreword vii Acronyms and Abbreviations ix Glossary x Overview 1 The Situation of Preschool Children in the Philippines Government Policies, Goals, and Intervention Programs 6 Strategy Issues 11 Financing a Strengthened ECD Program 19 Recommendations 22 Notes 24 1. Introduction 25 What Is Early Childhood Development? 27 Why Should the Government Invest in Early Childhood Development? 32 2. The Situation of Children in the Philippines 43 Developmental Status 43 Causes of Disadvantage 48 The Worst-off 63 Implications for Action 65 3. Government Policies, Goals, and Intervention Programs 71 Child Development Policies and Goals 71 Health Intervention Programs 73 Nutrition Intervention Programs 80 Early Education 94 v  vi CONTENTS 4. Creating an Integrated, National Early Childhood Development Program 106 An ECD Program Model 107 Community and NGO Participation 114 Program Management under Devolution 121 Central Support and Direction 127 Conclusions 133 5. Financing Early Childhood Development 135 Trends and Levels in Spending 135 Six-Year Financing Needs 141 Sourcing and Sustaining the Financing 153 Conclusions 161 Note 162 Bibliography 163  Foreword This book is a joint product of the World Bank and the Asian Development Bank (ADB), and of a consultation process with key members of the child development community in the Philippines. It is based on a report that was produced to help in the preparation of a national investment plan for early childhood development (ECD). This is the first time either development bank has done a country study that looks at ECD in an integrated way, across health, nutrition, and early education. It is hoped, therefore, that this book will be of interest to the international child development commu- nity, as well as in the Philippines. The first draft of the report was based on the findings of a joint mission in March 1994. Team members were Richard A. Heaver, IBRD (mission leader and management specialist); Joseph M. Hunt, ADB (ADB team leader and economist); ADB consultant Keith McIn- nes (financial analyst); and IBRD consultants Rosendo Capul (public health), Sony Chin (nongovernmental organizations and commu- nity participation), John Kevany (nutrition), and Fred Wood (early education). During this mission a workshop was held with leading specialists in child development in the Philippines, including gov- ernmental and nongovernmental organizations and the United Na- tions Children's Fund, to define the main issues on which the report should concentrate. A second workshop with similar partici- pants was held in Manila in September 1994 to provide reactions to the first draft. Both workshops were chaired by the Philippine Council for the Welfare of Children. The current version of the report, on which this book is based, took into account comments from the second Manila workshop as well as comments by review- ers from inside and outside the World Bank at review meetings in Washington, D.C., in July and December 1994. The broad findings of the report were endorsed by a steering committee-consisting of representatives of the main government agencies involved in ECD in the Philippines-that was tasked with developing a proposal for a national ECD program. Institutions vii  viii FOREWORD represented on the steering committee include the Department of Health (chair); the National Council for the Welfare of Children; the National Nutrition Council; the Department of Social Welfare and Development; the Department of Education, Culture, and Sports; the Nutrition Center of the Philippines; the Department of Interior and Local Government; and the Museo Pambata Founda- tion. The findings helped the committee to prepare an ECD strategy paper for submission to the Social Development Committee, a high-level Philippine policymaking body, seeking endorsement of an integrated national ECD program. Although the report was broadly endorsed by the steering committee, the specific findings in this book and the levels of investment proposed represent the recommendations of the joint team, rather than the position of the government of the Philippines. To provide a smaller, more accessible volume for the nontechni- cal reader, the eleven annexes to the report are being published in a separate companion volume, Supplenmefit to Imryroving Early Chtild- hood Development. The authors gratefully acknowledge the contribution of all those in the Philippines and in the international agencies, as well as each member of the mission team, who provided data, shared their views about issues and priorities, and commented on drafts. Errors and omissions remain the responsibility of the authors alone. Children represent the future of the nation. This book is dedi- cated to the many Filipinos who are working for the cause of chil- dren, in the hope that preschoolers, especially the disadvantaged, will have a better future. Callisto E. Madavo Dinh X. Vinh Director, East Asia and Pacific Director, Agriculture and Country Department I Social Services Department (East) Thte World Bank Asian Developmnent Bank  Acronyms and Abbreviations ABCSD Area-Based Child Survival and Development ADB Asian Development Bank ARMM Autonomous Region of Muslim Mindanao CAR Cordillera Administrative Region CODE-NGO Caucus of Development NGO Networks Cwc Council for the Welfare of Children ECD Early childhood development EPI Expanded Program on Immunization FNRI Food and Nutrition Research Institute GDP Gross domestic product GMP Growth monitoring and promotion GNP Gross national product IALDM Integrated Approach to Local Development Management IEC Information, education, and communication IRA Internal Revenue Allotment IRS International Reference Standard for Growth NCR National Capital Region NEDA National Economic and Development Authority NGO Nongovernmental organization NNC National Nutrition Council ORT Oral rehydration therapy PEM Protein-energy malnutrition UNICEF United Nations Children's Fund USAID U.S. Agency for International Development WHO World Health Organization ix  Glossary Barangay The lowest level of local government, roughly equiva- lent to village; contains an average of 1,500 people (within a very wide range). Municipality The local government level (both urban and rural) between a province and a barangay; contains an average of 20,000 people (within a very wide range). x  Overview The situation of children in the Philippines is considerably worse than it need be for a country of its per capita income. Ill health, malnutrition, and poor psychosocial development among pre- schoolers are costing the country substantial amounts in terms of premature deaths, permanent disabilities, and lost productivity and income. The benefits to the nation of improved child develop- ment greatly outweigh the costs. However, the benefits will arise over a long period, whereas making the investment in children is an immediate priority. The cost of inaction is high. Every year lost can be measured in deaths, disease, and often permanent disabilities. This book argues that the Philippines should be investing more in child development and that doing so will have a high payoff. The objective is to convince those who control resources in the central and local governments, and in the nongovernmental and donor communities, that they should finance an integrated invest- ment package that has a real prospect of meeting the national goals for children. The technologies for program design and implementa- tion are well-enough known, the finance can be raised or reallo- cated, and the goals can be achieved-if the commitment of the government as well as the nongovernmental and donor communi- ties can be crystallized around a shared vision of what needs to be done. The Situation of Preschool Children in the Philippines Healthl In the Philippines two of every three preschoolers who die are infants. The infant mortality rate is about 57 per 1,000 live births. During the 1980s the infant mortality rate declined much more slowly than in other East Asian countries. For example, although Thailand and the Philippines had similar infant mortality rates in the 1960s, Thailand's rate is now only about 30 per 1,000. The main 1  2 IMPROVING EARLY CHILDHOOD DEVELOPMENT causes of infant and child deaths are pneumonia and other respira- tory diseases; bronchitis, influenza, and diarrhea are the leading childhood diseases. Most of these deaths are preventable, and most of these diseases are treatable with cheap, simple technologies. Child health has improved more slowly in the Philippines than elsewhere for a number of reasons. The deep economic recession and years of slow growth of the 1980s limited the access of the poor to public health services. Little was spent on the key primary technologies until the Aquino and Ramos governments came to power. Underinvestment in sectors outside child health, but which powerfully affect child health, also played an important part. Slow progress with the family planning program took a heavy toll in children's lives; it has been estimated that the infant and child mor- tality rates would decline by as much as 25 percent if pregnancy were avoided by women who are under 20 and over 45, women who have four or more children, and women who are within fif- teen months of their last birth. There was also underinvestment in controlling protein-energy malnutrition (PEM, which depresses the immune system; severe PEM can increase the risk of death by up to eight times. Recent research has shown that even moderate PEM, the degree of severity most common in the Philippines, is associated with increased dis- ease and death rates; it is estimated that nearly half of infant and child deaths in the Philippines are the combined result of infection and malnutrition. Gains from further investment in child health programs may therefore be limited unless accompanied by equally determined efforts to improve nutrition. Nutritioni The commonest form of malnutrition in the Philippines is iron defi- ciency anemia, which affects more than 40 percent of pregnant and lactating women and about 50 percent of infants. These levels may increase further once the new international standard for measuring anemia, recently adopted by the World Health Organization (WHO), has been adopted in the Philippines. This deficiency ad- versely affects children's growth and performance, including intel- lectual development. Iodine deficiency remains a serious problem in parts of the country, leading to cretinism, mental retardation, reduced learning capacity, and hearing loss in infants and children. Vitamin A deficiency is mostly now at subclinical levels, but even this remains a problem because of its recently discovered links with mortality. Micronutrient deficiencies result mainly from low  OVERVIEW 3 dietary intakes: for anemia and vitamin A, through eating too few micronutrient-rich fruits and vegetables and, for iodine, because of geological conditions. Anemia is also exacerbated by iron loss caused by parasites-malarial, schistosomal, and helminthic-in ecological zones where these are prevalent. During the 1980s, PEM declined more slowly in the Philippines than in not only the better-off countries of East Asia (Malaysia, Thailand) but also the poorer countries of South Asia (Bangladesh, India, Pakistan). Different kinds of standards are used to define the magnitude of PEM. By the Philippines Reference Standard, about 11 percent of children under 60 months old were underweight in 1992; by the International Reference Standard, endorsed by WHO, 33 per- cent were underweight. Using the International Reference Stand- ard, which makes international comparisons possible, PEM in the Philippines in 1992 was worse than in poorer countries such as Egypt, Kenya, Tanzania, and Zimbabwe. Data from the 1993 Philippines National Nutrition Survey indicate that, by the Philip- pines Reference Standard, PEM had fallen to about 8 percent of children under age 6. This percentage would equate to about 29 percent by the International Standard. The continuing decline is encouraging, but the absolute amount remains a significant cause for concern. PEM is often thought to result simply from poverty and lack of purchasing power for food. In the Philippines, household food in- security affects 20 percent of families and is certainly an important factor in PEM. But so, also, are poor child health and poor caring practices for children. Wasting (low weight for height, which indi- cates current malnutrition) in preschoolers peaks between the ages of 6 months and 2 years and then, in most families with a nutrition problem, declines just when children are getting more expensive to feed. The peak around weaning reflects both the incidence of infec- tion and inadequate weaning practices, even in families who can afford the food. It is likely that most mothers feed their children too little because they do not realize their children are malnour- ished; moderate PEM is not easily visible to the untrained eye. The multiple causes of PEM have important implications for policy. Many policymakers favor livelihood-creation programs as the solution for the nutrition problem. But investment in health care and efforts to improve caring practices are also essential. A key intervention is an effective program to monitor and promote growth. Such a program permits parents to recognize malnutrition and the positive effects of feeding affordable, additional amounts of food.  4 IMPROVING EARLY CHILDHOOD DEVELOPMENT Early Education There is very little survey data that directly measure children's psychosocial development. But indirect evidence from surveys of performance in elementary school is worrying. Although 99 per- cent of Filipino children are enrolled, dropout rates are unaccept- ably high. Only 68 percent of grade I entrants actually complete elementary school, with 60 percent of the dropout occurring in grades 1 and 2. Also, test results for those staying in school are lower than for other East Asian countries. It is not known how much of the dropout and poor learning performance should be attributed to poor school readiness, how much to poor teaching in elementary school, or how much to other factors. But high dropout rates and poor performance in school must be due in part to inade- quate school readiness among Filipino children-readiness in their ability to deal with different ways of learning, their socialization with large groups of children their own age, and their language skills. As noted above, persistent poor health and malnutrition are themselves important causes of inadequate psychosocial develop- ment. They can inhibit the development of intelligence and of neu- rological and psychomotor systems, and they make children less active and less responsive to stimulation. Other important influ- ences are the amount of attention children receive from caregivers, the interaction they have with other children, and the richness of their environment. There is little solid data on any of these factors in the Philippines. In general, the families least likely to be able to provide for their children's developmental needs are the very poor, particularly those who have migrated to urban areas and are with- out extended family support systems to help with childcare. One study of women's work and infant care in Cebu showed that nearly 60 percent of mothers worked outside the home and that poor women with several preschoolers were the mothers most likely to be working outside the home. The Worst-off Depending on where they live and what type of family they come from, children are subject to different types and degrees of risk. Risk factors may be demographic (being an infant with closely spaced siblings), related to income (being the child of a poor, land- less laborer), environmental (living in an area with malaria or un- protected water supplies), geographic (living in a mountain area or a coastal community only reachable by water), related to peace and  OVERVIEW 5 order (being underprovided with services because of past armed conflict) or cultural (living in indigenous communities, which also have poor access to services). Families are worst-off usually because they suffer from combinations of such risks. In the Philip- pines, the worst-off areas in terms of high infant mortality and PEM rates are Bicol and Western Visayas; the best-off are the Na- tional Capital Region (NCR), Mindoro, and Region III in northern Luzon. But in terms of numbers of disadvantaged children, the picture is different: the worst-off include not only Western Visayas and Bicol, but also the NCR, Region I in northern Luzon, and Mindoro. Implicationsfor Action To best design and target interventions, better data are needed in several areas. On the technical side, improvements are needed in disease surveillance and in measuring iron deficiency, PEM in pregnant and lactating women, and psychosocial development. For targeting purposes, better data are also needed on the most disad- vantaged, including studies of their risk profiles, and better mecha- nisms are needed for identifying disadvantaged children scattered among populations of the better-off. Growth monitoring and household asset surveys appear to be cost-effective ways to collect these kinds of data. The nature of child development problems in the Philippines suggests that the main priorities should be programs for: * Child survival, with special attention to maintaining the Ex- panded Program on Immunization, acute respiratory infection control, oral rehydration therapy, and interventions aimed at neonatal mortality . Disease control, with special attention to diarrhea and pneu- monia nationally and to malaria, schistosomiasis, and helminth control in heavily endemic areas . Deficiency control, for iron, vitamin A, and iodine among pregnant and lactating women as well as children * PEM control, focusing on food security and behavioral change and on pregnant and lactating women as well as children . Early education, for disadvantaged children (however, the lack of hard data makes it difficult to determine the appropri- ate extent and type of intervention) . Maternal care and birth-spacing, aimed at improving mothers' health and nutrition and reducing infant and child mortality and malnutrition  6 IMPROVING EARLY CHILDHOOD DEVELOPMENT . Water supply and sanitation, in areas where limited coverage leads to high diarrhea rates. Government Policies, Goals, and Intervention Programs The Philippines has a set of laws and policies, including a national Plan of Action for Children, that strongly support child develop- ment. The government's qualitative and quantitative goals for the survival, protection, and development of children are clear and ambitious. Between 1990 and 2000 the goal is to reduce the infant mortality rate to 37.6; to halve the prevalence of PEM among pre- schoolers; to reduce low birth weight to less than 10 percent; to virtually eliminate vitamin A and iodine deficiencies; and to estab- lish a preschool center in every barangay. To be most effective, early childhood development programs should attempt to integrate interventions in health, nutrition, and early education so as to respond to children's needs in a holistic way. Some of the strategy issues that cut across these three sectors are discussed in the following section. But first the existing pro- grams in health, nutrition, and early education are reviewed sepa- rately because, until the recent devolution,I they have mainly been seen-and managed-as separate programs. Only the nationwide programs are reviewed, because the success or failure of these large-scale programs will determine whether the nation's child de- velopment goals are achieved. There are also a number of small- scale projects and programs in the Philippines that have attempted to integrate health, nutrition, and early education interventions and from which much can be learned about how to strengthen the national programs. Health Programs During 1991-93, health services were devolved to local govern- ments. Now most of the hospitals are controlled by the seventy- seven provincial governments, and most public health services by the more than 1,500 municipalities. At the periphery, the key health worker is the rural health midwife, of which there is one for every 5,000 people on average, and one for every 2,000 to 3,000 people in most poorer provinces. Rural health midwives are as- sisted by barangay health workers. These volunteer workers help for two or three hours a week encouraging community participa- tion in health campaigns and providing health education. A typical barangay of 1,500 people might have ten such volunteers, of whom half might be active workers.  OVERVIEW 7 The various child health programs have had different impacts, depending on the levels of commitment and funding they have had, how difficult their technology is to manage, and how long they have been established. The immunization program has been the most successful; strong commitment and ample funding have increased coverage to more than 90 percent. The diarrhea program has been the next most successful, with oral rehydration being used in 50 to 60 percent of cases. But more needs to be done to promote home prevention and management of diarrhea. The con- trol of acute respiratory infections is a newer technology. This pro- gram was launched only five years ago. Much training has been done, but the current monitoring system has not been able to deter- mine how far the new case management system is being followed in the field. Financing for expansion of the program is uncertain. Although support from the United Nations Children's Fund (UNICEF) will continue, assistance from the U.S. Agency for Interna- tional Development (USAID) and the World Bank for acute respira- tory infection control and other child survival interventions was scheduled to end in late 1994 or early 1995. In contrast to the earlier, weak commitment to family planning, the Department of Health has now made the program for family planning, women's health, and safe motherhood its flagship pro- gram and is implementing two major, donor-supported projects to support it. Although efforts to improve and expand family plan- ning should greatly affect infant mortality, more needs to be done to reduce the 35 percent of infant deaths that occur in the first month after birth. With the government's increasing commitment to the child survival program and to women's health and family planning, the rural health midwife's workload is growing steadily. This increase implies the need to carefully review the ratio of field staff to population. It also implies the need for more systematic plan- ning of the rural health midwife's time and the division of labor between her, the barangay health workers, and the doctors and nurses in the health centers. Efficiency would increase if fieldwork- ers' time were focused on providing integrated services to the cli- ents who are most at risk and at the times when they most need assistance. Except for interventions to reduce deaths in the first months of life, the technical strategies for child health interventions are well developed. The main constraints are institutional and finan- cial. Since devolution there have been varying degrees of commit- ment and resource allocation, and at least in some local governments there are worrying signs that the delivery of public  8 IMPROVING EARLY CHILDHOOD DEVELOPMENT health services is beginning to falter. On the financial side, local governments inherited a series of child health programs that varied in their stage of development and effectiveness and still suffered from the legacy of underfunding of primary care during the 1980s. Substantial additional resources are required to consolidate these programs. Nutrition Programs At least eight agencies are involved in implementing nutrition pro- grams. Foremost are the Department of Health and the Department of Social Welfare and Development. The Department of Health is responsible for the micronutrient program and for growth monitor- ing, as well as for nutrition education and supplementary feeding for pregnant and lactating women and children under age 4 (age 0 to 36 months). The Department of Social Welfare and Development runs a nutrition program, including supplementary feeding, for the 4- to 6-year-olds. At the periphery, the same rural health midwives and barangay health workers who are responsible for health are also responsible for nutrition. They are assisted by barangay nutri- tion scholars-volunteer workers with very small allowances (mostly not more than P50 [less than $212 a month) who work for one or two hours a day on growth monitoring, supplementary feeding, micronutrient distribution, and nutrition education. On average, there is one barangay nutrition scholar for every three barangays in the country. The Department of Health, with good support from local govern- ments, has launched major campaigns promoting vitamin A and iodine supplementation, and coverage rates are rising fast. Iron supplementation does not lend itself to the campaign approach for implementation because iron supplements have to be taken daily or weekly. The Department of Health therefore plans to improve the delivery of iron to pregnant women in the context of its women's health and safe motherhood program. Anemia also must be attacked through well-targeted efforts to control parasitic dis- eases, but more work is needed to define the areas of highest prevalence and to develop appropriate interventions. Efforts to fortify staples with key micronutrients and to change dietary habits have moved less fast than supplementation interven- tions. Fortification has suffered from an ad hoc approach and would benefit from technical assistance to develop industrywide plans and the capacity to design, monitor, and evaluate the fortifi- cation program. The emerging overload on field staff, coupled with  OVERVIEW 9 their inadequate training, is making it difficult to promote dietary change seriously. Most cases of PEM in the Philippines are moderate rather than severe and hence not easily visible to the untrained eye. Growth monitoring is an essential tool for showing parents that their chil- dren are malnourished and that malnutrition responds quickly to feeding small additional quantities of food. For the same reason, short-term supplementary feeding of growth-faltering children is also useful. However, the growth promotion program in the Philip- pines has not worked well. Growth monitoring is often infrequent and of poor quality, as is counseling. Food supplementation has not been adequately targeted on the 0- to 24-month age group most at risk, food supplements for children are often taken home and shared with other family members, and many children stay in the feeding program for six to twenty-four months, thus encourag- ing dependency on it. There have been ambivalence and lack of understanding as to whether supplementation is a growth pro- motion intervention to educate parents about better childcare or a food security intervention to provide a safety net for the very poor. Managing an effective growth promotion program focusing on children under 3 in a barangay of about 1,500 would take a worker four to six hours a day, six days a week. This kind of time commit- ment cannot be expected from volunteers. It is therefore recom- mended that a part-time community worker in each barangay be hired to run this program, with an allowance of about P750 ($27) a month. Existing barangay nutrition scholars could be used for the program where suitable. The food supplementation program has depended heavily on U.S. Public Law 480 (PL 480) food aid, which is to be phased out in the next few years. We recommend that a suitable, locally pro- duced weaning food be substituted for the PL 480 commodities and that the supplementation program be reoriented to focus on on-site feeding for at-risk pregnant women and 0- to 24-month- olds, the highest risk group. A separate intervention will be required for families in which child malnutrition is the result of food insecurity rather than, or in addition to, poor health care and poor feeding practices. These families can be identified through household asset surveys, and the appropriate intervention will be an income supplementation pro- gram, such as food stamps or job creation through public works. At present the National Food Authority spends P2 billion3 to P3 billion ($71 million to $107 million) a year to finance a generalized  10 IMPROVING EARLY CHILDHOOD DEVELOPMENT food subsidy, which has been shown to do little or nothing to im- prove the nutritional status of the poor. These funds would be better reallocated to finance effective growth promotion and food security programs of the above type. In contrast to its commitment and initiative in micronutrient malnutrition, the government has mounted no comparable effort to improve the PEM control program. Despite a continuing reduction in PEM rates, moderate malnutrition, as measured by international standards, still affects more than a quarter of preschoolers. And given the close links between PEM and child deaths, continuing slow progress in reducing PEM may also threaten the achievement of national goals to reduce mortality. The proposed rapid phaseout of the PL 480 program will precipitate a reorientation of the nutri- tion program. It is essential to use this reform opportunity to re- design the nutrition program to benefit the most vulnerable: pregnant women and very young children. Reducing PEM will re- quire not only livelihood-creation programs, as currently empha- sized, but also a revamping of the growth promotion program and the creation of a new and more efficient, targeted food security intervention. Early Education Programs Before devolution the Department of Social Welfare and Develop- ment, through the Day Care Center Program, was the main govern- ment provider of early education services. As with health and nutrition programs, this program has now been devolved, and lo- cal governments are legally required to provide it. Although called a day care program, the Day Care Center Program is really a pre- school program, because it takes children for only two to three hours a day. Its coverage has been expanding very rapidly, from 13,900 centers in 1991 to more than 18,000 in 1992, but the program still covers less than half of all barangays. The key peripheral worker is the day care worker, who is responsible for a day care center serving about sixty 4- to 6-year-old children in a barangay, about 45 percent of the population of that age group. Day care workers receive an allowance ranging from P500 to P1,000 ($18 to $36) a month and are supervised by social welfare workers at the municipal level. In addition, the Department of Education, Culture, and Sports runs about 2,900 preschool classes for 6-year-olds, using its exist- ing school buildings and teachers. (Elementary education in the Philippines has in the past not begun until age 7, but the govern- ment recently decided to extend entry to 6-year-olds.) The depart-  O V E R V I E W 11 ment has also recently allocated a small amount of money to begin a new community-based preschool program for 4- to 6-year-olds, bringing to the fore the question of how responsibility for early education should be divided between agencies. Given that the De- partment of Education, Culture, and Sports will be preoccupied with expanding elementary school and has no comparative peda- gogical advantage in preschool, and given that the Department of Social Welfare and Development already has a very substantial preschool infrastructure, it seems sensible to upgrade the day care centers to become the national public sector preschool program for 3- to 5-year-olds. It is generally agreed that the quality of the day care centers is low. Learning materials are in short supply, workers are gener- ally poorly trained, and in some areas workers are not receiving a sufficient financial incentive for good-quality work. A variety of measures are needed to improve the program: improving curricu- lum content, developing minimum acceptable standards for a day care center, creating a new training capacity, raising day care workers' allowances where these are less than P1,000 ($36) a month, limiting the number of children in each class to no more than twenty, and adding a social welfare worker in each mu- nicipality to ensure good-quality supervision and on-the-job training. To increase the outreach and equity of the program, satellite home-based centers, serving six or seven children, could be developed where poor clients live outside easy reach of the village center. It is difficult to assess how effective the operation of the early education program is because systematic evaluation is not taking place. This situation needs to be remedied as a priority. But it is clear that the quality is low and that most local governments are preoccupied with expanding the number of centers rather than making them work well. If the quality is to be improved, local governments will have to have an assistance package in which the local government would undertake to improve quality according to measures that have been agreed on in return for technical, finan- cial, and training assistance from the Department of Social Welfare and Development. Strategy Issues This section begins by summarizing some technical, institu- tional, and financial issues that are specific to nutrition and to early education. The subsequent issues-the overriding ones in child development-all relate to how the government can integrate  12 IMPROVING EARLY CHILDHOOD DEVELOPMENT what is now essentially a series of vertical interventions into a child development program that responds to the needs of the child as a whole. Cross-cutting issues include how to target the most disadvantaged and provide integrated services to them, how to maximize the contribution of local communities and nongovern- mental organizations to the program, and how to manage the pro- gram under devolution. Strategies for Reducing PEM As noted above, the current nutrition strategy has not reduced moderate malnutrition to acceptable levels. Several changes in strategy appear to be required. First, the growth promotion pro- gram at the barangay level seems unlikely to succeed unless nutri- tion workers are better trained and paid a financial incentive commensurate with the time it takes to do good growth monitor- ing, counseling, and supplementary feeding for a large population of malnourished mothers and children. Second, with the phasing out of PL 480 resources, the government will need to take financial responsibility for the supplementary feeding program. Further- more, it will need to retarget the feeding program to the neediest women and children to make sure the additional expenditure is used as efficiently as possible. Third, the growth promotion pro- gram will need to be complemented by an effective nutrition safety net program for the food insecure, perhaps through a food stamp or public works program. These three changes will together require a significantly increased financial commitment to the nutrition program. Such a commitment is affordable for a country with the Philippines' per capita income; poorer countries such as India have already been able to put na- tional PEM programs with similar strategies and financial require- ments into place. Nevertheless, putting additional resources into the PEM program will be difficult, given the current fiscal constraints. Because the government is already spending, unproductively, an amount on a generalized food subsidy that would be enough to finance the recurrent costs of reorienting the PEM program along the above lines, the most efficient financing option would be to reallo- cate resources currently going to the National Food Authority. The Government's Role in Early Education Although the government's role in financing a minimum package of health and nutrition services is well accepted in the Philippines, its financing role in early education is more controversial. The  OVERVIEW 13 key issues center on the role of government in early education and day care-the areas that involve significant capital and recurrent costs. Data on the cost-effectiveness of preschooling in the Philip- pines are very weak. A recent study concluded that preschooling reduces the dropout rate from school and improves the perform- ance of those who stay in school. But the study did not look at the cost or quality of the existing system or analyze the relative cost-ef- fectiveness of different approaches. Given the uncertainties about relative cost-effectiveness and the best way to design a preschool program in the Philippines, we conclude that not enough is known for the government to fund a program of universal preschooling. To determine whether the government should do so, a longitudinal cost-effectiveness study of different approaches to preschooling should be undertaken. Despite uncertainties about funding universal preschooling, a case can be made for the government to improve the quality and coverage of the existing day care center program, provided that the most disadvantaged children in each barangay get access to the program and that the day care center become a convergence point for all early childhood development (ECD) services in the barangay and hence be used to maximize the synergy of health, nutrition, and education interventions. The poor cannot afford to send their children to private sector preschools. But the study of preschooling mentioned above did unambiguously show that going to preschool reduces the likelihood of poor children dropping out of elementary school to the point where they are no more likely to do so than the children of the better-off. From an equity perspective, an already mandated intervention that significantly narrows the differential between poor and rich should receive continued public sector sup- port until there is hard evidence that an alternative approach is more cost-effective. The situation with regard to day care for the children of working mothers is different. Here the potential role for the private sector is much greater. In addition to providing long-term benefits to soci- ety, day-long day care (as opposed to the two to three hours of preschool offered by the so-called day care program) offers imme- diate financial benefits to parents because it frees their time to en- ter the labor market or to take a higher-paying job outside the home. Private sector, home-based day care has been shown in other countries to be both financially viable and equitable; low overheads mean that the service is affordable even for poor women, and the centers themselves generate additional employ- ment for poor women. But this system is not yet widespread in the Philippines. Therefore a case can be made for the government to  14 IMPROVING EARLY CHILDHOOD DEVELOPMENT provide seed money and technical support for demonstration home-based day care centers so that poor women are aware that they can be both users and providers of the service. Targeting Field Services The government has ranked provinces in terms of disadvantage using a weighted indicator that includes measures of illiteracy, infant mortality, malnutrition, sanitation, and the head count and poverty gap definitions of poverty. This mechanism for geographic targeting is proposed as the main way to allocate additional re- sources for antipoverty programs. But, as noted above, many dis- advantaged children in better-off regions of the country, such as the National Capital Region and Mindoro, will be neglected if this targeting mechanism is applied to the ECD program. Thus the gov- ernment should adopt alternative targeting mechanisms that are able to select the most disadvantaged and the most at risk from among populations of the better-off throughout the country. Given the difficulties of using income as a targeting mechanism, and given that low income often inadequately predicts which fami- lies will have an at-risk child, a two-step, non-income-based target- ing mechanism should be used. The first step identifies those women in each barangay who are pregnant or lactating, as well as all children under 6, as the members of the population who are at the most vulnerable period of the reproductive cycle from a devel- opmental perspective. This would be the broad target group on which fieldworkers should concentrate their time. The second step identifies families within this group that are actually or potentially most at risk by measuring PEM status and family assets as proxies for the whole range of indicators of disadvantage. The Convergence of Field Services Evidence from around the world clearly shows that ECD programs that integrate health, nutrition, and early education interventions have more impact than those aimed at one aspect of child develop- ment alone. This is because disadvantage in one aspect of develop- ment reinforces disadvantage in another (Box 1). Children who are malnourished are more likely to fall ill, and vice versa. And chil- dren who are malnourished or ill learn more slowly. The mutually reinforcing nature of child development problems means that inte- grated programs benefit greatly from synergy. Strategies to ensure the convergence of services in the field assume particular impor- tance in this context.  OVERVIEW 15 Box 1. Interrelation of Health, Nutrition, and Education on Early Childhood Development Health impacts on nutrition * Severe or multiple acute respiratory infections and fevers lead to weight loss. * Severe or repeated diarrhea and associated dehydration reduce nutrient uptake and lead to weight loss. * Heavy parasite loads (intestinal, malarial, schistosomes) reduce nutrient uptake. Nutrition impacts on health * Children not eating enough have weakened immune systems and are more likely to get infections and die. * Vitamin A-deficient children also have weakened immune sys- tems and are more likely to be ill and die. Health and nutrition impacts on psychosocial development and learning * Children with iodine deficiency have lower IQs. * Malnourished and frequently ill preschoolers are listless, play less, learn less at home, and become less well socialized. * Malnourished and frequently ill children have poor school at- tendance and are more likely to drop out. * Malnourished children have shorter attention spans and less learning capacity in class. Preschool impacts on school * Children who have been to an organized preschool are better socialized and adjust more quickly to elementary school. * Children who have attended preschool are likely to progress more quickly and achieve better test results, particularly in the early primary grades. * Children who have attended preschool are less likely to drop out in the course of primary school. Because of devolution, and for the first time, the key ECD work- ers at the barangay level now all report to one authority at the city or municipal level. Advantage needs to be taken of this new oppor- tunity to integrate services. In the past, the delivery of ECD services was split among several agencies, and heavy reliance had to be placed on interagency committees to coordinate the integration of services. Interagency committees are a relatively weak mechanism  16 IMIPROVING EARLY CtHILlDHOOD DEVELOPMENT for changing the behavior of workers in the field. Now that the management of service delivery for all ECD interventions is inte- grated at the local government level, the convergence of services can be approached through the more effective mechanism of rede- signing both the job content of workers at the periphery and the way in which supervision and on-the-job training are carried out. The job content of the proposed new child development worker for children under age 4 and of the existing day care worker should be designed so that each can provide the full range of core ECD services appropriate for the age group for which the worker is responsible. In practice, because children's needs are different at different ages, the child development worker would spend more time on health and nutrition, and the day care worker would spend more time on organized preschool activities. Much could also be done to integrate supervision and training: redesign supervision routines so that health, nutrition, and social welfare staff make some joint visits and attend staff meetings together; develop a com- mon core curriculum for training child development workers and day care workers; and have an integrated team of health, nutrition, and social welfare staff provide training. Participationi by Commuiiiiinities anid Nonigovernmenetal Organiizationls For communities and nongovernmental organizations (NGOs), par- ticipation in development programs can vary from simple consul- tation, through involvement in program monitoring, to full-scale program management. A systematic process of consulting witlh dis- advantaged communities, using structtured interviews and focus groups, needs to be set up, preferably using the skills of NGOs that have the confidence of client communities. These consultations should be used to gain a better picture of communities' preferences and needs and to develop options for ECD programs appropriate for different circumstances. Also, communities and NGOs could be given a greater role in monitoring programs. For example, they could post key program performance information at dav care cen- ters. And communities could be involved in "verbal autopsies"- inquiries into what went wrong witlh the ECD program in the event of a preventable child death. Government funds should also be used to finance ECD interven- tions jointly planned and managed by local governments, commu- nity organizations, and NGOs along thie lines of the Community Health Partnerships already set up by the Department of Health. Where experienced NGOs exist and can help intermediate between  OVERVIEW 17 local governments and communities, these partnerships are likely to be the best mechanism for developing the Child Development Program Agreements proposed below and for ensuring that they reflect local priorities. Outstanding NCOs could also greatly in- crease their impact if given more opportunities to leverage their resources and expertise by helping other institutions expand and improve their quality. They could help in consultations with local governments and communities; with curriculum development and training; with experimenting with and evaluating different ways to deliver services, especially in early education; with developing the institutional capacity of other NGOs; and with policy analysis and evaluation. The for-profit NGO sector is most active in preschool education. The Department of Education, Culture, and Sports has accredited more than 1,300 private preschools, and it is believed there may be several times that number of small, unaccredited preschools and day care centers. The government's main current involvement is with accreditation. A more proactive role is recommended, includ- ing experimentation with technical assistance and training to im- prove the quality of private preschools and, more radically, with financing private sector preschools on a contract basis. But the cost- effectiveness of private sector support and provision needs to be carefully evaluated before applying such approaches nationwide. Progrann Managenwenit iwititer Devoluttion Most provincial and municipal governments took over child devel- opment and other social services with very little experience in how to manage them. There are few data as yet on how they have per- formed or how spending behavior in the social sectors has changed. However, there is some concern that public demand for clinical care and new day care centers may cause priorities to shift at the expense of outreach care and program quality. The central government is also having to adapt to a new role-that of not man- aging, but influencing, program implementation. This is done through "marketing" priority programs, providing technical assis- tance, and using central financing to supplement and influence the use of local government resources. Both the Department of Health and the Department of Social Welfare and Development need to develop their capacity to advo- cate child development to local governments and to systematically consult them about their priorities. In training, the Department of Social Welfare and Development in particular, as a small agency,  18 IMPROVING EARLY CHILDHOOD DEVELOPMENT needs to build up its institutional capacity to support local govern- ments. In financing, the Department of Health has developed the concept of Comprehensive Health Care Agreements, in which local governments agree to provide certain services in return for speci- fied hardware, cash, and software from the national government. It would be desirable for the Department of Social Welfare and De- velopment to adopt a similar mechanism and to form with the Department of Health and local governments joint "Child Develop- ment Program Agreements" that would govern all investment in ECD in an integrated way. The Role of the Central Support Institutions The Council for the Welfare of Children is the main agency for formulating policy on, coordinating, and monitoring child devel- opment. A fairly new and very small agency with a budget of only P5 million ($0.18 million) in 1994, the council has few highly skilled technical personnel and limited influence with the cabinet and line agencies when it comes to budgets for child development programs. For the council to become a fully effective national over- sight agency for children, its structure needs to be reviewed, the number and levels of professional posts increased, and its budget increased substantially. The National Nutrition Council's staff is more than three times as large as that of the Council for the Welfare of Children, but it, too, because of its advisory status, has had difficulty in influencing policies and budgets. And although it has done much useful re- search, it has not rigorously analyzed some of the key issues, such as what causes malnutrition in the Philippines and whether expen- ditures from the generalized food subsidy should be reallocated into an effective program to both promote growth and provide a safety net. A key issue with regard to the National Nutrition Coun- cil is whether it should develop a comparative advantage in one or two major missions or continue with its multiple missions, which now include policy analysis and development; program coordi- nation; nutrition surveillance; information, education, and com- munication; and coordination of the implementation of certain intervention programs. Finally, early education has no national support institution com- parable to those already established in health and nutrition. Con- sideration needs to be given as to whether a new institution should be created for this purpose. Given the government's lack of com- parative advantage in early education, and given existing moves to  OVERVIEW 19 streamline the civil service, it may be preferable to support early education by establishing a network of existing governmental and nongovernmental institutions with expertise in this area. This net- work would need a small secretariat that would provide direction and guidance and that would have a discretionary budget allowing it to commission work from qualified network members. Financing a Strengthened ECD Program The budget for ECD programs in 1994 was approximately P2,107 million ($84 million), or about P195 ($7.80) for each preschooler. Allocations to ECD need to rise substantially to meet the gaps in coverage and quality noted above. However, unless policy action is taken, allocations for ECD will probably fall by as much as half a billion pesos (about $18 million) rather than rise. Unless other re- sources can be found to substitute for the P430 million ($15 mil- lion) PL 480 spending on food supplements, the current amount spent on nutrition will fall by about half. If the apparently excep- tional P91 million ($3.26 million) 1994 congressional insertion for the day care center program is not sustained, the amount spent on early education may also fall. The 1995 budget included P63 mil- lion ($2.26 million) for the day care program, a reduction of almost one third. As a congressional initiative, there is no guarantee that this item will be renewed annually. This would reduce spending to about P150 ($5.90) per child. On the basis of assumptions detailed in the following chapters, the cost of bringing the national ECD program up to a level of quality and coverage sufficient to meet national targets would be P9.6 billion to P10.5 billion ($342 million to $374 million) over six years. Table 1 shows the breakdown of these costs, assuming Table 1. Estimated Costs, Available Resources, and Financing Gap for Investments in Early Childhood Development Programs over Six Years in the Philippines (millions of pesos) ______ =_____ Healthl Nutrition Educatiotn Total Total costs 7,128 6,793 4,937 18,857 Available resources 4,433 2,951 1,451 8,835 Resources as a percentage of costs 62 43 29 47 Financing gap 2,695 3,842 3,486 10,023 Financing gap (millions of dollars) 96 137 124 358 Source: World Bank and ADB data.  20 IMPROVING EARLY CHILDHOOD DEVELOPMENT investment in the middle of this range. It indicates that, overall, the resources currently planned for ECD are about 47 percent of what is needed. These estimates are conservative in that they assume a fairly modest, even phasing of program expansion over six years. At the time of devolution, local governments inherited an unfin- ished agenda for ECD, an agenda that required substantial addi- tional investment. The revenues that provinces and municipalities were allotted then and their revenue growth since are insufficient to strengthen and expand the program. Although local govern- ments and local communities should pay their share, it is clear that the central government will need to provide continuing financial support for ECD activities, as it does in other countries. However, the central government must also avoid simply substituting its fi- nancing for efforts that local governments could otherwise make. This implies that a cost-sharing policy be developed. Such a policy should ensure that local governments increase their share of ECD program financing over time as their revenues and their ability to sustain the ECD program increase. At the same time the policy should ensure that the central government continue to partly finance the ECD program, if necessary, over the long term in mu- nicipalities whose weak revenue base, large populations, and poor ECD indicators make it impossible to sustain the program alone. Developing an appropriate cost-sharing policy will require the collection of additional data on local governments' ability and willingness to pay for ECD programs. Collecting these data is a high priority. The incremental recurrent cost required to sustain a strength- ened and expanded ECD program would be in the range of P1.5 billion to P2 billion ($54 million to $71 million) a year over five to ten years. It is now not clear how much of this the local govern- ments could finance. On the central government side, much of the Department of Health's requirement could be met from the pro- posed allocation for ECD in its investment plan. But the Department of Social Welfare and Development would require an increased ceiling to fund a strengthening of the day care program. Reallocat- ing resources within and between government departments could free up substantial additional funds for ECD if this program is des- ignated as a national priority. With the upcoming reduction in PL 480 support, a particularly strong case can be made for reallocating food subsidy expenditures made by the National Food Authority into an effective nutrition program for children. However, budget reallocations are politically difficult and take time. Time is also required for local government revenues to grow to a point where local governments can sustain an increasing share of the ECD pro-  OVERVIEW 21 gram. In the interim, foreign aid could help to fill the financing gap. The donor community is putting few resources into ECD; a strong case could be made for donors to substantially increase their commitments if the government decides that reorienting and strengthening the ECD program is a national priority. The Retuirns to Investnient The kinds of primary care interventions in health and nutrition in- cluded in the Philippines ECD program rank among the most cost-ef- fective of all health interventions. Global estimates indicate that the equivalent of an extra year of healthy life can be obtained by spend- ing $25 to $30 on immunization, vitamin A, and iodine supplemen- tation or about $63 on food supplementation. For comparison, prenatal and delivery care cost $60 to $110 and family planning $100 to $150 for each healthy life-year gained. These ECD interven- tions are not only quite cheap to implement, but also save later government expenditure on much more expensive hospital care and rehabilitation. And they are good for equity, because the children of the poor suffer disproportionately from ill health and malnutrition. A recent computer simulation of the impact of improving child malnutrition in the Philippines indicated significant potential bene- fits. It estimated that a 50 percent reduction in PEM would avert more than 37,000 infant and child deaths each year and save 150 million to 200 million days of illness each year. Reducing iodine deficiency by half would avert more than 15,000 cases of mental retardation every year. Reducing anemia by half might lead to ad- ditional earnings from increased agricultural productivity of more than P1,340 million ($48 million) a year. And reducing iron defi- ciency, stunting (low height for age, which indicates cumulative malnutrition over time), and malnutrition-related mortality by half might lead to additional wage earnings of P8,400 million ($300 mil- lion) a year. Quantifying the cost-effectiveness of preschool is more difficult. But it is clear that integrated interventions in health, nutrition, and early education reduce the school dropout rate and improve chil- dren's performance in school. There is also evidence that inte- grated ECD programs have sustained long-term benefits to the economy and society. Evaluation of a U.S. ECD program for disad- vantaged inner city children that has run since 1962 showed that for every dollar invested, $7 was gained in lower expenditures on edu- cation and welfare and higher productivity among participants. At age 19, former participants were 56 to 80 percent more likely to be literate, enrolled in postsecondary education, or employed and 39 to  22 IMPROVING EARLY CHILDHOOD DEVELOPMENT 57 percent less likely to be classified as mentally retarded, school dropouts, arrested for criminal activity, or on welfare. Recommendations A serious effort to improve the situation of preschoolers would require a commitment to the following four policies.