Philippines - New directions in the Philippines family planning program

l~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Report No. 9579-PH New Directions in the Philippines Family Planning Program October 1, 1991 Population and I luman Resour(es Division Country Department 11 Asia Region FOR OFFICIAL USE ONLY ., ,Document of the WVorld Bank This document has a restricted distribution and may be used by recipients only ijg the performance of their official auties. Its contents may not otherwise be disclosed without World Bank authorization. 0  CURRENCY EQUIVALENTS Currency Unit - Philippines US $1.00 = P 7.40 (May 1979) = P 21.1 (end 1988) = P 21.7 (end 1989) = P 28.0 (end 1990) ABBREVIATIONS AND ACRONYMS AIM - Asian Institute of Management BFAD - Bureau of Food and Drugs BHS - Barangay Health Station BHS-MW - Barangay Health Station Midwife BHW - Barangay Health Worker BSPO - Barangay Service Point Officers BWL - Bureau of Women's Welfare DBM - Department of Budget and Management DECS - DEpartment of Education, Culture, and Sports DOF - Department of Finance DOH - Department of Health DSWD - Department of Social Welfare and Development FHSIS - Field Health Services Information System FIES - Family Income and Expenditures Survey FP - Family Pla.;ning FPP - Family Planning Program FPS - Family Planning Service GOP - Government of the Philippines IEC - Information, Education, and Communication LAM - Lactational Amenorrhea Method (of NFP) MCH - Maternal and Child Health MCRA - Married Couples of Reproductive Age MIS - Management Information System MPC - Municipal POPDEV Committee MSSD - Ministry of Social Services and Development NCR - National Capital Region NCW - National Commission on Women NDS - National Demographic Survey NEDA - National Economic and Development Authority NFP - Natural Family Planning NGO - Non-Governmental Organization MSO - National Statistics Office OPI - Open Pregnancy Interval PASE - Population Awareness and Sex Education Project (of DSWD) P/CPC - Provincial/City POPDEV Committee PDPR - Population and Development Planning and Research Project PEP - Population Education Programs (of DECS) PFPP - Philippines Family Planning Program PHC - Primary Health Care PHO - Provincial Health Officer PIHES - Public Information and Health Education Service PNC - POPDEV National Committee POPCOM - Population Commission (formerly Commission on Population) POPDEV - Integrated Population and Development Program RHU - Rural Health Unit RPC - Regional POPDEV Committee RPO - Regional Population Office TFA - Task Force on Advocacy (of POPCOM) TFIA - Task force on Innovative Approaches (of POPCOM) TFIB - Task Force on Institution Building (of POPCOM) TFR - Total Fertility Rate TIDA - Technical and Institutional Development Assistance UNFPA - United Nations Population Fund UPPI - University of the Philippines Population Institute USAID - United States Agency for International Development WHO - World Health Organization  FOR OFFICIAL USE ONLY - ii - DEFINITIONS Child Mortality Rate: The probability of dying between ages 1 and 5. Crude Birth Rate: Annual number of births per 1,000 persons. Crude Death Rate: Annual number of deaths per 1,000 persons. Contraceptive Prevalence The percent of married women in reproductive age Rate: groups who are using (or whose husbands are using) any form of contraception. Contraceptive Users: The number of women Jf reproductive age who are (or whose husbands are) current users of any form of contraception. Contraceptive Acceptors: The number of women who become (or whose husbands become) users of a contraceptive method they have not used in the months immediately prior, for a given time period. Dependency Ratio: The ratio of those under 15 and over 65 to the working age population, defined as those 15 to 64 years of age. Exclusive Breast-feeding: Breast-feeding not supplemented by bottle feeding or other foods. Infant Mortality Rate: The number of deaths to infants under 1 year of age in a one-year period per 1,000 live births in that period. Married Women of Currently married women between the ages of 15 Reproductive Age: and 44 or 49. Maternal Mortality Ratio: The number of deaths to women due to pregnancy and childbirth complications per 100,000 live births in a given year. Singulate Mean Age at Average age at first marriage, adjusted for the Marriage: age distribution of a population. Total Fertility Rate: The average number of children that would be born alive to a woman (or group of women) during her lifetime if she were to pass through her childbearing years conforming to the age-specific fertility rates of a given year. Total Effective Demand: The proportion of married women of reproductive age who, at a given point in time, are protected by contraceptive practice (commonly expressed as the contraceptive prevalence rate). Total Potential Demand: The hypothetical maximum proportion of currently married women aged 15-44 who would be protected by contraception if all unmet need were satisfied and continuing use maintained. Unmet Need: Condition of those women who should, by one or more criteria, be protected by family planning practice but are not. 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.  - iii - NEW DIRECTIONS IN THE PHILIPPINES FAMILY PLANNING PROGRAM Table of Contents Page No. EXECUTIVE SUMMARY . . .................... . 1 I. THE FAMILY PLANNING PROGRAM IN CONTEXT . . . . . . . . . . 14 A. Introduction ... . . . . . . . . . . . . . . . . . . 14 B. The Pnpulation and Development Context . . . . . . . . 15 C. Fertility Trends ... . . . . . . . . . . . . . . . . 22 II. LESSONS FROM THE 1970-1989 PROGRAM . . . . . . . . . . . . 37 A. Major Phases of the Historical Program ... . . . . . 37 B. The Iew Program ... . . . . . . . . . . . . . . . . . 40 C. Complrative Experiences ... . . . . . . . . . . . . . 44 D. Issues in the Historical Program . . . . . . . . . . . 51 III. HEALTH AND FERTILITY IMPLICATIONS OF THE NEW PROGRAM STRATEGY . . . . . . . . . . . . . . . . . . . . . . . . . 62 A. Health-Based Need ... . . . . . . . . . . . . . . . . 63 B. Preference-Based Need ... . . . . . . . . . . . . . . 66 C. Health-Based and Preference-Based Criteria Considered Jointly .... . . . . . . . . . . . . . . . . . . 67 D. Impact on Fertility ... . . . . . . . . . . . . . . . 72 E. Impact on Health ... . . . . . . . . . . . . . . . . 74 F. Need for Spacing Versus Need for Limiting ... . . . . 75 G. Need for Family Planning and Effective Demand for Services ... . . . . . . . . . . . . . . . . . . 76 H. Assessment of Program Capacity ... . . . . . . . . . 78 I. Conclusion .... . . . . . . . . . . . . . . . . . . 81 Sharon Stanton Russell had lead responsibility for preparation of this report, with major contributions provided by Catherine Fogle, John Casterline and Stanley Scheyer. Significant contributions were also made by Shaikh Hossain and Miriam Labbok, and valuable assistance was provided by many others, including Enrica Aquino, Cecilia Cabanero-Verzosa, Jack Graves, Genevieve Kenney, Lourdes Pagaran, Warren Sanderson and Detlef Schwefel. The team is grateful to the many Department of Health and other Philippine Governnment officials and to the researchers of the University of the Philippines Population Institute, who contributed generously of their time and expertise. The team was further assisted by the participation in its work of USAID and UNFPA staff in Manila.  - iv - Page No. IV. ISSUES IN PROGRAM IMPLEMENTATION . . . . . . . . . . . . . 83 A. Introduction . . . . . . . . . . . . . . . . . . . . . 83 B. Program Organization and Management Structure . . . . . 83 C. Technical Standards ... . . . . . . . . . . . . . . . 91 D. IEC Approaches .... . . . . . . . . . . . . . . . . 95 E. Training . . . . . . . . . . . . . . . . . . . . . . . 100 F. Logistics and Procurement Systems . . . . . . . . . . . 103 G. NGO, Commercial and Private Systems . . . . . . . . . . 107 H. Program Information, Monitoring, Evaluation, and Research . 112 V. ISSUES IN PROGRAM COST AND FINANCING . . . . . . . . . . . 119 A. Introduction .... . . . . . . . . . . . . . . . . . 119 B. Estimates of Program Costs and Financing Requirements 119 C. Family Planning in the Context of Health Financing . 124 D. Alternative Financing Strategies and Resource Mobilization .... . . . . . . . . . . . . . . . 127 VI. REFERENCES ........................ . 137  -v - List of Tables in Text Table 1.1 - Trends in Fertility and its Proximate Determinants: 1968- 1988 Table 1.2 - Trends in Post-Prrtum Behavior, by Place of Residence and Schooling Attainment: 1978-1988 Table 1.3 - Trends in Contraceptive Prevalence: 1968-1988 Table 1.4 - Trends in Fertility and its Proximate Determinants, 1973-77 to 1988: Unadjusted and Adjusted Survey Estimates Table 1.5 - Trends in Fetal Mortality, 1980-88. Table 2.1 - Projected Annual Accomplishments Table 2.2 - Declines in Total Fertility Rates 1965-69 to 1988, Thailand, Indonesia and the Philippines Table 2.3 - Annualized Change in Contraceptive Prevalence Rates Selected Asian Countries, Married Women 15-49 Table 2.4 - Percentage Distribution of Contraceptive Use by Currently Married Women, Indonesia and Philippines, by Method Table 2.5 - Breakdown of Outreach Project Costs Table 3.1 - Total Potential Demand Calculated in Health-Based Criteria Table 3.2 - Total Potential Demand Calculated According to Preference- Based Criteria for Family Planning Table 3.3 - Total Potential Demand for Family Planning Calculated on Health and Preference Criteria Considered Jointly Table 3.4 - Percentage Distribution of Currently Married Women Aged 15-44 Having Unmet Need for Family Planning (Health and/or Preference Based) Table 3.5 - Hypothetical Fertility Implications of Contraceptive Use by Women with Unmet Need According to Health Risk or Expressed Preferences Criteria Table 3.6 - Intention to Use Contraception in the Future Table 3.7 - Timing of Future Contraceptive Use Table 3.8 - Number of Acceptors Required to Satisfy Unmet Need and Serviceable by DOH: 1989-1994 Table 3.9 - Number of Acceptors Required to Satisfy Unmet Need and Proportions Serviceable by DOH with Improving Method Mix Table 5.1 - Preliminary Estimates of Family Planning Program Costs 1990- 1994 Table 5.2 - Preliminary Estimates of Family Planning Program Financing 1990-1994 Table 5.3 - Ordinary Least Squares Estimates of Government Health Expenditure and Revenues Table 5.4 - Share of Medical Care to Total Family Expenditure, By Income Class, Urban-Rural, 1988  - vi - List of Figures Figure 1.1 - Map of 1980-1990 Population Growth by Province Figure 1.2 - Percentage Reduction in Total Fecundity Rate Figure 1.3 - Decomposition of Declines in Fertility, 1973-77 to 1988 Figure 1.4 - Decomposition of Declines in Fertility, By Place, 1973-77 to 1983-87 Figure 1.5 - Decomposition of Declines in Fertility, By Schooling (years), 1973-77 to 1983-87 Figure 2.1 - Real Expenditure in Family Planning Program (Constant 1980 Prices) Figure 3.1 - Health-Based Total Potential Demand, by Place Figure 3.2 - Health-Based Total Potential, by Years of Schooling Figure 3.3 - Preference-Based Total Potential Demand, by Place Figure 3.4 - Preference-Based Total Potential Demand, by Years of Schooling Figure 3.5 - Total Potential Demand for . mily Planning, (Health and/or Preference Based) by Place Figure 3.6 - Total Potential Demand for Family Planning, (Health and/or Preference Based) by Years of Schooling Figure 5.1 - Average Family Income by Province, 1988  - vii - List of Annexes Annex 1 Table 1 - Philippines: Demographic Indicators, 1968-1990, Various Sources Annex 2 - Technical Annex - Integrating Health Risk Considerations and Fertility Preferences in Assessing the Need for Family Planning in the Philippines Annex 2 - Appendix A - Trends in Fertility and the Proximate Determinants: Data Sources and Methodology Annex 2 - Appendix B - Measurement of the Desire for Another Child, An Estimation of the Unmet Need for Contraception Based on Expressed Preferences Annex 2 - Appendix C - Conversion of Proportion Having Unmet Need Into Impacts on Contraceptive Prevalence and the Total Fertility Rate Annex 2 Table 2.1 - Trends in Fertility and its Proximate Determinants: 1968-1988, Unadjusted Survey Estimates Table 2.2 - Trends in Post-Partvm Behavior, By Place of Residence ar.d Schooling Attainment: 1978-1988 Table 2.3 - Trends in Contraceptive Prevalence: 1968-1988 Table 2.4 - Trends in Fertility and the Proximate Determinants of Fertility, 1973-77 to 1988 Table 2.5 - Components of the Bongaarts Model of Fertility and the Proximate Determinants of Fertility, 1973-77 to 1988 Table 2.6 - Decomposition of Declines in Fertility into Contributions of Each Proximate Determinant, 1973-77 to 1988 Table 2.7 - Decomposition of Declines in Fertility into Contributions of Each Proximate Determinant, 1973- 77 to 1983-87, by Place and Schooling of Subgroups Table 2.8 - Trends in Total Fertility, 1980-1989 Table 2.9 - Trends in Fetal mortality, 1980-1988 Table 3.1 - Trends in Fertility Preference, 1978-1988 Table 3.2 - Unmet Need Implied by Expressed Preference: Contraceptive Use by Desire for Another Birth Table 3.3 - Unmet Need Implied by Expressed Preference Table 3.4 - Unmet Need Implied by Expressed Preference: Variation by Place Table 3.5 - Unmet Need, as Assessed by Expressed Preferences: Variation by Years of Schooling Table 4.1 - Unmet Need Implied by Health Risk Criteria Table 4.2 - Unmet Need for Family Planning Implied by Health Risk Criteria, by Place and Years of Schooling Table 5.1 - Unmet Need for Family Planning Implied by Expressed Preferences and Health Risk Criteria Table 5.2 - Unmet Need for Family Planning Implied by Expressed Preferences and Health Risk Criteria Table 5.3 - Unmet Need for Family Planning, according to Expressed Preferences and Health Risk Criteria, by Schooling, Place, and Region Table 5.4 - Unmet Need for Family Planning, according to Expressed Preference and Health Risk Criteria, by Schooling and Place  - viii - Table 5.5 - Unmet Need, Contraceptive Prevalence Rate, and Demand for Family Planning, by Schooling, Place, and Region Table 6.1 - Contraceptive Use ard Use-Effectiveness, by Desire for Another Birth and Health Risk Status Table 6.2 - Fertility implications of Contraceptive Use by Women with Unmet Need According to Expressed Preference or Health Risk Criteria Table 6.3 - Marginal Effects on Infant and Early Childhood Mortality of Maternal Age, Parity, and Birth Spacing Table 6.4 - Infant Mortality Implications of Averting Births of Women at High Health Risk Table 6.5 - Early Childhood Mortality Implications of Averting Births to Women at High Health Risk Table 6.6 - Infant Mortality Implications of Averting Births to Women at High Health Risk Table 6.7 - Early Childhood Mortality Implications of Averting Births to Women at High Health Risk Table 7.1 - Number of Acceptors Required to Meet Demand and Serviceable by RPFPP: 1989-1994 Table 7.2 - Number of Acceptors Required to Satisfy Unmet Need, as Implied by Expressed Preference and Health Risk Criteria, and Percentage Serviceable by the RPFPP Assuming Improving Method Mix: 1989-1994 Annex 3 Table 3.1 - Family Planning Program Expenditures, 1970-1989 (in million pesos, at current prices) Table 3.2 - Family Planning Program Expenditures, 1970-1989 (in million pesos, at constant 1980 prices) Table 3.3 - Percentage Distribution of Family Planning Expenditure, By Funding Source, 1970-1989 Table 3.4 - Percentage Distribution of Real Expenditure in Family Planning by Category (1980 Prices) Table 3.5 - AID and UNFPA Funding for the Philippine Family Planning Program, Various Sources Annex 4 Table 4.1 - Department of Health: Current Expenditure by Category Table 4.2 - Department of Health: Real Expenditure in Health by Category Table 4.3 - Structure and Composition of Health Expenditure Table 4.4 - DOH Expenditures by Region Table 4.5 - Per Capita Health Expenditure, by Region (In Nominal Terms) Table 4.6 - Per Capita Health Expenditure, by Region (In Constant 1980 Prices) Table 4.7 - Average Family Income, by Income Class, Urban-Rural, 1988 Table 4.8 - Average Expenditure for Medical Care by Income Class Table 4.9 - Distribution of Sources of DOH Finance Map  EXECUTIVE SUMMARY i, For the past two decades, concerns about promotion of family welfare and the effects of rapid population growth have been central issues in the development process of the Philippines. The Family Planning Program has figured prominently in the efforts to address these issues. However, over the course of its history, the Philippines Family Planning Program has been characterized by vacillating political support, variable levels of financing from both domestic and external sources, diffused responsibility for Program functions, and lack of consensus on Program goals. As a result, despite modest increases in contraceptive prevalence and declines in total fertility, tbe Philippines Program has not attained its own stated objectives nor achieved the results observed in neighboring countries. ii. Following the change of Gevernment in 1986 and adoption of a new Constitution, there has been a renewed debate on fundamental policies and a concerted effort to rethink strategies guiding the National Program. Four significant changes have been adopted: (a) A new population policy distinguishes between the country's Family Planning Program on the one hand, and its broader population and development concerns on the other. While rapid population growth remains a strategic national development issue, the Family Planning Program's stated primary goal is no longer to reduce fertility, but rather to improve family welfare by providing accurate and timely information and services to support individual couples' fertility decisions; (b) A new Program strategy is anchored in the significant health improvements that result from family planning practice. Thus, the new Program will address two sources of demand for services: (a) that based on the demonstrated benefits of family planning for the health of mothers and children; and (b) married couples' expressed fertility preferences; (c) The institutional and operational locus of the Family Planning Program has shifted from the Population Commission (POPCOM) to the Department of Health (DOH). the country's major family planning service provider. POPCOM will continue to address broad national population and development concerns, including rapid population growth. The DOH will assume leadership in defining national family planning policies and standards for the provision of information and services by the DOH itself, and by other public and private sector partner agencies; it will also provide technical and financial support to its partner agencies; and (d) The new P-ogram is domestically, not externally driven. The Government has grounded the new Program in a broad-based process of national consensus building. Internatio:.,i agencies have been con- sulted and participated in this process, .ut the Program's "ownership" is Philippine and its policies and strategies are clearly those of the Government.  iii. The potent'al henefits of these changes are of strategic importance for family and social welfare in the Philippines, and have significant long- term consequences for sustainable development and poverty alleviation. This report provides the Government and the international community with an assessment of the lessons to be learned from the history of the Program, and the potential health and fertility outcomes that could result if unmet needs for family planning were to be fully satisfied. The report also examines the implementation issaes confronting the new Program and the prospects for achieving sustainable financing in the future. Background iv. Population. The Philippines' total population increased from 36.7 million persons in 1970 to 60.5 million in 1990, making it now the 14th most populous country in the world and the 8th in Asia. The Government had aimed to reduce the annual rate of population growth from 2.97 in 1970 to 2.3 percent by 1982, but achieved this goal only in 1990. Today, the population growth rate is higher than that of many other Asian countries, including China, India, Sri Lanka, Indonesia, Thailand and Korea. v. Poverty. Despite impressi've gains on many fronts, the incidence of poverty in 1985 was 58 percent; over half of Philippine families had incomes below the poverty line of P 4,764 or $256 per month. In absolute terms, an estimated 5.5 million farilies or about 31 million people out of the 54 mil- lion population in 1985 were poor. While the proportion of the poor has remained unchanged since 1971, an additional 13.8 million people have been added to their ranks as a result of population increase during the period. vi. Environment. Population dynair.ics and uneven resource management policies have interacted to threaten prospects for sustainable development in the Philippines. Rapid population growth, internal migration and poverty have had demonstrable negative effects on the environment, notably on rural natural resources. This degradation affects the Agriculture, Fishery, and Forestry sectors which, together, employ half the labor force, generate two-fifths of export earnings, and contribute one quarter of GDP. vii. Maternal and Child Hea h. Aggregate health indicators for the Philippines have improved over the past two decades. Life elppctancy now stands at 66 and 62 years for women and men, respectively, about average for lower middle income countries. The infant mortality rate (IMR) has continued to decline steadily diring the 1970s and 1980s and is now estimated at between 45 and 51.5 per 1,000 live births, below the average for lower middle income countries but still high relative to neighboring countries such as Malaysia, Thailand and Korea. However, these aggregate indices mask considerable variations within as well as between provinces and obscure the persistence of serious health problems among women and children, especially among low income groups. viii. Pregnancy and childbirth place Philippine women and their children at particular risk. The high maternal mortality ratio, estin,ated at 80 to 90 per 100,000 live births, results mainly from hemorrhage and hypertensivs complications of pregnancy. Maternal illnesses including anemia and nialnutri-  tion affect almost half of all pregnant women. Medical complications from illegal abortion has been estimated to account for up to one quarter of the cc.untry's maternal deaths. "he poor nutritional and health status of women is associated with similar cond-tions among their children. Malnutrition among women, along with closely spaced births, contributes to the relatively high percentage of babies born with low birth weight and, in turn, to the infant mortality rate. The prevalence of malnutrition among children under the age of 5 is esrimated by UNICEF to be amor.g the highest in Asia. ix. Fertility. The Philippines Total Fertility Rate (TFR) declined by 1.46 births, from 5.72 in the late 1960s to 4.26 in the mid-1980s. As of 1990, the TFR is estimated to be slightly below 4.00 The Contraceptive Prevalence Rate (CPR), rose frormi 17.4 percent of currently married women aged 15-44 in 1973 to 36.1 percent in 1988 (45.8 percent according to the 1986 National Demographic Survey). x. Thailand and Indonesia began their family planning programs at about the same time as the Philippines and with similar demographic profiles, and all three countries implemented their programs primarily through public sector health services. Yet fertility decline over the past 20 years has been sig- nificantly greater in Thailand and Indonesia, where, respectively, TFRs have fallen by 3.3 and 2.17 births, and CPRs were 68 and 48 percent in 1987. Socioeconomic differences among the three countries should have contributed to better, not lower, relative performance by the Philippines. xi. In the Philippines, ferLility appedrs to have declined most rapidly in the first half of the 1970s and in the first half of the 1980s. However, the rate of decline slowed in the later 1980s, and fertility may even have increased temporarily in 1987. xii. Ln most time periods examined, for the population as a whole and for selected social sub-groups, declines in fertility can be attributed demographically mainly to increases in contraceptive prevalence, particularly use of modern methods, which nonetheless remains well below the levels observed in other Asian countries. However, in certain time periods, and among both rural and the best educated women, the contribution of nuptiality is also substantial. This effect results from an increase in the number of women never married, rather than any '.ncrease in the adjusted mean age at first marriage, which has remained consistently high and has little potential to contribute to further fertility decline. xiii. Changes in post-partum practices have contributed little to overall fertility decline, and in some periods and groups, have worked against it: both the duration of post-partum amenorrhea and duration of the post-partum non-susceptible period (amenorrhea and abstinence) have become shorter, as a result of declines in the proportion of children breastfed and the average duration of breastfeeding. These trends are cause for considerable concern: they not only contribute to increased fertility, they are detrimental to infant and child heL 'l.  -4- Historical Experience xiv. In 1968, the Project Office for Maternal and Child Health was established under the Secretary of Health to administer a population planning program (which included non-governmental organizations (NGOs) and the private sector) and to provide family planning services. In 1969, a Commission on Population was created and, upon its recommendation, the National Population Program was launched in 1970 with the explicit goal of reducing fertility for the benefit of national welfare. Originally, POPCOM served as the central coordinating and policy-making body, while family planning services were delivered primarily through the Department of Health, complemented by NGOs and other Government agencies. xv. Surveys conducted in the mid-1970s found that contraceptive preval- ence rates in rural areas were less than half those in urban areas, and that the rates dropped as the distance from clinics increased. In an effort to improve accessibility of services, as well as to broaden and deepen local Government support for the Program, the Outreach Project was launched in 1976. In keeping with prevailing international views (which held that family planning should be a vertical initiative distinct from health), and because development of the DOH's rural care network was still in its infancy, it was decided to separate family planning outreach from that of the health system. xvi. Although well-intentioned, this strategic decision had a number of unanticipated negative outcomes. First, two dichotomized family planning service delivery structures emerged. By the early 1980s, POPCOM effectively had become an implementing arm of the Program, as its role expanded to include not only Program coordination, but also technical and logistical support; local governments provided counterpart funding and staff. Competition and conflict arose between POPCOM and the DOH, where attention came to focus increasingly on extending rural primary care and less on family planning. Although the Department remained the country's major service provider, the staff of the DOH's Family Planning Service dwindled from 150 in 1976 to fewer than 50 in 1989, and the number of new acceptors served by the Department dropped from 336,577 in 1973 to only 179,603 in 1984. xvii. Second, the prominence of the Outreach Project stimulated growing public debate over the Program's emphasis on fertility reduction and the focus on contraceptives to achieve that goal. Eroding political support and related changes in internal leadership and policy orientation were associated with severe budgetary contractions, all of which constrained POPCOM's management of the Program. After the change of Government in 1986, institutional development and service delivery continued to decline while the new policies were being debated. Training funds, which had averaged P 18 million annually in the early 1980s, dropped to only P 4 million in 1987 and 1988 and were virtually nil in 1989. Although stocks of oral contraceptives were adequate to meet demand through 1990, imports in 1989 and 1990 fell below annual requirements, and both public and private family planning service providers experienced supply disruptions as commodities were delayed in customs or the logistics system. According to results of a survey conducted by the DOH's Family Planning Service in late 1990, not a single DOH hospital, less than one percent of rural health units, and only two percent of barangay health  stations nationwide had both adequately trained staff and adequate contraceptive supplies. The New Program xviii. The first and most fundamental step toward establishing a new population policy framework was taken in April 1987, with adoption of a new Constitution which recognized the right of couples to choose for themselves the size of family they would like to raise in accordance with their religious convictions and considerations of responsible parenthood. This measure was followed by issuance of a new Medium-Term Development Plan and a new popula- tion policy which recognized the close interrelationship of population and a number of other factors, including maternal and child health. xix. The new policy principles and "Program thrusts" asserted the importance of family welfare and responsible parenthood; rejected abortion; stressed the need for enhanced public-private sector partnerships; and adopted an integrated approach to delivery of health, nutrition, and family planning services. xx. To clearly delineate responsibilities under the National Population Program, the DOH was designated lead agency for family planning, charged with establishing policies and standards for its own activities and those of participating Governmental and Non-Governmental agencies. Other Government Agencies include the Departments of Labor, Education, Environment and Natural Resources, and Defense, Municipal and City Governments, the National Nutrition Center, and the Bureau of Agricultural Extension. Major participating NGOs include the Institute for Maternal and Child Health (IMCH), the Family Planning Organization of the Philippines (FPOP), and the Population Center Foundation (PCF). xxi. The POPCOM Board will continue to serve as a coordinating and policy-making body for the overall National Population Program, staffed by a Secretariat responsible for monitoring and documenting interactions between population dynamics and other aspects of economic development, and for l,roviding support to all participating agencies, including DOH. xxii. In July 1989, the POPCOM Board approved a new Five Year Directional Population Plan, which formed the basis for subsequent articulation of the DOH's 1990-1994 Family Planning Program Plan by six joint working groups comprising Philippine and international representatives. The Program Plan was reviewed at a Consultative Meeting in July 1990. xxiii. The Program's stated objective is to respond to the demands of families for assistance in meeting their health and fertility aspirations. Specific objectives include increasing the number of acceptors and the proportion of women practicing family planning; decreasing the dropout rate; and continuing services to current users. To meet these objectives, projected accomplishments are quantified for establishing services in public and private facilities with unused capacity, maintaining existing service outlets, and training of health workers.  -6- Lessons for the Future xxiv. At its core, the Philippines Family Planning Program has always been a strategic social development initiative intended to advance family as well as national welfare. In retrospect, however, the social service character of the Program became obscured, and the attainment of its stated goals impeded, by a number of factors. xxv. The policy environment. Political commitment to family planning has vacillated, in large part because of the singular focus on fertility decline, which opened the entire Program to questions about the appropriate role of Government in a predominantly Roman Catholic country. The new Program's emphasis on the health benefits of family planning practice, the new role of Government as provider of information and services in response to the demands of individual couples, and the decision to view satisfaction of this demand as separate from (albeit contributing to) fertility decline, promise a firmer foundation for more sustained political commitment in the future. xxvi. Organization and management. The Program's organization and management suffered from blurred responsibilities for policy and implementa- tion, as well as changes in leadership and vacillating political support. An international comparative study of 100 developing countries found that the Philippines scored only 15.6--lowest of any East Asian country--on a scale measuring the degree to which organization, support, supervision, and the activities of program personnel facilitate the delivery of services. By comparison, Thailand had a score of 25.1, and Indonesia a score of 29.5, second only to Hong Kong. xxvii. Under the new Program, and consistent with its role as the country's major service provider, DOH has clear responsibility for family planning policy and implementation, with purview over the activities of participating agencies. The DOH must now forge new relationships with these agencies as well as with Local Government Units. Within the DOH itself, a number of units will have important roles in the Program. Historical experience suggests it will be essential to avoid recreating the conflicting roles and responsibil- ities that characterized the past, and to ensure that intra-agency conflicts do not supplant the old interagency ones. xxviii. Contraceptive mix and supply. Contraceptives useu in the Program were provided as commodity grants by external donors, which made supply vulnerable to changes in donor support, contributed to perceptions that the Program was externally driven, and made contraceptive mix "supply driven". The new policy framework will require a more client-centered demand-directed approach toward determination of contraceptive mix. Working within budget constraints DOH will need to optimize its response to such demand and diversify sources of contraceptive supply. xxix. IEC and Training. In past IEC efforts, practical information on contraception was often incomplete, inaccurate, and conflicting, and the audience (all married couples of reproductive age) was too diverse to be reached through a single strategy. New efforts must tailor information to the needs of diverse client groups, including men. Further, neglect of human  - 7 - resource development in the DOH has left many health workers misinformed about health risks associated with pregnancy and contraception and poorly informed about methods and their use. The health rationales for family planning will need to be included in both IEC and training. xxx. Program financing. Throughout its history, the Program has been characterized by the lack of a sustainable financing strategy and a reliance on external funding sources that, on average, exceeded 50 percent of total expenditures, giving donors considerable influence, and undermining the Program's domestic credibility. During the past decade, the Program has experienced severe declines in financial support: between 1982 and 1986, real expenditures declined by nearly 9 percent annually, and irn 1986-87 the rate of decline exceeded 10 percent. The share of family planning in real total government expenditures declined from 0.51 percent in 1984 (close to the twenty year average), to 0.18 percent in 1988. During the latter half of the 1980s, absolute levels of funding were precariously low and affected the quality and quantity of services. Future financing strategies will need to address these problems. Potential Health and Fertility Impacts of the New Program xxxi. The new Family Planning Program strategy is based on twin concerns for the health of women and children who would be exposed to significant risk in the absence of family planning, and respect for the rights of women who wish to regulate their fertility. Analyses conducted for this report have found that the Philippines' new health oriented, demand-driven family planning strategy has the potential to yield significant health and demographic results. xxxii. Several terms and concepts are key to understanding these findings. "Unmet need for family planning" refers to the condition of those women who, by one or more criteria, should be using family planning but are not. Health risk criteria identify women for whom a pregnancy presents an elevated health risk to themselves and/or their children. The risk factors selected for this analysis--those currently used by the DOH's Family Planning Service (FPS) include: the woman's age (below age 20 and above age 35), parity (number of children born alive--in this case 4 or more children) and number of months since completion of the most recent pregnancy (15 months). Such women who are not using contraception are considered to have "unmet need according to health risk criteria.' xxxiii. Fertility preference criteria identify women who indicate a desire to regulate (space or limit) childbearing. This analysis uses preferences as expressed by women interviewed in the 1986 Contraceptive Prevalence Survey Women who are not using contraception are considered to have 'unmet need according to expressed preference." xxxiv. "'Total potential demand' for family planning comprises women with unhiet need by health or preference criteria, and those already expressing their demand for family planning by current, continuing use. Total potential demand is the hypothetical maximum proportion of married women of reproductive age who would be protected by family planning if all those at health risk and  those wishing to regulate their fertility had access to and used services. "Effective demand" (i.e. those actually protected by contraception at a given point in time) will always be less than potential demand. xxxv. By the FPS criteria, nearly two-thirds of currently married women aged 15-44 should be protected by family planning because they face sig- nificant related health risks. Of these, about half are using contraception, so that 28.4 percent have unmet need for family planning on health grounds. By the preference-based criteria, almost three-quarters of currently married women aged 15-44 express a desire to regulate their fertility. Of these, nearly half are already using contraception, so 26.1 percent of women have an u unmet need for family planning on preference grounds. xxxvi. There is considerable overlap in the potential client groups identified by preference and health approaches. Each definition captures about three quarters of the women having unmet need by the other criterion and about 90 percent of total potential demand estimated by the two criteria combined. These results suggest that adoption of a health approach to family planning will not significantly alter the programmatic effort required. This extent of overlap also implies that a high degree of client receptivity can be expected if the Program stresses reproductive health concerns and service availability as the Government intends. xxxvii. However, the estimated level of u.imet need for family planning in the Philippines is high: roughly one third of married women aged 15-44 are not using family planning services but ought to be, based on calculations of preference and health risk. While unmet need is higher among rural residents and those with less education, total potential demand does not vary by subgroups examined and is high overall: approximately 80 percent of married women aged 15-44 would require services if both their unmet needs were to be satisfied and their continuing contraceptive use maintained. xxxviii. While it is unlikely that the Program can satisfy the estimated levels of unmet need implied by both criteria within the next several years, achieving this aim by the year 2000 is theoretically feasible with expansion of DOH capacity and increased role for private providers and local government. Attainment of such results would depend on successful translation of total potential demand into effective demand--actual contraceptive use. There is no basis for assuming that such a direct translation will occur; the health criteria are not necessarily recognized by couples in the Philippines, but rather are superimposed on existing expressed desires to regulate fertility. xxxix. However, successful translation of potential demand into effective demand would likely have a significant impact on lowering mortality and fertility. Preliminary analyses of available data indicate that if pregnancy were avoided by women under the age of 20, over 35, with 4 or more children, and less than 15 months post-partum, both the infant and child mortality rates would decline by almost 25 per cent and the number of infant and child deaths would decline by 35 tc 50 percent. Thus, family planning could have a very significant effect on mortality which should be recognized along with other infant and child survival interventions.  - 9 - xl. The hypothetical fertility implications of satisfying estimated levels of unmet need for family planning (identified by both preference and health criteria) are also substantial: the contraceptive prevalence rate would increase by 30 points (from 43.6 to 76.7 percent) and reduce the Total Fertility Rate by 2 births, from 4.10 to 2.08--replacement level fertility. xli. Analyses for this report suggest that, because women with an unmet need to space are concentrated at younger, high fertility ages, satisfying the spacing need could have an effect on fertility equal to that of satisfying the need to limit, despite the greater number of women in the latter group. Furthermore, improved birthspacing is estimated to have an even greater impact on infant and child mortality than would limiting births to older, high parity women, even though methods to limit fertility (notably female sterilization) now predominate among contraceptive use patterns in the Philippines. Thus, identifying and serving those women who should space their pregnancies is a clear priority. Services should, of course, continue to be available to women and men who wish to limit their fertility. xlii. These outcomes would be impressive and would represent substantial benefits to Philippine society in the form of reduced fertility and mortality. Achieving these results, howevar, will require careful and concerted implemen- tation of the new Program, translation of potential demand into sustained contraceptive use, and adequate, reliable funding. Implementing the New Program Directions xliii. The first priority of the new Program is to establish DOH as the main technical and service resource for family planning. Despite lagging staff interest and a weakened capacity to provide such services in the 1980s, the DOH has consistently provided more than half of the country's family planning services over the past two decades. Both unused capacity and commitment to the Program remain untapped in other Governmental and Non- Governmental agencies as well. There is now an important opportunity to greatly expand access to family planning services nationwide through existing health facilities where such services are either not now available or provided at minimal levels. Once ratified by Congress, the new Local Government Code will give LGUs a much greater share both in national tax revenues and much greater responsibility for provision of social services, including health and family planning. The DOH will need to develop new working relationships with LGUs to help the LGUs carry out these new responsibilities. To do this, however, the DOH must concentrate as its first priority on developing its own capacities for Program management and service delivery. xliv. Establishment in 1990 of a Technical Secretariat within DOH was an important step toward strengthening DOH's ability to provide overall Program direction, in keeping with its new, broader responsibilities. Among the Secretariat's management functions will be establishing Interagency Policy Development Committees to formulate operational policy recommendations. The Secretariat will need the capacity to manage program change over time, since family planning programs must function as dynamic processes, continuously learning from their immediate past. The Secretariat will require the flexibility and authority to collect needed information on the Program's  _ 10 - environwpent and achievements, and to use this information for timely corrections and adaptations to the Program at all levels. xlv. Clear identification of specific client groups is needed for IEC and training, as well as resource allocation. The first task is for the Clinical Standards Committee to review and choose among alternative health risk criteria currently under consideration. It is critical to ensure that iden- tification of client groups for Program planning purposes is not misunderstood by front line health workers as any interncion to "ration" or restrict access to services. The Program will need to rerun client analyses with new data from the 1990 census and, eventually, to reconsider its focus on married couples, given evidence that unmarried couples also face pregnancy risks. Both individual men and unmarried women are in need of services. xlvi. Before launching new IEC efforts, the Program must define clearly the audiences to be reached (including both male and female contraceptive users, non users, policy makers, and advocacy groups); revise message content to provide more specific and correct information on both natural and modern contraceptive methods and to incorporate the health rationales for family planning; review and select (or revise) materials and media. Implementation of IEC activities should be timed so that health workers are already trained to respond. xlvii. The task of integrating family planning activities or services with those of MCH and other priority services will require careful planning, particularly in view of the heavy workload already borne by the midwife. Integration around the birth event is an efficient way to begin, although a large proportion of women with unmet need have not had a recent birth. DOH leadership (from central to regional and field levels) will need to give focussed attention to developing integration strategies and patterns of frequent and regular communication and interaction to support the provision of complementary services. This effort will require participation by and close coordination among the Family Planning Service (FPS), the Maternal and Child Health Service (MCHS), the Public Information and Health Education Ser';ice (PIHES), the Health Manpower Development and Training Service (HMDT), and the Technical Secretariat. xlviii. In order to achieve its stated intent of making available nodern commodity-based and surgical contraceptive methods as well as Natural Family Planning and breastfeeding, the Program must consider expanding the currently limited number of contraceptive formulations and methods now available. Wider range of choices would attract new clients and increasing the numbers of continuing users. The DOS will also need to adopt new contraceptive prescribing protocols which provide balanced descriptions of available family planning methods, as well as information regarding the role of family planning in reducing reproductive risk. xlix. Training--linked to revised performance measurement and resource allocation procedures--is arguably the linchpin of the new Program. The content of training and supervisory materials needs to reflect approved technical standards, and implementation of the massive training effort ahead will probably require assistance from resource groups outside the DOH. Family  - 11 - planning training will need to be carefully integrated with other DOH training activities. 1. Establishment of a reliable contraceptive logistics system must be a very high Program priority. The DOH is not yet prepared to assume all the contraceptive logistics and distribution functions formerly carried out by POPCOM, and until the new DOH logistics system is operational, an interim system with support from POPCOM is envisaged. Current arrangements for transport of supplies are ad hoc and diverse. As the new planned DOH logistics system is implemented, it should enable the supply and logistics system to respond rapidly to changes in client demand. li. Following completion of the ongoing National Inventory of Contraceptive Supplies, and again after approval of National Guidelines on Contraceptive Mix, forecasts of existing contraceptive stocks and future needs should be reviewed by DOH and adjusted on a regular basis, and any changes communicated to relevant donors. Because choice of technically-approved contraceptives will be based upon specific client preferences, the review should be repeated quarterly, or more often if significant changes in demand become evident. It should be noted that contraceptive sourcing and procure- ment policies profoundly affect costs, as does the current policy of imposing import taxes of 10-20 percent on contraceptive supplies. lii. Nongovernmental organizations and the private and commercial sectors are important partners in implementing the new Program. Technical standards will need to be drafted in cooperation with representatives of these groups to provide them with much needed policy guidance for participation in the new Program. However, the DOH must further develop comprehensive strategies for expansion of NGO services; using the DOH Family Planning Service's 1990 Annual Assessment to the greatest extent possible, data should be collected on where DOH and NGO services are co-located and determination made whether these are overlapping or complementary. liii. Apart from NGOs, two other important mechanisms exist within the private sector to expand the accessibility and quality of family planning services. The first is social marketing, the provision of contraceptives through normal merchandizing channels such as pharmacies and village stores; such services may or may not be subsidized. The second mechanism is the provision of family planning services by private sector health practitioners. The feasibility of providing incentives to private physicians, nurses and midwives to include family planning in their practices should be explored. Programs designed to encourage private sector firms to include family planning as an employee benefit (such as those currently sponsored by the Department of Labor and Employment) may also be expanded. liv. Current family planning monitoring systems need to be expanded and updated. Base population data should reflect the 1990 census results and intercensal population adjustments mechanisms established. It is desirable to begin monitoring by province, rather than region, given evidence of high degrees of inter and intra provincial variation. Continuing users--not only new acceptors--should receive more balanced attention in monitoring procedures, and contraceptive requirements should be communicated to the  - 12 - logistics system on a timely basis. The "percentage of target" indicators now in use should be replaced by indicators more closely linked to health worker performance, client satisfaction, and attainment of health objectives. One promising approach would be to focus on birth-based indicators. Issues of Program Financing and Sustainability lv. The Government has adopted ambitious objectives for the 1990-94 Family Planning Program. Achieving them will require both strengthened implementation capacity and a large increase in resources compared with recent years. Significant growth in Program financing is warranted in view of the major lorg-term benefits for family welfare, sustainable development and poverty alleviation that Philippine society stands to gain from Program success in reducing fertility and improving health status. lvi. While revised projections of the 1990-1994 Program's costs may well result in lower financing requirements than previously estimated, the current fiscal crisis in the Philippines is likely to mean that Program financing will pose significant challenges, and that the Government will need to mobilize additional resources and prioritize the allocation of available funds. A number of options exist. lvii. Mobilization of new rescurces. Local Government Units (LGUs) are a possible source of increased domestic support for the Program. Past LGU expenditures on family planning (through the Outreach Project) have been sig- nificant, especially relative to those for health in general. The potential for increased LGU support for the Program depends, however, on a number of factors, including the extent of LGU revenue-raising authority under pending national legislation, variations in municipal revenue generation capacity, differences in willingness among LGUs to support family planning on religious or political grounds, and differences among LGUs in degrees of current financial capacity and prospects of future economic growth. lviii. Private as well as public domestic support should be sought for the Program and vigorous efforts undertaken to expand the private sector's role in family planning financing as well as service delivery. These efforts will take time to organize and expand, however. The potential for greater household contributions to the Program appears to be limited. It has been noted that 58 percent of Philippine families are below the poverty line; the lower five decile groups receiving barely 20 percent of income, while the top decile alone receives almost 36 percent. Efforts to shift public subsidies to low income groups and to expand private sector services for higher income groups will need to consider the small proportions of the population in the latter category and the very real limitations on ability to pay among a substantial majority of the population. lix. Prioritizing allocation of resources. Using DOH's newly adopted Area Based Program Planning Process as a vehicle, public resources for family planning can be targeted geographically to those areas characterized by the highest levels of poverty, the greatest health risk, the least access to alternative-services, and the lowest ability to pay. These allocation  - 13 - criteria have been employed by the DOH since 1986 in the distribution of other health resources. lx. There are a number of options for improving the organization of services, and thereby internal efficiency. The implementation steps discussed in Chapter IV of this report should be pursued in priority order, with emphasis on building capability within the DOH to make use of existing (but underutilized) capacity internally and in other partner agencies. Further efficiencies can be achieved by the full integration of family planning with related health services, and by focussing family planning services on key points of contact with clients, such as immediately following the birth of a child, or during child immunization visits. lxi. Even with mobilization of new funds, targeting of resources, and improvements in efficiency, the Government may fa e a choice between scaling back the program or expanding resources through external financing, since even with large increases in public resources, domestic financing for the Program is not expected to reach much above 50 percent in the medium-term. Continued reliance on external sources entails some risks: Government will need to coordinate donor activities with a firm hand in order to maintain control over the Program, and interim external financing must be placed in the context of a long-term financing strategy of expanding domestic funding, if the Program is to be sustainable over time. lxii. Even greater, however, are the social and long term financial costs of not implementing the Program at a pace consistent with absorptive capacity and at levels necessary to address existing need. Further delays in providing services will take a serious toll in poor maternal and child health outcomes. Continued population growth from unwanted births will only add to future fiscal strains on both Government and families and exacerbate environmental degradation and poverty. For these reasons, rapid mobilization of both domestic and external financing is indicated. lxiii. However, no matter how well intentioned and designed, the new Program could easily falter if needed resources are not forthcoming. Inadequate funding could lead to inefficient and inequitable allocation of available resources, interruptions of priority activities, and unmanageable fiscal imbalances in the Program. Thus, it is essential that implementation planning proceed on the basis of realistic financing assumptions as well as realistic costing and time-phasing of program activities. A sound financing strategy is needed to ens.a,re that funding is adequate to accomplish feasible objectives in the near-term and to ensure sustainability in the longer-term.  - 14 - I. THE FAMILY PLANNING PROGRAM IN CONTEXT A. Introduction 1.1 The Government of the Philippines (GOP) has embarked on major new directions in its twenty year old National Family Planning Program. Four significant changes form the basis for the new Program: (a) A new population policy distinguishes between the country's Family Planning Program and broader population and development concerns. While rapid population growth remains a strategic national develop- ment issue, and family planning will contribute to general welfare through its impact on population growth, the Family Planning Program's stated goal is no longer to reduce fertility, but rather to improve family welfare by providing accurate, timely information and services to support individual couples' fertility decisions. (b) A new Family Planning Program strategy changes the role of Govern- ment from that of 'advocate" to "service provider", and places new emphasis on the health rationales for family planning. Accordingly, the new Program addresses two sources of total need for family planning: (i) married couples' expressed preferences in matters of fertility, and (ii) need based upon the recognized benefits of family planning for the health of mothers and children. Consistent with the shift from an authoritarian regime to one that values individual decisions, Government will be responsive to preference- based demand, and proactive with respect to health-based demand. (c) The institutional locus of the Family Planning Program has shifted from the Population Commission (POPCOM) to the Department of Health (DOH), already the country's major family planning service provider. POPCOM, now officially attached to the Office of the President, will continue to address broad national population and development con- cerns, including rapid population growth. The DOH will assume major responsibility for defining national family planning policies and standards for the provision of information and services in both public and private sectors. (d) The new Program is domestically, not externally, driven. Recogniz- ing that the past Program lacked crucial domestic political and financial support, the Government has grounded the new Program in a process of national consensus building. International agencies have been consulted and participated in this process and committed new funding, but the Government has remained firmly in control. 1.2 The purpose of this report is to provide the GOP and the interna- tional community with an assessment of these important and promising policy changes. In subsequent chapters, the report reviews the lessons learned from the history of the Program and quantifies the potential demographic aild health  - 15 - outcomes whic;. could result from successful implementation of the Program's new directions. The report also examines a range of implementation issues facing the new Program, as well as prospects for mobilizing and sustaining the financial support. B. The Population and Development Context 1.3 The Philippines Family Planning Program is explicitly seen by the Government to operate within the country's broader population and development context, a-nd will both affect and be affected by that context. Population Growth 1.4 The Philippines has one of the highest populatior growth rates in Asia, where other countries, including Indonesia and Thailand, have been far more successful in moderating their rates of population growth. The Philippines is now the 14th most populous country in the world and the 8th in the region. 1.5 As shown in Annex 1 Table 1, total population of the Philippines according to the 1970 census was 36.7 million, growing at an annual average rate of 2.97 percent. Between 1970-80, the growth rate moderated slightly to 2.68 percent, with population reaching 48.1 million in 1980. Preliminary 1990 census results place the Philippine population at 60.5 million, expanding at the rate of 2.3 percent per year. With continued moderate declines in fertil- ity and mortality, the population will reach 75.2 million before the turn of the century. If fertility were to reach replacement level by 2010, the total population would still continue to grow to 127 million by 2075. 1.6 The Crude Birth Rate (CBR) declined from 46 births per 1,000 popula- tion in the mid-60s to 35 in 1975, increased slightly in 1980, but declined again to 33 in 1985. It is estimated that the CBR will have dropped further to 29 births per 1,000 population in 1990. The slow decline in birth rates is directly related to the increased proportion of women in childbearing ages, insignifican_. change in the mean age at marriage, and slow decline in marital fertility. 1.7 The Crude Death Rate (CDR) declined rapidly between 1940 and 1968, dropping more than 21 percentage points from 32 to 10.7 deaths per 1,000 population. Between 1968 and 1986, the CDR declined by only 3 percentage points, to 7.6 in the latter year -- a rate comparable to Canada and Japan. Given the already low level, there is limited scope for further decline in the aggregate CDR. 1.8 Estimates discussed at greater length later in this chapter indicate that the total fertility rate (TFR) has declined by 1.46 births, from 5.72 in the late 1960s to 4.26 in the mid-1980s. The singulate mean age at marriage for Philippine wromen has remained relatively stable and high over the past two decades, fluctuating between 23 and 24 years.  - 1G Regional Differences and Migration 1.9 National surveys of contraceptive acceptors have been , iJue,ted tc: measure the proportion of currently ruarried wom;en aged 15-44 year. using family planning methods. Between 1968-88, the Contraceptive Prevalence Race (CPR) increased from 15.5 percent to 36.2 percent (45 percent according to the 1986 data). The use of modern methods increased steadily from 2 percent in 1968 to 21 percent in 1988, but rem. ins well '.elow that of ocher Asian countries. The CPR varies across regicns (see Annex 5 for regional bound- aries), with Region XI exhibiting the high.est rate. follovwed closely by the National Capital Region (NCR). 1.10 The Philippines has experie-nced considerable internal mnigLation since the 1960s, and census data show that between 1975 and 1980, 58 percent of all rural to urban migrants were young, unmarried, unskilled females. Al- though the NCR is perceived to be the preferred destination for internaXl migrants, it has not ranked among the top three fastest growing regions. In fact, the highest rates of aggregate population growth have been adjacent to the NCR in Region IV, where Rizal Province grew by approximately 6 percent annually between 1970 and 1990, and Cavite Province grew by over 4 percent in the past decade alone, On the other hand, as seen in Figure 1.1, the north and eastern Samar Provinces of Region VIII experienced little or no population growth over the past decade, indicating significant outmigration. 1.11 While net migration figures cannot be deduced without correcting for regional differences in natural increase, these data suggest that the Family Planning Program (along with other health programs) faces shifting population distributions (notably among females), and the current system of projecting the number of anticipated clients based on the most recent census results will not provide sufficient data either for resource allocation or for setting service objectives. 1.12 In addition, since 1980, international migration has become increa- singly important, with the number of Philippine migrant workers abroad climbing steadily from 214,590 in 1975 to nearly 523,000 irn 1989. Approx- imately half the contract workers registered at the Philippine Overseas Employment Administration are women, many employed as domestic helpers and entertainers. The absence or potential return of over a quarter of a million international migrant women also needs to be considered in Program pianning. Poverty and Employment 1.13 Despite impressive gains on many fronts, the Philippines continues to have substantial levels of poverty: according to official estimates, the incidence of poverty in 1985 was 58 percent, meaning that 58 percent of Philippine families had incomes below the poverty line of P 4,764 or $256 per month.l/ In absolute terms, an estimated 5.5 million families or about 31 1/ The World Bank. The Philippines: The Challenge cf Poverty, Washington, D.C.: 1988, p. 3.  Annual Population Growth By Province, 1980-90 The Philippines Notional Avg.: 2.32%7 '0 Hia,hest Growth Rates: (Region) i Ronge: 0.12% to 5.76Z 1. Rizol, 5.76% (IV) so 2. Aguson del Sur, 4.61% (X) 0 3. Cavite, 4.10% (IV) 3 Lowest Growth Rates: l1, 4. N. Samor, 0.12% (Vill) 0 5. E. Somor, 0.258% (Vill) 5 6. Mosbote. 0.26% (V) 2 1.00-1.75 0 1.76-2.32 0 2.33-3.00 **'^,db,