Report No. 4650-PH Population, Health and Nutrition in the Philippines: A Sector Review (In Two Volumes) Volume II: Main Report with Tables and Technical Annexes January 13, 1984 Population, Health and Nutrition Department FOR OFFICIAL USE ONLY FVWE CZ?N 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 US$1.0 = P8.5 1/ P1.0 = US$0.T176 P1 million = US$117,647 P1 billion = US$117.65 million FISCAL YEAR January 1 - December 31 ABBR]EVIATIONS AND ACRONYMS 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 Anima]L Industry BHS Barangay Health Station BHW Barangay Health Worker BNS Barangay Nutrition Scholar BOES Bureau of Health Services BOMS Bureau of Medical Services BSB Botica sa Barangay BSPO Barangay Supply Point Officer CBR Crude Birth Rate CDR Crude Death Rate CEB Children Ever Bcrn COS Community Outreach Survey CPR ContraceptiveL Prevalence Rate DIC Disease Intelligence Center DPT Diphtheria/Pertu.ssis/Tetanus FP Family PlanniLng FNRI Food and Nutrition Research Institute FPOP Family Planning Organization of the Philippines FTOW Full-Time Outreach Worker GNP Gross National Product GOP Government of- 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 F'Y 1983 US$1 = P11 - ii - FOR OFFICIAL USE ONLY 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 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. - iiii TFR Total Fertility Rate TIDA Total Integrated Developmenit Approach TMFR Total Marital Fertility Rate TWG Technical Working Group UNDP United Nations Development Programme UNF]'A United Nations Fund for Population Activities UNICEF United Nations Children's 'Emergency Fund UPI]4C University of the Philippines Institute of Mass Communication UPPE University of the Phil:ippines Population Institute USAID United States Agency for International Development WDR World Development Report WFS World Fertility Survey WHO World Health Organization -iv- PHILIPPINES: BASIC POPULATION, HEALTH AND NUTRITION 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 birtli rate 32.2 Total fertility rate 4.2 Crude death rate 7.0 Male 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 regional disparities in the availability of PHN services.l/ 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 f:indings, issues, and recommendations. Volume II is thes Main Report consisting of four parts; the first three parts cover population, health, and 'autrition respectively, since separate agencies (POPCOM, MOH, and the Nal:ional Nutrition Council) are responsible for these sectors. The three sectors are then treated together in part 4 on Economics and Financing. Vo.Lume II also contains tables and technical annexes. Mission Composition and Information Collection 6. The mission consisted of Mr. N. I. Khan (Mission Leader), Mr. J. Warford (Lead Adviser), and Messrs. V. Kumar, N. Prescott, R. VenkatanaLrayan (Consultants) from the World Bank; Dr. S. Siinding (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. KanTagarat:nam (Sr. Adviser, PHN Department, World Bank) joined the mission during field trips and in itis concluding discussions with senior GOP and participating donor agency officials. Consultants from the Faculty of Economics and the Institute of Public Health of the Uni.versity of the Philippines contributed useful technical data. The report also benefited frcm the mission's discussio:ns urith numerous senior government and non-government officials, field workers and other resident staff of UNDP, UNEPA, and UNICEF. - vii - POPULATION, HEALTH, AND NUTRITION IN THE PHILIPPINES: A SECTOR REVIEW (In Two Volumes) VOLUME II: THE N1AIN REPORT WITH TABLES AND TECHNICAL ANNEXES TABLE OF CONTENTS Page No. ABBREVIATIONS AND ACRONYMS ............................... . i BASIC POPULATION, HEALTH AND NUTRITION INDICATORS ............... iv PREFACE ........................................................ v LIST OF TABLES IN THE TEXT ...............................,. ix PART 1: POPULATION Chapter I. Population Size, Trends and Characteristics 1 Chapter II. Socio-economic Consequences of Population Growth 11 Chapter III. Population Policy and Organization .18 Chapter IV. Population Plans and Programs .24 Chapter V. Population Program Performance ................... 31 PART 2: HEALTH Chapter VI. Health Status, Policies and Plans .39 Chapter VII. Health Organization and Management ............... 43 Chapter VIII. Health Sector Performance .48 Chapter IX. Health Care Programs ............................. 58 PART 3: NUTRITION Chapter X. Nutrition Status, Policies and Plans .66 Chapter XI. Nutrition Program, Organization and Performance... 71 PART 4: ECONOMICS AND FINANCING Chapter XII. Expenditure Trends .79 Chapter XIII. Program Financing ................................ 83 Chapter XIV. External and Alternative Financing .90 - viii - ANNEXES Annex 1 - Annex Tables and Figures ....... .......... . 96 An-nex 2 Limitations of Demographic, Epidemiological and Nutrition Data in the Philippines ................. 164 Ann-iex 3 The Construction and Results of Population Projections for the Philippines (1980-2015) ........ 167 Annex 4 -- Scenarios for Future Demographic Effects of the Philippines Population Program ......... .. ......... 172 Annex 5 -- The "Community Organization" Approach in PHN: The Philippine Experience ................ 177 Anne-x 6 -- Bank Experience in thle PHN Sectors and Direction of Future Assistance ................................... 182 MAPS AND GRAPH IBRD #17342 Population Density (1980) and Poverty Rate (1975) IBRD #17342 Infant Mortality Rate (1978) and Poverty Rate (1975) IBRD #17342 Percent Malnourished Pre-Schoolers (1976) and Poverty Rate (1975) IBRD #17342 Total Fertility Rate (1973-77) and PoverzLy Rate (1975) IBRD #173,43 Per Capita Health Expe!nditure (1982) and Poverty Rate (1975) IBED #17344 Physical Facilitie's and Health Manpower Distribution (1980) and Poverty Rate (197-5) IBRD #17373 Contraceptive Prevalence Rate (1981-82) and Poverty Rate (1975) Graph I: Philippines: Alternative Population Program Scenarios and Their Demographic Impliciations - ix - LIST OF TABLES IN THE TEXT Table No. Page No. Part 1 2.1 Patterns of Land Use in the Philippines 1970-79 11 2.2 Projected Arable Land Per Capita, 1980-2015 13 2.3 Effects of Population Growth on Per Capita Income 15 2.4 Projected Labor Force Supply and Demand 16 5.1 Percentage of Married Couples of Reproductive Age 32 Admitting Knowledge of Family Planning 5.2 Contraceptive Use Effectiveness, 1978 34 Part 2 8.1 Health Service Delivery Network 48 (both Public and Private Sectors) 8.2 Number of Hospitals and Beds by Level of Health Care 49 (both Public and Private Sectors) 8.3 Pattern of Outpatient Visits 51 8.4 Ratio of Health Personnel to Population, 1977 54 Part 4 12.1 PHN Budget Shares, 1981 and 1982 79 12.2 Expenditure by the MOH, 1975-1981 80 12.3 Current Expenditure on Population, Health and Nutrition 80 By Local Governments, 1975-1982 13.1 Regional Distribution of MOH Expenditure, 1981 85 14.1 Cost Recovery Performance, Ministry of Health, 1977-82 91 14.2 Membership of the Medicare Fund, 1972-1981 92 14.3 Average Contribution per Medicare Member, 1972-81 92 14.4 Average Benefit Paid per Medicare Claim, 1972-81 93 PART 1: POPULATION Chapter I: Population Size, Trends and Characteristics Population Size and Growth 1.01 The Philippines, with about 50 million people, is the second most populous country in ASEAN.1/ The population increased from 7.6 million in 1903 to 19.2 million in 1948 at an average annual rate of 2.0 percent. During 1948-70, growth accelerated, eventually becoming stable at about 3 percent per annum; the total population doubled to 36.7 million. Between 1970 and 1980, the population increased by a third, from 37 million to 48 million (Annex Table 1). 1.02 The average annual growth rate during the 1970s was 2.7 percent, about 10 percent lower than during the 1960s. The 1975 Census suggests that much of the decline occurred during 1971-75, and that the decline slowed down during 1975-80. Prima facie, this is puzzling, though not impossible, because a decline in fertility, once begun, usually continues, and often accelerates. The factors to be explored include: (a) the reliability of the available demographic data, including recent censuses; (b) the amount and direction of migration; and (c) the trends in mortality, fertility, nuptiality, and contraceptive practice. The census data raise questions (Annex 2) that require a special exercise which cannot be undertaken as part of this report. International Migration 1.03 During the past two decades, there has been an appreciable increase in emigration from the Philippines. More than 546,000 Filipinos have emigrated to four developed "receiving countries," the most important of which is the U.S. As shown in Annex Table 2, after the enactment of the U.S. Immigration and Nationality Act of 1965, the number of Filipino permanent immigrants into the U.S. increased from 15,900 during 1960-65, to 85,600 during 1965-70 and almost doubled during 1970--75. Annex Table 3 shows that during 1966-70, over two-thirds of the Filipinos migrating to the U.S. were professional, technical and managerial workers, many of them doctors and nurses. After 1970, the proportion of housewives, children and persons with no occupation increased, and the proportion of professionals fell to a little below 50 percent of the working immigrants, probably because of restrictions placed by the U.S. on the inflow of health manpower. 1.04 The "brain drain' of professional and technical workers from the Philippines into the U.S. has caused the GOP some concern. During the past decade, however, the GOP has encouraged the emigration of workers on speci- fic contracts. As shown in Annex Table 4, the number of Filipino "contract workers" going abroad increased sharply from less than 7,500 during the 1/ The ASEAN countries are Indonesia, Malaysia, Philippines, Singapore and Thailand. - 2 - three year period 1969-71 to almost 300,000 during 1978-80. Annex Table 4 also shows that during 1978-8C0 nearly 80 percent of t:he contract workers went to the Middle East; almost 85 percent were miscellarneous production process workers, transport equipment operators and labore!rs or service sector workers. 1.05 The number of Filipino seamen processed by the National Seamen Board more than doubled from about 24,000 during 1975 to 57,000 during 1980.2/ The total number of Filipino seamen working abroad is estimated at over 200,000 and the total number of Filipino workers abroad at about 1.7 million.3/ 1.06 The Philippines does not attract much immigration. The number of aliens registered in the Philippines declined from about 146,000 in 1962 to about 57,000 in 1980, the decline being largely in the number of Chinese,4! many of whom have probably acquired Filipino nationality. The numtber or Indo-Chinese refugees in the Philippines in 1981 was between 3,800 to 6,600. On the other hand, during 1980-1981, approximately 90,000 refugees from the Philippines were reported to be in Malaysia.5/ On the whole, therefore, the evidesnce points to a net emigration from the country. 1.07 In so far as emigrants take their spouses and dependents with them, the number of Filipinos abroad is larger than t:he number of workers. The proportion of non-workers among Filipino immigrants into the U.S. -- about 50-60 percent -- is 'Likely to be higher than fcor other countries. Assuming that the overall proportion is 25-30 percent-, and that the figure of 1.7 million Filipinos working abroad is correct, the total number of Filipinos abroad may be conservatively estimated at between 2.2 to 2,4 million. The estimated 1.7 million Filipino workers abroad represent about 8.6 percent of the estimated potential total labor force of 19.8 million. 1.08 Emigration on this scale certainly has a significant economic im- pact. According to the Overseas Employment Development Board, remittances from Filipino workers employed abroad are estimated to have increased from US$ 384 million in 1978 to US$ 588 million in 1979 (by 53 percent) and to US$ 664 million in 1980. The Central Bank of the Philippines reports, however, that the personal remittances have increased, from US$ 53 million 2/ Republic of the Philippiines, National Economic Development Authority, 1982 Philippine Statistical Yearbook, Manila, 1982., p.474. 3/ The Fookien Times, Phil.ippines Yearbook, 1981-82, Manila, 1982, p. 257. 4/ Ibid., pp 50-51. 5/ See: United Nations Secretariat, Population Division of the Department of International Economic and Social Affairs, "International Migration: Levels and Trends," a paper presented at the Expert Group meeting on Population Distribution, Migration and Development, Hammamet (Tunisia), 21-25 March 1983, (IESA/'PIICP. 1984/EG.II/23), p.35. - 3 - in 1972 to US$ 112 million in 1976 and US$ 254 million in 1981, an increase of nearly 380 percent over the ten-year period.6/ 1.09 Assuming the census data to be dependable, an annual emigration of about 150,000 persons during 1978-1980 would account for about 0.3 percent of the total population and would lower the growth rate from, say, 3.0 percent to 2.7 percent. It is possible, therefore, that the observed decline in the growth rate from 3.0 percent during 1960-70 to 2.7 percent during 1971-80 could be largely accounted for by emigration. Vital Rates 1,10 Because of incomplete vital statistics, it is necessary to make indirect estimates of vital rates in the Philippines. Such estimates diverge considerably. Annex Table 5 shows the U.N. estimates for succes- sive quinquennia between 1950 and 1980. The death rate in the Philippines was already lower in 1950 than in the South Asian countries such as India, Pakistan or Bangladesh or even neighboring Indonesia. The rate of decline increased during the 1950s and the 1960s, but diminished during the 1970s. Life expectancy has risen by almost 15 years from 46 years during 1950-55 to almost 61 years during 1975-80, and the infant mortality rate has declined from 144 to 67. The youthful age composition of the population implies that the crude death rate is now about 7 per 1,000, with a rather limited scope for further decline. The rate of natural increase therefore depends mainly on the birth rate. 1.11 The birth rate declined from about 50 during the early 1950s to 36 during the late 1970s but this decline was largely offset by the decline in the death rate. Thus the rate of natural increase has declined by only one decile from its peak value of almost 3.1 percent during 1955-60, and was about 2.8 percent during 1975-80. 1.12 The estimates in Annex Table 5 assume an annual emigration from the Philippines during 1975-80 of about 34,000 persons. Since the actual net annual emigration was about 150,000, the actual birth rate during 1975-80 may have been higher than shown in Annex Table 5. However, a higher birth rate seems inconsistent with the results of the surveys of age-specific and marital fertility rates reviewed below. To put together the different pieces of the jigsaw puzzle of Filipino demography will require intensive research, particularly as more data from the 1980 Census and the results of the current demographic survey become available. Fertility 1.13 Determinants of the Birth Rate. The key variables determining the birth rate include: (a) the proportion never-married and age at marriage; (b) age specific fertility rates, including marital fertility rates; (c) contraceptive use; and (d) age composition and sex ratio. 6/ Cited in IBRD Report No.3861-PH, (June 1982). The wide disparity in estimates is indicative of the unsatisfactory data gathering and analysis. It is possible that the Central Bank figures refer only to the remittances from the U.S. 1.14 Age at Marriage. Annex Table 6 shows that the miean age at marriage for females was almost 21 years as far back as 1903. It rose very slowly to 22.3 years in 1960 and 23.2 years in 1975. The 1978 survey data suggest a further rise to 24.4 years. The mean age at: marriage of men has risen much less, from 24.9 years in 1903 to 25e5 years in 1975, with a narrowing of the sex difference from 4.0 to about 2.3 years. Marriage is almost universal. Only six percent of the women and five percent of men aged 45-49 in 1975 had never miarried. This percentage is higher than in Indonesia, Korea, Malaysia, Thailand or the South Asian countries, irLcluding Sri Lanka.7/ 1.15' Annex Table 7 shows the incidence of illegil:imate births in selected urban and rural locations. The proportion of il:Legitimate births varies aLcross regions, from 24.3 to 94.3 illegitimate birihs per 1,000 live-births in 1977. Nationwide, an average of 48.9 per 1,000 live-births were illegitimate. Since thesei dat:a relate to just one year, no conclusive estimate can be derived. Howevrer, the prevalence of illegitimate births may well call for corrections in the marital and age-specific fertility tables. The policy implications of this phenomenon deserve consideration. 1.16 Age-Specific Fertility Rates, Annex Table 3 shows the age- specific overall and marital ferti.lity rates estimatedl from the National Demographic Surveys (NDSs) of 1968 and 1973 and the World Fertility Survey (WFS) conducted in the PhilippiLnes in 1978. The age-specific fertility rELtes declined sharply between 1965 (the mid-point for the period 1963-67) and 1977 over the entire reproducti-ve age span. This decline is parti- cularly notable in the 15-19 age groupa among whom the proportion married has declined remarkably from 24 to 7 percent. The total fertility rate (TFR) shows a decline of the order of 20 percent between 1965 and 1977. If these figures are related to an est:imated TFR of 6.46 during 1958-62,8/ the pace of decline in TFR has risen from 2.5 percent during 1960-65 to 6.5 percent during 1965-70 and 11.7 percent during 1970-75. The rate of decline appears to have slowed down during 1975-1977. Data for subsequent years are not available. 1.17 The marital fertility raltes have declined much less than overall fertility rates. Marital fertility in ages 15-24 actaally shows a small ri'se of one to two percent. Such small differences can bea due to the sampling error alone, but a rise is not impossible. The percentages of 7/ Peter F. McDonald et al., 'Interrelations between Nuptiality and Fertility: The Evidence fromn the World Fertility Sarvey," in World Fertility Survey Conference, 1980, Record of Proceedings, Vol. 2, p.88. 8/ The estimate for 1958-62, made by Eliseo A, de GuzmIan, is reported in Mdercedes B. Concepcion, Chanlges in Period Fertility Gleaned from the 1973 NDS, Research Note No, 13, Manila, Population Institute, University of the Philippines, 1975. It impl-ied a total marital fertility rate durinig 1958-62 of 9.56, a little lower than that estimated for 1963-67. The IJN estimates of TFR shown in Annex Table 5 imply a decline of around 4.5-4.7 percent during 1953-63, and around 9 perceat over successive quinquennia during 1963-78. decline in age-specific marital fertility show an odd pattern which might reflect response errors (e.g. age misreporting), but the total marital fertility rates show a decline of the order of only six percent between 1965 and 1977. Such a disparity between the decline in total fertility rate (20 percent) and that in total marital fertility rate (6 percent) is not surprising when age at marriage rises but those who marry do not exercise control over fertility. 1.18 During 1963-67, the total marital fertility rate was nearly 10.0 in rural areas, and 9.0 in urban areas; it was 8.5 in metropolitan Manila. Between 1965 and 1975, the total marital fertility rate (defined for married women aged 15-44, rather than 15-49 as shown in Annex Table 8) declined to 7.22 in Metro-Manila (by 19.2 percent), 8.02 in other urban areas (by 16.5 percent) and 9.16 in rural areas (by 6.5 percent). These comparative data indicate that urbanization in general and proximity to Manila in particular has an inhibiting effect on fertility rates. The causes of the regional fertility differentials have yet to be analysed. 1.19 While urbanization is associated with diminished fertility, the growth of the urban population shows no signs of abating. Indeed, the population of metro-Manila and other urban areas has been increasing rapidly as a consequence of migration from the rural areas. The causes of migration may be multifarious: lack of opportunities in the rural areas, the "glittering city lights," improved access to social services, and urban-rural wage differentials. However, this increasing number of urban dwellers has intensified the demand for services and opportunities, and it is evident that a policy is needed for creating opportunities in the rural areas so as to arrest this rapid influx. Furthermore, the transient nature of much of this migration to the city makes it difficult to provide and maintain health and family planning services. 1.20 Annex Table 9 shows the WFS data on the average number of children ever born (CEB) to ever-married women ages 45-59 (as a proxy for total marital fertility rates), by level of women's education, region and place of residence, husband's occupation and the pattern of work done by the women. The standardized mean number of children ever born, standardized on age at first marriage, is also shown. The CEB varied inversely with the level of education: women holding college degrees had, on average, three children fewer than those without any education. The regional and the rural-urban differences also conform to the usual pattern; the same is true of the differences according to husband's occupation. The pattern of women's work shows smaller differences than is usually expected, probably because a large majority of the Filipino women enjoy a high status and most of them are free to work if they so choose. Likewise, it is a little surprising that the differences in CEB between the college-educated women and those with only primary or no education were not larger, or that the wives of husbands with white-collar occupations did not report fewer than 5.5 to 5.9 children on an average. 1.21 Differentials in decline in fertility are consistent with dif- ferences in contraceptive use, which are also consistent with the decline in marital fertility. Estimates of fertility changes after 1977 are based largely on an extrapolation of past trends, taking into account the prevalence of contraception. - 6 - 1.22 Contraceptive Prevalence Rates. Estimates cf contraceptive prevalence rates are available from different sources. Annex Table 10 summarizes the estimates based on the National Demographic Surveys (NDSs) of 1968 and 1973, a survey by the Bureau of Census anc Sta,tistics in May 1972, the National Acceptor Survey in February 1977, and t:he Republic of the Philippines Fertility Study (RPFS) in May 1978. Annex Table 11 summarizes the statistics supplied by the Population Commission of the Philippines to the Population Council for its factbook on family planning. 1.23 The difficulty of arriving at reliable estimates of the prevalence of contraception is evident from these data. The 1981 figures showing an increase in contraceptive prevalence from l-ess than 40 percent in 1980 to 48 percent in 1981 (Annex Table 11) are inconsistent with the previous estimates as well as recen.t figures supplied to the Bank (which suggest a rise in the level of cont:raceptive practice from 43 percent in 15'80 to 45 percent in 1982 and 47 percent in 1983). The latter remain to be confirmed by the NDS of 1983. H[owever, the 1981 sl:atistics, indicating that abcut 13 percent of married ccuples of reproduct Lve age were using orals, injectables or IUDs froni private sources, are out of line with the irformation for 1980 supplied by the Population Commission. Given the wide and implausible disparities in estimates, a better system for estimating contraceptive prevalence is clearly' necessary. 1.24 A signiificant feature of the contraceptive prevalence rates in the Philippines is the high proportion of couples (21--22 percent according tc t:he WFS estimates for 1980) relying on traditional methods such as rhythm, withdrawal and abstinence (Annex Table 10). Che use of modern methods has increased very slowly indeed from about 11 percent in 1973 to about 13 percent in 1980. (As note!d above, the 1981 figures seem questionable.) The heavy reliance on these traditional methods is not surprising because of the religious background of a large majority of the Fil:ipino population. The users of rhythm and withdrawal tend to be highly moti vated and the age-standardi zed percentage reduction in conception with the use of these methods is slightly higher than with the use of condoms. Abst:inence had the same use-effectiveness as pills, tlhough IUDs were somewhat more effective. Current efforts to improve the efficacy of rhythm should improve the situation. However, the fact that the total marital fertility rate declined by only six percent from 9.67 to 9.10 between 1968 and 1978, despite a rise in the contraceptive prevalence rate from about 16 to :37 percent, indicates that the Philippine authorities Eace an uphill task in reducing the high marital ifertility. Furthermore, unless the significant rise in the age at marriage between 1975 and 1977 has persisted (and, in fact, unless there has been a further rise), the effect of the change in the nuptiality pattern onI overall fertility would also be min:imal. .0:her Demographic Characteristics 1.23 Age Composition. During 1918-1975, children below age 15 formed between 43 and 46 percent of the total population. The tentative age distribution of the population enumerated in the 1980 Census shows about 41 percent of the population in the age group 0-14, lower than the - 7 - corresponding 44 percent in 1975 and 46 percent in 1970.9/ These preliminary data suggest that the decline in the proportion of children aged 0-14, first evident in the 1975 census, has continued and in fact accelerated. It is difficult, however, to reconcile this phenomenon with the stability of the population growth rate between 1970-75 and 1975-80. The high proportion of children between ages 0-14 is also reflected in the high dependency ratio (0.77). 1.26 Sex Ratio. All censuses have shorn the sex ratio of the popu- lation to be close to unity. The 1970 census showed about one percent deficit of males whereas the 1960 and the 1975 censuses reported an excess of males by about two percent. The excess of males diminished in 1980, probably because of sex-selective emigration. Except in parts of Mindanao, the urban population shows an excess of females. The rural population shows an excess of males. Females are predominant in the rural-urban as well as inter-urban migration streams. 1.27 Urbanization. As of 1980, only 37 percent of the population lived in urban areas, but this proportion was significantly higher than in 1970 (a little below 32 percent). About one-sixth (15.6 percent) of the urban population is concentrated in the twin cities of tainila and Quezon in the national capital region, which continues to be the primary metropolis and a major attraction for migrants from the Ilocos and Bicol regions of Luzon and the Visayas. The second largest urban center, Davao in Mindanao, had a population of only 610,000 in 1980. (Trends in urbanization and related issues are discussed in Chapter II.) 1.28 Average Household Size. The average size of a Filipino house- hold, estimated at 5.94 in 1970, remained virtually unchanged in 1975 and fell to 5.57 in 1980, a decline of about 6 percent (Annex Table 12). In both 1970 and 1975, urban households were 3 to 5 percent larger than rural households, presumably because of the problem of finding accommodation in urban areas. However, urban household size declined during 1970-75 while rural household size increased slightly. The decline in household size cannot be related directly to fertility change because of the possibility of a change in the prevalence of joint or extended families. (According to the 1968 and the 1973 National Demographic Surveys, about 79 percent of households were nuclear or one-person households. The remainder were families extended either vertically or laterally.) Average household size is likely to decline over the period of demographic transition, partly because of fertility decline, and partly because of the spread of individualism and modernization, which reduces the number of extended families. 1.29 Literacy and Education. Unlike that of many developing countries, the Philippine population is predominantly literate, The 1970 9/ The WFS reports the population under 15 years of age in 1970 to be 43 percent but it is difficult to verify the source of this information. See: World Fertility Survey, Republic of the Philippines Fertility Survey 1978, First Report, London, 1980, p,6. -8- censuas found over 83 percent: of the population aged 1C and. above literate, with only a very small difference between men and women (an indicator of the high status enjoyed by Filipino women). The 1975 census ascertained only the highest grade completed. The data suggest that among persons aged 10 and above, only 9.2 percent (8.4 and 10.0 percent of males and females respectively) had not completed even the first grade. Among persons agecl 20 and above, 9.2 percent (10.8 and 7.7 percent of males and females respect:ively) were high school graduates. About 13.5 percent of those over 20 years have completed at least one year of college. Almost 6.4 percenl: of this age-group (5.7 and 7.0 percent of males and females respectively) have completed their post-secondary education and hold academic degrees. Such a wide diffusion of high school education and literacy facilitates the relatively high mean age at: marriage among Filipino females. Regional Demographic Differentials 1.30 Given the large size of the population, regional differences are important in the Philippines. Annex Table 13 shows t:he total population and the intercensal growth rates for six regions of Luzon island, three regions in the Visayas and four regions in Mindanao. Luzon, which accounts for 54 percent of the popu:Lation, had a faster population growth than either the Visayas or Mindanao during 1970-75. During 1975-80, however, the population of Mindanao recorded substantially higher growth than either luzon or the Visayas. Within Mindanao, there is considerable difference between the growth rates for the Western and Central region, which is perplexing. The underlying factors remain to be identified. 1.31 The overall density is 160 persons per sq. km., but there are wide inter-regional differences (Annex Table 13). Population density is lowest in Mindanao (107 persons per sq. km.) and highest in the Visayas (196 persons per sq. km.). The entirely urban national capitaLl region has a miuch higher density of population than the rest of Luzon or the Visayas. l.32 The Visayas are the traditional source of migrants to both the r.ational capital region and MindarLao. The present density in Mindanao is the outcome of substantial immigration from the Visayas. The Western and the Cen.tral Visayas have a higher density of population than other regions, with the exception of the Capital and Central Luzon. 1.-33 Annex Table 14 shows the major socio-economic and demographic characteristics of each region. The birth and death rates for 1978 shown in the table are based on registration data, which are deficient. (According to the estimates fcor 1971, death registration was almost 91 per- cent complete in Manila and its suburbs, but in Northern and Southern Mindanao, only about 37 percerLt of deaths were registered.) In other regions, registered deaths foimed between 63 and 85 percent of the total (see Annex 2). As a result, the regional differences in vital rates show%n in Annex Table 14 are rough approximations. The possibility of their being misleading is illustrated by the infant mortality data, which suggest that two regions in the Mindanao had the lowest infant mo.rtality rates; other estimates for 1970 indicate much higher rates of infant mortality in N[indanao. The situation is unlikeLly to have changed between 1970 and 1973 or 1974, and therefore the life expectancy figures for 1973 and the crude death rates for 1978 do not reflect reality. - 9 - 1.34 The net migration rates for 1960-70, however, are based on the census data and reflect the sizeable migration from the Visayas to Mindanao as well as Southern Tagalog, which includes the capital region. Ilocos, Bicol and Central Luzon have been other traditional sources of migrants. 1.35 There are marked regional variations in urbanization as well. Outside the entirely urban metro-Manila region, Central Luzon and Southern Tagalog are the more urbanized regions, whereas Cagayan Valley, Western and Central Mindanao and the Eastern Visayas are the least. These regional differences in urbanization are associated with differences in the distribution of the industrial labor force. Population Projections 1.36 The preceding discussion has stressed the difficulty of estimating vital rates in the Philippines, and thus of trying to predict the trend of fertility. Annex 3 reviews the population projections made by the GOP's National Economic Development Authority (NEDA) and the University of the Philippines Population Institute, and outlines the six projections made in the Bank, with two variants of mortality trends and three variants of fertility trends. The medium projection of fertility envisages a net reproduction rate (NRR) of unity by 2010-15, whereas the low and the high projections envisage a NRR of unity by 2000-05 and 2030-35, respectively. Neither of these projections makes any allowance for international migra- tion on the ground that it has been negligible (around 0.3 percent) in recent years. 1.37 Under any assumption, the projections imply a substantial growth in population over the next 35 years. The projected total population in the year 2000 ranges between 73 and 82 million (an increase of 52 to 69 percent), and in the year 2015 between 89 and 111 million (an increase of 84 to 129 percent.) The Bank's 1982 World Development Report (WDR) projection (the medium-growth variant) forecasts a doubling of the population by 2015. 1.38 The rate at which mortality is expected to decline has little effect on the projections. In the year 2000, the two mortality variants yield a difference in population of only about a million, or roughly 1 percent. In 2015 the difference is still only 1-2 million, or roughly 1.5-2.0 percent. 1.39 The pace of future fertility decline will have a significant effect on population size and growth and an even larger effect on the ulti- mate size at which the population stabilizes. The projected fast fertility decline would reduce projected growth rates by 17 percent during 1985-90 and around 30 percent during 1995-2000, compared with what they would be with the slowest decline. Hence the time required to double the popula- tion could be increased from 37-38 years to 55-56 years, a reduction of nearly 50 percent in the potential for further growth. - 10 - 1.40 An Alternative View of Philippine Population Trends. According to an alternative view suggested by the University of the Philippines Population Institute (UPPI), if the 1975 census count is corrected to yield a mid-year population of 42.3 million, the average annual growth rate during 1970-75 would be 2.79 percent, about 6 percent below the figure of 2.97 percent during 1960-70. T'he 1975-80 intercensal growth rate would then be around 2.57 percents 7.9 percent less than during the previous quinquennium 1970-75. This would imply that the birth rate fell more rapidly than indicated above, as a result of a sharp rise in the mean age at marriage (as suggested by the WF'S data) as well as in the prevalence of contraception. It requires relatively small adjustments in the level of effectiveness of contraception to work out an internally consistent profile of population trends. 1.41 Annex Table 15 summarizes the key elements of this exercise as well as of projections into the future. It would be useful for the Bank as well as the Philippine authorities to undertake a careful joint assessment of both published and unpubLishLed data from the censuses, vital regis- tration and other sources to identify and resolve the inconsistencies. Issues and Recommendations 1.42 Several major issues emerge from this review of population trends. The Philippines has experienced a massive increase in population from 37 million to 48 million in the ten years between 1970 and 1980. This rapid growth seems likely to continue, given the prese!nt youthful age structure of the population. T'his emphasizes the neecL for intensive family planning efforts. 1.43 The increase in population is unevenly distributed among the 13 regions. The least-developed and least-urbanized regions show little or no decline in fertility, higher current fertility and lower contraceptive practice than wealthier and more urbanized regions. T'hese differences could be partly due to unequal access to family planning and maternal and child health services (Maps IBRD 17342 and IBRD 17373). 1.44 Between 1960 and 1980 the urban population doubled, and may double again in the next 20 years, with an inevitable increase in social and economic problems. Efforts to strengthen the family planning program in urban areas and to reduce rural-urban migration may be needed. In addition to the internal migration noted above, many Filipino workers have emigrated either permanently or temporarily, a factor not allowed for in official population growth estimates. It is important: that appropriate corrections be made in the population statistics. Ret:rospective adjustments must, of necessiLty, be made by extrapolation; prospective census and surveillance exercises should be improved by a more compre- hensive design that expliciltly takes into account emigration. 1.45 The decline of fertility had accelerated during the decade 1960-65 to 1970-75. Data for 1980 are not available, but information up to 1977 indicates that fertility may have leveled off. I'he current round of the National Demographic Survey should help to clarify this important point. - 11 - 1.46 There is a serious lack of acceptable time series data on demo- graphic variables. The GOP should review the evidence in order to resolve present ambiguities. Although massive growth in population seems all but inevitable over the next 35 years, a rapid decline in fertility could reduce the population in 2015 by as much as 18 percent, as compared with the level that would result from the current trend and, in addition, reduce the potential for further growth. CHAPTER II: Socio-economic Consequences of Population Growth 2.01 This chapter reviews the various ways in which demographic change may affect economic growth. Despite real GNP growth of 6.4 percent a year in the Philippines during the postwar era, poverty, unemployment, and regional imbalances in income and economic opportunity remain. And 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. 2.02 The most urgent problem created by a rapidly growing population is pressure on a limited land area. Additions to the labour force will lead to diminishing per capita income and output unless accompanied by increases in the capital employed in industry and agriculture and by improved technology. 2.03 A primary concern is the resources needed to meet basic needs, such as education and public health, already a burden at present, as the proportion of the population in low-income groups increases. Population Growth, Land, and Other Natural Resources 2.04 Population Growth and Access to Land. Table 2.1 shows changes in patterns of land use in the Philippines over the period 1970-1979. Table 2.1: Patterns of Land Use in the Philippines 1970-79 Land Use Category Area ('000 ha.) Average Annual 1970 1979 Change ('000 ha.) A. Forest 15,899 12,661 -360 1. Productive forest 14,114 10,901 -357 2. Unproductive forest 1,785 1,760 -3 B. Non-forest 14,101 17,339 +360 1. Open and grassland 3,486 1,870 -180 2. Marsh and small water 215 118 -11 3. Cropland and plantation 9,795 14,523 +525 4. Urban areas 605 828 +25 Total Country Area 30,000 30,000 0 Source: Philippine Forestry Statistics - 12 - 2.05 The area used for agriculture (cropland and plantations) increased by almost 50 percent, at a rate of about 525,000 hectares (ha.) annually. Urban areas expanded by 37 percent, an indication of urban sJrawl.10/ In turn, unsettled areas decreased significantly. Forests siirank i over 3 million hectares during the period, an average of 360,000 ha. a year, thus providing 65 percent of the total area taken over by human settlement. Another 33 percent came from open land and grassland, which decreased by an average of 180,00 ha. per year. The remainder came from marshlands. 2.05 The Philippines Forestry Statistics cited above seem to have underestimated the loss of forests. Satellite photographs taken in 1976 show that only 3.64 million ha. were actually forested, compared with the 4.4 million ha. cited in the 1979 forestry statistics. Moreover, forestry reserves are increasingly being threatened by illegal settlements. According to the Bureau of Forest Development about 600,000 people have settled on statutory forest lands. Figures provided by other agencies are e-ven larger, so that 600,000 czan be accepted as a conservative estimate. Thlese changes in land allocati[on have implications for economic and social development, particularly for growth in agricultural productivity, u-Tbanization, and preservation of forestlands and watershed areas. 2.07 Effects on Farm Size: Fragmentation and Low Productivity. The Philippines is mainly an agricultural country with 53 percent of its labcor force employed in agriculture.. As a result of population growth at the unprecedented rate of about 3 percent in the 1950s and 1960s, arable land per capiLta fell from 0.18 ha. in 1960 to 0.11 in 1975, although 99 percent of all arable land had been broughl: under cultivation by then. There was a decrease in average farm size, excessive fragmentation, and expansion of agriculture into marginal lands, with the result that many farms were cut down to a minimum viable size and the marginal product of agricultural labor fell. 2.08 These pressures on thle land were relieved somewhat in the 1970s by programs designed to improve irlrigation and introduce short-maturing seed varieties, thus raising cropping intensity and productivity on land aLready under cultivation. There is scope for further substantial increases of productivity through investment in irrigation. 2,09 Population Pressure and Land Scarcity. Of immediate concern is the prospect that the number of landless people in rural areas will grow more rapidly than farm output. By 1980, arable land per capita had declined to less than a tenth of a hectare and, in another 35 years, the f-:gure will be less than 0.05 haD per capita under the medium and high projections for population growth, and just over 0.05 ha. per capita ever. under the most optimistic projections (Table 2.2). 10/ UrbEan areas are defined principally on the basis of population density, which increases as a result of both natural increase as well as rura l-to-urban migration. - 13 - Table 2.2: Projected Arable Land Per Capita, 1980-2015 11/ Population Growth Scenarios (from Chapter 1) Year Low Medium High 1980 .0965 .0965 .0965 1990 .0756 .0746 .0734 2000 .0637 .0608 .0580 2015 .0524 .0486 .0430 Source: National Economic Development Authority As further fragmentation of the available land or extension to new areas becomes uneconomic, a larger proportion of the growing population will be unable to own land. As early as 1971, 59 percent of tenant farmers and 52 percent of farm laborers were earning incomes that fell below the poverty line.12/ Even among farm owners, 48 percent were below the poverty line, farm size being the most important variable explaining differences in income. While some share of the gains from increased output may raise incomes even among the landless or small farm owners, the bulk of these gains will accrue to those who are most able to invest in the infra- structure that will generate these gains, namely the large farm owners. 2.10 Deforestation. The excess population is moving deeper into the country's forest areas as well as into the cities. Although forests are one of the Philippines' most valuable natural resources, covering an estimated 17 million ha., they have been seriously depleted by excessive logging and by shifting cultivators (caingineros), who move into logged-over areas and, using slash-and-burn methods of cultivation, cut down all remaining vegetation to plant subsistence crops. As a result, more than 5 million ha., mainly sloping land, is now denuded, even though the demand for wood, an important fuel in rural areas, has been growing as population increases and oil becomes dearer. About two-thirds of the loss of forest lands occurred during the 1970s as population increased and opportunities for movement into cities declined. 2.11 All these factors have led to land erosion, with serious consequences for watershed preservation and the maintenance of important forest resources -- problems which were of no immediate concern in the past. If these trends continue, however, the Philippines will probably have to import timber, and its wood industries will face impending shortages and a possible cutoff of their raw material supplies. 11/ Total arable land is assumed constant at 4,662,000 ha. 12/ The poverty line was set at 500 pesos per capita on the basis of the cost of a consumption basket necessary to meet specific minimum needs, primarily for food. -. 14 - 2.12 Migration and Urbanization. As the numbers of landless increase, migration into the cities will also increase. During the twentieth century, urban growth in the Philippinies has ranged between 3.5 and 4.8 percent a year. Between 1960 and 1980, the urban population doubled. Thirty-seven percent ot the nation lived ia towns and cities in 1980, and the urban population may double again in the next 20 years. Metro-Manila is likely to grow to over 13 million people by 2000, and there will be about eight cities witlh ovier 500,000 people (compared with 2 such cities in 1980). While rural-urban migration has declined after it reached its peak in the 1960s, the rate remiains high. Durinig 1960-70, migration contributed 11 percent of the increase in the country's urban population-13/ In the metropolitan Manila area, however, migration contributed as mLTh as 42 percent of growth in 1960-70. Before 1965, rural-to-rural and rural-to-urban migration streams were of about equal size. During 1965-73, the rural-urban exceeded the rural-rural flow as pressure on land increased. This flow was mainly towards Manila. 2.13 The concentration of migration flows into Metro-Manila could lead to even greater poverty in Manila, The cost of providing infrastructure fo- urban settlement -- housing, water, sanitation and transportation - increases with population density. The cost of house building is already Ilargely beyond the means of low-income earners. The result has been over- crowded and insanitary squatter settlements which provide little security of residence to their occupants. Further migration into the city would only exacerbate these problems. Population Growth, Production, and Employment 2.14 Population and Oultput. From the ead of World War II until 1979, GNP at constant prices grew at thle rate of 6.4 percent per annum. Since the second oil crisis in 19379, however, the rate of growth of output has fallen drastically to around 4.0 percent per annum so that the current population growth rate of 2.5 has 'Limited tCe growth in per capita income to berween 1.0 and 1,5 percent per annum. 2.15 As a result of planned high levels of investment in agriculture and industry, GNP growth is; expected to return to the pre-1979 level of around 6.5 percent per annum for the plan period 1983-87. However, because population is expected to grow at 2.5 percent up to 1985 and 2.3 percent afterwards income per capita might only inCcrease at the moderate rate of about 4.0 percent per annumll. Table 2.3 shows; how per capita income would grow over the next t-wo dec des under various assumptions about population growth. GNP is assumed to grow at 6.5 percent per annum. 2.16 Although prospects for the increase of basic crops are good, this does rot necessarily mean iXhat all people will be well fed. If income distribution becomes evern rnore skewed than at present, as a result of an 13/ The rest of the increase was due to natural growth and several reclassificatiors du.e :co* the absorption of rural areas into adjacent urban areas. - 15 - Table 2.3: Effects of Population Growth on Per Capita Income Per Capita Income (in 1980 pesosl4/) Assumed Population Growth Rate Year Low Medium High Zero 1980 5487 5487 5487 5487 1990 8090 7960 7830 10300 2000 12760 12170 11610 19334 Source: WDR 1982 Projections increase in the number of landless peasants, the anomaly of insufficient average food consumption in a food-exporting country may emerge. 2.17 Population Growth and Employment. The number of entrants into the labor force is principally determined by the rate of natural increase lagged by 15 to 20 years. During the period 1976-80, the labor force increased by an average of 4.06 percent per annum. About four-fifths of this growth was due to increases in the size of the working age population (growing at 3.25 percent annually), and the remainder was due to increases in the labor force participation rate (growing at 0.79 percent per annum). During the same period, employment increased by 4.0 percent per annum, i.e., more slowly than the labor force. The number of unemployed increased from 779,000 in the third quarter of 1976 to 950,000 in the corresponding quarter of 1980, i.e., at a rate of 5.09 percent annually. Between 1980 and 2000, the growth of the working age population is expected to slow down to 3.02 percent per annum as a result of a slowing of population growth in the late 1960s and 1970s. This will still mean an increase of at least 13 million persons in the work force during that 20-year period. If employment continues to grow at its current rate of 4 percent per annum, the prospects for employment are quite good. As Table 2.4 shows, at this rate of labor absorption and the current participation rate (61.4 percent), full employment could be attained as early as 1990 under any of the three assumptions on population growth. 2.18 If the economy is unable to maintain the current rate of labor absorption -- not unlikely considering the large amount of investment needed -- a different picture would emerge. With a 3 percent annual growth in labor demand, there would be 2.4 percent unemployment in 1990 and either 2.5 percent, 3.0 percent or 3.5 percent unemployment in 2000 depending on 14/ US$1.00 = 8.4 pesos in 1980. - 16 - Table 2.4: Projected Labor Force Supply and Demand Labor Supply 15/ Labor Demand (according lo population (according to assumed rate Year growth projection) of increase) Low Medium High 3% 4% 1980 17607 17607 17607 16657 16657 1990 23182 2_3182 23182 22386 24656 2000 30850 31006 31173 30084 36498 Source: WDR 1982 projections the rate of population growth after 1980. (Projected labor supply in 1990 is the same under all these assumptions because of the lag between population and labor force.) 2.19 Table 2.4 obviously simplifies the working of the labor market. Participation rates seem to be experiencing a long-term upward trend, and are also likely to increase with increased employment opportunities, thus establishing a built-in mechanism that would prevent eventual attainment of full employment. If the participation rate continues to grow at 0.79 percent per annum (instead of staying steady at 61.4), unemployment would remain at 1.6 percent in 1990 and full employment would be attained only in 2000 under a 4 percent annual output growth. With only 3 percent output growth, unemployment would be 10.7 percent in 1990 and 17.1 percent in 2000, a potentially explosive situation. 2.20 Even under full employment, an important issue will be the compo- sition of employment and the level of earnings. During the period 1956 to 1976, the share of agriculture in total employment diminished (from 59.1 percent to 52.7 percent), while the share of the service sector increased (25.1 to 32.6 percent). The share of industry declined slightly (15.8 percent to 14.7 percent). During that period farm wages declined by slightly less than 40 percent. In addition, although employment growth in the service sector was impressive, value added per worker increased sianificantly only in transport but stagnated or even declined in commerce and other services. ThiLs strongly suggests l-hat much of the employment created in services was residual in the sense that it represented the push of those entering the labor force to find work, which led to declining productivity and income. Although it is true that the manufacturing sector has picked up slightly during the second half of the 1970s in response to the rapid growth of manufactured exports, the extent to which this sector could support increased employment levels and raise real wages still remains to be seen. 15/ At 61.4 percent labor force participatiorn rate of population aged 15+. - 17 - Population Growth and Expenditure on Human Resources 2.21 The GOP is committed to providing basic education and health care. The services that must be provided will grow in direct proportion to the size of the population. Hence the rate of population growth is an important determinant of the resources required for these services as shown in the subsequent paragraphs. 2.22 Education Expenditure. Annex Table 16 summarizes the projected numbers of children of primary school age. In 1980 there were about 7.5 million children in this age group, and this number will increase by about 30-32 percent to just under 10 million by 1990. The number will depend on how fast fertility declines thereafter; however, on the assumption of maximum decline, the school age population starts to decline between 1990 and 2,000, so that the increase between 1980 and 2015 would be only 13 percent, or about a million children. On the medium assumption the numbers increase throughout this period, by 41 percent or about 3 million altogether. Even more striking is the overall increase of 81 percent or about 6 million which results from the minimum assumption. 2.23 Primary school enrollment is now almost 100 percent in the Philippines, and the GOP presumably wishes to maintain this level. To do so will call for an increase of at least 30 percent in spending on primary school education over the next eight years or so, on the basis of current standards and methods of education. After 1990, however, a fast decline in fertility (such as could result from an improved family planning program) would eliminate the need to raise expenditure, or alternatively would permit an upgrading of the system. A medium fertility decline (or maintenance of family planning at its current level) would entail continued increases in expenditure until at least 2015, though to a much lesser extent. A slow decline, of the kind that might result from a weakening of the program, would require substantial growth in expenditure throughout the next 35 years, and make upgrading of the system considerably more difficult. Similar increases in expenditure can be expected at the secondary and tertiary levels of education. The effects of current fertility rates will of course be more delayed for higher education, but past high fertility is already affecting expenditure. In 1975 secondary school enrollment was about 57 percent and enrollment at the tertiary level 19 percent. If enrollment is to be improved, as would be essential for sustained economic development, increases in educational expenditure would have to be even higher in the future, 2.24 Clearly, therefore, a rapid decline in fertility would considerably ease the burden of educational expenditure for the GOP. With such a decline, the maintenance of current educational levels would need substantial increases in funding only over the next decade or two; after the year 2000, the numbers of children would drop steadily, and improvements in services could be financed without an increase in spending. Without such a decline, the numbers of children will continue to grow over the next 35 years, and steady increases in government expenditure will be necessary merely to preserve the current level of educational services. 2.25 Health Expenditure. In the last five years, unprecedented atten- tion has been focused on the need to establish an efficient primary health - 18 - care system in the Philippines. The principal focus of these attempts, have beern children under 5 and women of reproductive age, i.e., 15-49. Together, these two groups constitute thie target group for the maternal and child health (MCH) services that are central to primary health care. The projected total numberis in these two age groups are summarl zed in Anne!x Table 17. The projected increases are as follows: froimi 19.4 million in 1980 to 23-25 milli-on, in 1990y an increase of 21-28 percent; by 18-25 percent between 1990 a-ad 2000 to reach 28-31 million in 2000; and by 17-28 percent thereafter to reach 32-39 million in 2015. Because the size of the relatively large adult female component of this population will not be greatly affected by the course followed by fertility over the next 35 years, the choice of projection of school noplation growth does not h:lave as dramatic an effect as for school age groups'3 Nevertheless, it is clear that the MCH population i.s bound to grow from about 66 to 106 percent over the 1980-2015 period, depeknding on the rate of fertility decline. By 19990, the MCIH population will be 7 percent (or 1,5 million) lower with the fastest decline than wi th the slowest, and by 2015 the differential widens to 19 percent (or 7.6 million persons). 2.26 Present coverage of MCIH care is far from adequate, and a significant -increase in expenditure would be necessary to provide basic care for the current ta,rget population. The expected growth of these target groups over the next 35 years will call for still greater increases in health expenditure. It is clear that the more fertility can be reduced, the less will be the demand on public resources. ;ssues and Recommendations 2.27 Population growth cor,sequences mr-st be taken into account in economic planning for various sectors. In agriculture, a fdecreasing land-man ratio makes it urgent that productivity be raised by providing better infrastructure and redistributing land, Urban growth makes the provision of urban services, particularly in the metro-Manila area, an important priority. The conflict between the need for new areas of hurman settlement and the need for forest conservation must be taken into account. 2.28 These and other factors discussed above should be given serious consideration in regional planni eg. Public sector planning should allow jor the growing number of indivduials., child-en in particular, for whom adequate health and education services must we provided. And finally, if th e costs of economic growth are to be mininized and the resultant gain in welfare maximized, efforts should be made to reduce fertility as quickly as possible. Chapter III: Popuiation Policy and Organization Historical Background 3.01 Tn 1967, the Philippines, along w-th 16 other nations, signed the UN Declaration on Population, thereby accepting the importance of population for development planning. The fol.lowing year, a small unit was established in the Department of Health, with responsibilities for maternal - 19 - and child health and family planning services. ITn 1969, Presidential Executive Order No. 171 established a National Commissioni on Population (POPCOM), with memabers from both the public and private sectors, to study population problems, recommend population policies, and disseminate research findings. A national population program was launched in 1970 with the object of reducing population growth. 3.02 In 1970, POPCOM was given the additional task of coordinating and evaluating the execution of population programs and undertaking its own programs as necessary. In 1971, a law was enacted defining national popil- lation policy and giving legislative approval to POPCOM. In 1972, the role and objectives of POPCOM were redefined to include: (a) formulation of population policies integrated with broader socio-economic development; (b) recommnendation on policies and programs for guiding and regulating labor force participation, internal migration, and spatial distribution consistent with national development; (c) provision of family planning services as part of overall health care; and (d) making family planning part of a broad educational program. 3.03 In 1972, the Population Center Foundation (PCF) was fouinded to strengthen partnership between the GOP and the private sector, and the executive director of PCF was given a seat on the POPCOM Board. In 1973 the Philippines Constitution reiterated the State's responsibility for achieving and maintaining population at the level most conducive to national welfare. In addition, various presidential decrees and letters of instruction issued in 1974-76 directed government agencies, provincial governors, and city mayors to provide increased support for population and family planning activities., Included in these activities were: (a) the Total Integrated Development Approach (TIDA) implemented oan a pilot basis in 1975-76 in seven provinces; and (b) the National Population and Family Planning Outreach Project (NPFPOP) implemented natiLonwide in 1976, to provide family planning motivational activities and services to all couples regardless of proximity to stationary clinics. 3.04 In addition, the inter-ministerial Social Development Committee (SDC) of the National Economic Development Authority (NEDA) was charged with the responsibility of relating national population policy to other socio-economic development policies. Besides POPCOM, t'ne Ministries of Health, Education and Culture, Local Government and Community Development, Social Services and Development, and Labor and Employment are represented on the SDC. Examples of measures sponsored by the SDC are: limiting personal tax exemption to four dependents, lowering the dependency age from 23 to 21 years, limiting maternity benefits to the first four births, requiring all establishments with 200 or more employees to provide free family planning services, and promoting population awareness. Policy 3.05 POPCOM, the national agenicy responsible for an integrated popu- lation policy, has so far concentrated mainly on fertility reduction. However, population growth targets have not been closely linked with resource availability or with specific targets for the family planning - 20 - program (e.g., the number of acceptors and/or the contraceptive prevalence rate). Furthermore, POPCOM 'nas thus far lacked the capability for policy analysis, especially of the population impact of various socio-economic policies (Chapter II). This analysis, if properly undertaken, could lead to specific policy changes, such as discouraging the use of population as a basis for resource allocat:ion (this createE a bias in favor of population growth), explicitly advocating smaller families (a three-child instead of the four-child norm implicitly accepted now', or a higher age (25 years) at marriage for both males and females. In ac.dit:ion, as recommended in 1978 'by the Special Committete to Review the Philippines Population Program (SCRPPP), development plans could set specific national and regional population targets in addition to target ra.tes of population growth. :3.06 The main responsibility for these broader policy concerns rests wqith the SDC. Nevertheless, in view of POICOM's role as the chief popula- tion agency, it should be expected to cooDerate with other agencies, primarily through the SDC, in order to heli coordinate population policy. 'This could be done without sacrificing POPCOM's direct responsibilities for t:he more specific fertility reduction aspects of national population policy. Organization 3.07 Over forty public and private agencies are engaged in population related activities in the Philippines. As m-ntioned above, the integration of family planning with other socio-economic policies is the responsibility of NEDA's Social Development Committee (SDC). Coordination between POPCOM aend SDC is facilitated by Dverlapping Board membership (several cabinet ministers are ex officio m(embers of' both). The primary private agencies involved in population activities are the Population Center Foundation, the Family Planning Organization of thne Philippines and the University of the Philippines Population 'Insltitute. 3.08 Commission on Population (POPCOM). The POPCOM Board comprises six cabinet ministers (Economic Planning, Hezalth, Education and Culture, Labor and Employment, Local Government and Tmommunity Development, and Social Services and Development) and the heads of four private agencies, including the Population Center Foundation. In practice, since many of the Board members are ministers with other respornsibilities, it is not uncommon for Board meetings to be attended by substi:mutes, often not of high enough rank either to appreciate the wider implica'i'on`os of population policy, or to commit their ministries to a decision. As a result, POPCOM's coordination of sectoral population-related policies has been deficient. 3.09 Assisting the POE'COM Board is a Technical Committee of selected Board members and outside specialists, which reviews project proposals submitted by participati'ng agencies for funding and approval. Coordination of program implementation i.s undertaken by POPCOM's Secretariat, headed by the Executive Director. The Secretariat is organized at both central and resgional levels, into the following seven di.visions/sections: (a) Finance, (b) Training, (c) Clinic Services, (d) Logistics, (e) IEC, (f) Planning and Ressearch, and (g) Monitoring/MIS (Annex Figure 1). Regional specialist staff are administratively under the Regional Population Officers (RPOs), - 21 - but are functionally responsible to the head of the relevant central technical division in Manila. 3.10 The Regional Population Officers (RPOs) work with provincial and city governments in implementing various service delivery and outreach programs, and also coordinate their activities with the regional and local offices of government agencies. Below them are the Provincial, District, and City Population Officers who act as links with the local government, conduct IEC programs, and provide participating agencies with supplies and funds. At the village level, POPCOM's Full-Time Outreach Workers (FTOWs) are administratively under the local government, and are supported by 50,000 volunteer Barangay Supply Point Officers (BSPOs). These outreach workers are expected to keep in touch with the field staff and clinics of the MOH, but in practice coordination at the village level has been marginal. Although the role assigned to the BSPOs -- largely educational, non-clinical contraceptive supply, and referral of clinical contraceptives -- is complementary to the contraceptive dispensing and clinical follow-up role of MOH field staff, there is considerable duplication of activities and functions. 3.11 Ministry of Health (MOH). The family planning program under the MOH is implemented through the National Family Planning Office (NFPO), which is largely concerned with the training of MOR personnel at various operational levels, and with the organization of community-based outreach activities. The latter function is similar to the activities of POPCOM's clinic services division. The actual delivery of family planning services is done through the MOH's regular health service outlets such as hospitals, rural health centers and barangay health stations. The NFPO has also established a community-based FP program network using community leaders (Sarikaya), successful elements of which are now being integrated with the nationwide primary health care program (for details see para. 4.08 and Chapter IX. 3.12 Other Ministries. The Ministry of Labor and Employment (MOLE), through its Population and Family Planning Office, enforces labor laws and coordinates family planning services provided by health clinics in over 1,000 firms. The MOLE also coordinates over 4,500 labor management commit- tees, whose functions include the organization and promotion of family planning services. The Ministry of Social Services and Development (MSSD) organizes programs for out-of-school youth and other disadvantaged segments of the population. It oversees population awareness and sex education programs designed to prepare such youth for responsible parenthood. The Ministry of Education and Culture (MOEC) is responsible for population edu- cation in public schools. The Ministry of Local Government and Community Development (MLGCD) formulates national policies which guide the local government's supervision of the Full-Time Outreach Workers (FTOWs) and the BSPOs of the POPCOM outreach network, and shares the operational cost of the outreach structure of the national population program. 3.13 The National Economic Development Authority (NEDA). Through its Social Development Committee (SDC), NEDA coordinates the broader (beyond family planning) aspects of population policy (manpower, welfare, distribution etc.), and ensures that population issues are considered in development planning. The National Census and Statistics Office under NEDA - 22 - is responsible for collecting and analyzing population data, estimating population parameters and making demographic projections. However, its role remains limited to producing and analvzing demographic data, and does not extend to reconciling discrepancies among demographic estimates. This remains a serious limitation which hinders the effective planning and monitoring of population policy and the setting of performance targets. The SCRPPP recognized this problem in 1978 and recommended that the GOP's Statistical Advisory Board should assume the responsibility for reconciling discrepant estimates and xeaching a consensus on an offical estimate of population parameters which could then be used for the purposes of planning, policy making, and research. 3.14 Private Agencies. The Populatiorn Center Foundation (PCF) is a private, grant-giving agency which helps tco integrate private family planning efforts. It also undertakes pilot projects and research into family planning service delivery. The Institute of Maternal and Child Health (IMCH) provides information, referral and counselling services lhrough its telephone network; conducts family planning training for medical and paramedical personnel; and offers family planning services 1through its 392 clinics and 62 barangay supply points. The Family Planning Organization of the Philippines coordinates and supports family planning training, communication and service delivery offered by voluntary groups ind family planning associations. The Institute of Community and Family flealth coordinates and promotes community-based family planning activities tin(er various private development programs. (See the chart of inter- agency relationships for the Philippine population program, Annex Figure *2) Issues and Recommendations 3.1.5 In view of the large number and diversity of activities carried out by the various participating agencies (Annex Figure 2), POPCOM's coordinating role is extremely important: directly, in formulating and implementing policies aimedl at fertility reduction; and indirectly, in `ielping the SDC to devise broader policies directed towards socio-economic development. However, at the central level, it appears that POPCOM's Secretariat has been diverted from its primary coordination role. Frequent changes of POPCOM's Executive Director have created discontinuities in program leadership. As a result, the Secretariat has been unable to give the SDC and the POPCOM Board adequate staff support. In order to facilitate POPCOM's coordination of multiagency 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 miore centrally located witlin the government decision making structure. GOP should review the structural and reporting relationships between 'OPCOM's Board and higher government authorities, with a view to improving inter--ministerial coordinat:ion of all population-related policies. In addition, it might be useful to make POPCOM's Executive Director a voting mamber Df his own Board, thus not only strengthening POPCOM's influence with higher policy-makers, but also making the position of Executive Director more attractive arLd effective. 3.16 The status, respcnsibilities, authority, and salary of the Exfecutive Director are especially important, as is the greater freedom to design and implement policy. The inter-ministerial POPCOM Board shouLd - 23 - concentrate on broad intersectoral policy issuaes and on program strategy decisions with wide social or financial implications, leaving the program planning, implementation, monitoring and evaluation activities to the technical Secretariat headed by the Executive Director. Inter-agency coordination could be facilitated by replacing the Board's Technical Committee with a Program Committee at the Director (not Minister) level, chaired by the Executive Director, and accountable to the POPCOM Board through the Executive Director. This Committee could be assigned the task of formulating and implementing POPCOM's medium--term and annual plans (after Board approval), and of evaluating projects submitted by participating agencies. 3.17 In addition, in order to improve the relevance, reliability and timeliness of the policy analysis carried out by POPCOM, and of the research and evaluation supervised by its Secretariat, it is desirable not only to upgrade central staff capabilities but also to modify the role of regional and lower level population officers. A better trained staff would improve POPCOM's ability to offer technical assistance to participating agencies, and to keep the Board informed of changing program demands on a regional basis. The improved research and evaluation capabilities of POPCOM's regional staff could be used for providing input into NEDA's national and regional development committees, and thus help to integrate family planning and social development policies. 3.18 POPCOM could also benefit from a better working relationship with the PCF. Established with the purpose of increasing the private sector's participation in the population program, thet PCF can effectively complement POPCOM's role. However, it seems inappropriate for the PCF to receive government funds; instead, it should continue to utilize the considerable resources and capabilities of the private sector. Such a demarcation of roles and funding sources of the PCF and POPCOM would improve the coordination activities of both. 3.19 A demarcation of roles is needed at the field level as well. Since the Outreach Project forms the core of POPCOM's implementation acti- vities, POPCOM's support structure extends down to the field level, as does that of the Ministry of Health. Though the proliferation of field positions was initially expected to be an advantage in service delivery, it has had the unintended consequence of duplicating the functions and staff of implementing agencies, thus creating competition for scarce resources at the community level. In view of the expected expansion of MOH's primary health care (PHC) program, in which a large cadre of community-based outreach workers will be deployed, there is a need to review the complementarity of functions between MOH and POPCOM outreach systems in order to better utilize recurrent funds and operational staff (see Chapter IX). 3.20 In summary, at the policy level, there is a need for an integrated population policy geared to broad socio-economic development objectives. POPCOM's improved policy analysis capabilities should be used to support NEDA's national development planning. However, before an integrated population policy can become a reality, it is necessary that responsibility for the various steps in the policy formulation process be carefully assigned. Better coordination of the fertility reduction policies that are POPCOM's direct responsibility is needed. It is - 24 - zmocip3.rtat that POPC<0MMs rolea and f unctions be clear'-y defined, so that -it i_ 'o o" r.-ersextended. an-.id z:er'1'Lappinig cxf its activities with those of other agenc.5 es is avo'idedt There is a need tto rEdace duplication, realign staff fi.inet c D L Ve smaaagfsgemect system,s and strengthen controls for morDc0i.Crig performance. Th.e nce of administrative reform should depend on proFrao"rF prLioriries and on practicai feasibility, both of which should be ca r,%sy assessede Chapter IW Popglation Plans and Programs 4,0' Four-Year Plan (1971-197 4), The target of reducing population gmro7th *rom 3.Z percen,t in 1970 to 3.2 percent in 1974 was first mentioned irn the Fo-r-Year Develocpment Plan of 1971-1974. Subsequent analysis revealed th-at the rate .f. 3s5 percent assumed in this plan was an overesti- mates the actual rate in 1971 uas about 3 percent. Hence, the target rate for the 1'9275 four-vyear r-ll-over ol.anl6/ was adjusted to 2.7 percent. 4 02 FPi'"o-Year Plan (1976-11.9U In 1977 the GOP prepared the Five- Y'a o Philia-pine Deveaipm; nt Plan (19781982), which included a family plan- n ,ng program ai'med at realucting popi;rT1tion gr)wth from 2.5 percent17i in 197'8 to 2.3 percent in 1982 and to 2.0 percent.: by 1987. The long-term goal was a ,ret reprotuztion rate of one, to be attained by the year 2000, when te "po-pulat3o.n s be o7r mi> liion and would have grown at a compound 2'n'r5
Группа Всемирного банка · Pre-2003 Economic or Sector Report
Philippines - Population, health and nutrition : a sector review (Vol. 2 of 2) : Main report with tables and technical annexes
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