Overview
Addressing malnutrition in children requires effective monitoring and management of problems from their conception, while they are in their mother’s womb, and upon and after they are born. Nutrition of children especially younger ones depends a lot on the nutritional status of women as well as their knowledge and skills on proper nutrition practices.
It has been established that “maternal factors account for a significant 50% of the gap in child stunting in the Philippines. Maternal education (18%), height (26%), body mass index (17%), quality of prenatal care (12%), diversity of child’s diet (12%), and iron supplementation (5%) for children were the significant contributors to the large disparity between poor and non-poor (Ulep et al., 2022).”
Undernutrition in women is primarily monitored in terms of deficiencies in iron (Anemia) and Vitamin A both of which have consistently dropped in the Philippines in recent years.
In particular, anemia prevalence has been decreasing among pregnant, lactating, and non-pregnant women. Anemia among pregnant women aged 15-49 years is even lower than the latest estimated global average. The number of nutritionally at-risk pregnant women in the Philippines has also significantly decreased between 2015 and 2021.
Child Rights Situation Analysis
The key indicators of undernutrition in women include the prevalence of nutritionally at-risk pregnant women, anemia (iron deficiency) and Vitamin A deficiency (VAD) among pregnant, lactating, and non-pregnant/non-lactating women, and chronic energy deficiency and overnutrition (overweight and obesity) among lactating women.
Prevalence of anemia among pregnant and lactating women aged 15-49 years has consistently and significantly dropped since 1998. In 1998, 5 out of ten pregnant women had iron deficiency and the same number among lactating women.
By 2019, only two of every ten pregnant women and one of ten lactating women had anemia. A similar trend is observed among non-pregnant women, from 14.2 per cent in 2014 down to 11.6 per cent in 2019, which is substantially lower than the estimated global average of 29.6 per cent in the same year. In 2021, the prevalence of anemia among teens or girls aged under 20 years, at 23 per cent, was a moderate public health concern.
Vitamin A deficiency (VAD) among pregnant and lactating women aged 15-49 years has declined substantially since 1998. Among pregnant women, cases of VAD decreased from 22.2 per cent in 1998 to only 2.8 per cent by 2019. Similarly, VAD prevalence among lactating women was 16.5 per cent in 1998 and got down to 2.2 per cent in 2019. Still, the latest VAD levels are categorized as mild public health significance.
Fewer among pregnant women are nutritionally-at-risk. The prevalence of nutritionally-at-risk pregnant women aged 15-49 years has gradually but steadily decreased, by almost half from 30.7 per cent in 1998 to 16.4 per cent in 2021. However, the PPAN finds that a higher percentage of teenage mothers (those under 20 years old) are still at-risk, considered a moderate public health concern.
Chronic energy deficiency among lactating women has been reduced significantly to 8.4 per cent in 2021, from 13.6 per cent in 2015. Overnutrition (or overweight and obesity) has remained a problem, at 35-36 per cent among non-pregnant/non-lactating women from 2015-2021, and has worsened among lactating women, from 22.4 per cent in 2015 to 30.6 per cent in 2021.
Quick notes
- Anemia and Vitamin A Deficiency: Decreased significantly among pregnant and lactating women since 1998.
- Nutritionally-At-Risk Pregnant Women: Decreased prevalence, higher among teenage mothers.
- Chronic Energy Deficiency: Reduced in lactating women from 13.6% (2015) to 8.4% (2021).
- Overnutrition Issue: Remains high in non-pregnant/non-lactating women; increased in lactating women from 2015 to 2021.
Equity & Risk
Equity
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Maternal factors account for more than 50 % of the gap in child stunting in the Philippines. This signifies the critical role of maternal biological and socio-economic circumstances in improving the linear growth of children.
Maternal factors account for more than 50 % of the gap in child stunting in the Philippines. This signifies the critical role of maternal biological and socio-economic circumstances in improving the linear growth of children.
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This situation analysis has not been able to determine any data which disaggregates by disability under this subdimension.
This situation analysis has not been able to determine any data which disaggregates by disability under this subdimension.
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Pregnant and lactating women living in rural areas face significantly greater barriers to access to adequate health and nutrition care. Early pregnancy, poor birth spacing, and large family sizes are issues that continue to persist and impact women’s nutrition, particularly in rural areas.
In 2022, BARMM had the lowest percentage of women receiving antenatal care from a skilled provider at 47.5 per cent, much lower than the national average of 86 per cent, and with over a quarter of women without any antenatal care visits.
Pregnant and lactating women living in rural areas face significantly greater barriers to access to adequate health and nutrition care. Early pregnancy, poor birth spacing, and large family sizes are issues that continue to persist and impact women’s nutrition, particularly in rural areas.
In 2022, BARMM had the lowest percentage of women receiving antenatal care from a skilled provider at 47.5 per cent, much lower than the national average of 86 per cent, and with over a quarter of women without any antenatal care visits.
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Wealth is a contributing factor to women’s nutrition. Women from the lower socioeconomic classes receive less antenatal care from a skilled provider compared to women from higher economic classes, who have at least four antenatal care visits, and have birth delivery through a skilled provider.
A contributing factor is the limited purchasing power of women from the poorest quintile. The proportion of women in the lowest wealth category is significantly lower than the average across all quintiles in terms of receiving ante-natal care (ANC) from a skilled provider at 73.5%, having at least four ANC visits at 65.6%, and delivery by skilled birth provider at 72.7%.
Wealth is a contributing factor to women’s nutrition. Women from the lower socioeconomic classes receive less antenatal care from a skilled provider compared to women from higher economic classes, who have at least four antenatal care visits, and have birth delivery through a skilled provider.
A contributing factor is the limited purchasing power of women from the poorest quintile. The proportion of women in the lowest wealth category is significantly lower than the average across all quintiles in terms of receiving ante-natal care (ANC) from a skilled provider at 73.5%, having at least four ANC visits at 65.6%, and delivery by skilled birth provider at 72.7%.
Risks
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- In times of disasters and emergencies, longer-term nutrition and food security programming tends to pause and stop as humanitarian priorities takeover.
This is highly disruptive to longer-term nutritional outcomes, including the development and growth of children and adolescents who cannot access the nutrition services they may need. The impact of this is the potential reversal of gains made on matters like stunting and wasting.
- Another risk for nutritional outcomes is the global economic and food crisis, which is reportedly affecting the Philippines which is seeing rising food prices. In addition, the current El Niño is likely to impact agricultural productivity and food prices globally. These risks are highly likely to affect food security, particularly for poorer families and will have knock-on impacts for nutritional outcomes in children, adolescents, and women.
Climate change is also affecting the quality of food; for example, nutrients are more diminished in some foods due to poorer or unseasonal growing conditions.
- Reallocation of development and government funding to emergency response is an ongoing risk faced in planning and programming across all child rights fields, likely to be exacerbated by climate change.
- In times of disasters and emergencies, longer-term nutrition and food security programming tends to pause and stop as humanitarian priorities takeover.
This is highly disruptive to longer-term nutritional outcomes, including the development and growth of children and adolescents who cannot access the nutrition services they may need. The impact of this is the potential reversal of gains made on matters like stunting and wasting.
- Another risk for nutritional outcomes is the global economic and food crisis, which is reportedly affecting the Philippines which is seeing rising food prices. In addition, the current El Niño is likely to impact agricultural productivity and food prices globally. These risks are highly likely to affect food security, particularly for poorer families and will have knock-on impacts for nutritional outcomes in children, adolescents, and women.
Climate change is also affecting the quality of food; for example, nutrients are more diminished in some foods due to poorer or unseasonal growing conditions.
- Reallocation of development and government funding to emergency response is an ongoing risk faced in planning and programming across all child rights fields, likely to be exacerbated by climate change.
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Internal conflict, particularly violent conflict between state forces and non-state armed actors risks severe disruption to all essential services, as well as regression in key child rights areas including nutrition. Areas with higher conflict incidence, like Mindanao and Masbate, are particularly affected by this risk which results in worse nutrition outcomes for children.
Internal conflict, particularly violent conflict between state forces and non-state armed actors risks severe disruption to all essential services, as well as regression in key child rights areas including nutrition. Areas with higher conflict incidence, like Mindanao and Masbate, are particularly affected by this risk which results in worse nutrition outcomes for children.
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Changes to personnel and leadership within the DoH, and at the more local level, affect the delivery of child health services in the Philippines, including those pertaining to nutrition in women.
Each new senior official or representative appointed or elected may introduce new structures and priorities, which can make it challenging for INGOs and other partners to work effectively as they need to rebuild connections, networks, and relationships, particularly for advocacy work.
This is an ongoing risk of which multiple actors are aware as a key challenge. Pandemic quarantine lockdowns provided challenges in accessing nutrition and other antenatal care services.
Changes to personnel and leadership within the DoH, and at the more local level, affect the delivery of child health services in the Philippines, including those pertaining to nutrition in women.
Each new senior official or representative appointed or elected may introduce new structures and priorities, which can make it challenging for INGOs and other partners to work effectively as they need to rebuild connections, networks, and relationships, particularly for advocacy work.
This is an ongoing risk of which multiple actors are aware as a key challenge. Pandemic quarantine lockdowns provided challenges in accessing nutrition and other antenatal care services.
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- At the LGU level, the short, three-year election period means advocacy and programming at the LGU and LCE level generally needs to be reviewed and revised regularly, and new relationships built. Newly elected LCE’s can have new and different priorities, some of which will not be aligned with efforts to make progress on child rights realization.
- Limited time and resources of INGOs, UN agencies and sector partners to work as effective technical advisers and partners was cited as a risk, given the number of competing priorities and challenges within the Philippines. This is particularly a risk at LGU level, as agencies tend to prioritize their resources for greater impact at national level, which risks LGUs being unable to effectively conduct their mandates with regard to child rights.
- At the LGU level, the short, three-year election period means advocacy and programming at the LGU and LCE level generally needs to be reviewed and revised regularly, and new relationships built. Newly elected LCE’s can have new and different priorities, some of which will not be aligned with efforts to make progress on child rights realization.
- Limited time and resources of INGOs, UN agencies and sector partners to work as effective technical advisers and partners was cited as a risk, given the number of competing priorities and challenges within the Philippines. This is particularly a risk at LGU level, as agencies tend to prioritize their resources for greater impact at national level, which risks LGUs being unable to effectively conduct their mandates with regard to child rights.
Quick notes
Legislation and Policy Analysis
The Philippines Plan of Action for Nutrition (PPAN) 2023-2028 is the main plan to articulate government’s actions to decrease all forms of malnutrition across the age groups, including a group for pregnant and lactating women. The PPAN results areas include ensuring access to nutritious food and good diets, practices, and behaviors, access to multi-sectoral nutrition services, and an enabling environment.
The PPAN interventions covers package of counseling service for pregnant and lactating; integrated and quality nutrition and maternal and reproductive health services to pregnant and lactating mothers; and improved food supply and distribution, as well as availability of nutrient-dense and fortified foods.
The PPAN includes the following key targets for pregnant and lactating women for 2028: prevalence of anemia among pregnant women at 17.2 per cent, and among women of reproductive age at 4 per cent; prevalence of nutritionally at-risk among pregnant women at 13.2 per cent; prevalence of VAD among pregnant women at 0.53 per cent, and among lactating women at 0.38 per cent.
At subnational level, particular mechanism in place to assist children between 0-5 years of age as well as pregnant and lactating women includes the nutrition scholar and health worker in every barangay in the country. Republic Act 11148 also known as ‘Kalusugan at Nutrisyon ng Magnanay Act’ aims to scale up activities in nutrition intervention programmes in the first 1,000 days of a child’s life. It also focuses on pregnant and lactating women, ensuring proper nutrition and health care before, during and after giving birth.
Education regarding good practices on breastfeeding and the use of supplementary foods is encouraged. The law and its implementation plan also identify the importance of adolescent nutrition. A vaccination programme for pregnant women against tetanus and diphtheria was also mandated under the act.
Bottleneck Analysis
- Poor health-seeking behaviour of PLWs. In the PPAN 2023-2028, this has been highlighted as a major cause of malnutrition in women. Conversely, nutrition education and programmes such as the 4Ps programme have been found to have a positive impact on nutritional knowledge, and improved treatment- and health-seeking behaviours, particularly among mothers and expectant mothers.
- A lack of finances to travel to healthcare facilities. This is particularly a bottleneck in more deprived regions and among families affected by issues like unemployment. Social protection schemes go some way to providing safety nets for these families, but the reach of these programmes varies significantly across the Philippines. Furthermore, this is likely to be a bottleneck particularly for families with children with disabilities who may need greater accessibility requirements, or with parents with disabilities who are more likely to have employment challenges. This is a bottleneck with regard to health seeking behaviours for the early detection and treatment of malnutrition.
- Women and girls have limited access to healthcare facilities due to gendered norms of household responsibilities. Prevailing gendered norms which view women and girls as the primary duty bearers of household responsibilities are a major bottleneck for the realisation of women and girls’ access to healthcare services. For instance, it was reported that women often cannot take the time out to travel to healthcare facilities due to childcare responsibilities.
- Insufficient household income to afford nutritious food. This has been identified as a major bottleneck affecting the realisation of children’s nutrition rights in the Philippines. Between 2017 and 2020, the cost of a healthy diet per person per day increased from USD 3.8 to USD 4.1, with nearly 68 % of the population being unable to afford a healthy diet as of 2020. A related consequence of financial difficulties is the lack of adequate food storage facilities (such as fridges and freezers) in households. As a result, fried foods, which keep for longer than fresh fruit and vegetables, are chosen by households as a more viable, cost-effective option.
- Limited knowledge and awareness of the importance of good nutrition. At the household level, lack of knowledge around good health and nutritious diets is considered to be a bottleneck affecting realisation of children’s rights. For instance, a 2019 UNICEF study highlighted a widespread perception among the population that stunting is a natural, genetic phenomenon, and that being overweight is a marker of a healthy child. However, it is reflected that this issue is not just at the household level, as there is currently a lack of a national-level strategy on how to raise households’ awareness around nutritious diets.
- A community-level perception of the ability to afford fast foods (and other unhealthy foods) as a marker of success. The issue of a lack of affordability of healthy food is compounded by a widespread perception that the ability to afford fast food is a marker of success. A 2019 UNICEF study found that families choose to consume fast foods because they want to eat the food they see on television or hear about, even though they know it is unhealthy. One participant in the study described fast foods as “the food of the rich people.”
- Limited access to healthcare facilities due to long travel distances and inadequate transport links, particularly in rural areas. The number and distribution of accessible healthcare facilities varies greatly by province and municipality. For instance, a 2019 UNICEF study highlighted that all study participants from San Jorge, a first class municipality, had a travel time of less than fifteen minutes to a health facility, while of those from Dipolog, a third class municipality, a lower 46.2 % were this near. This bottleneck is particularly important given that poorer families often lack the necessary finances to travel to healthcare facilities, as identified in the Immediate bottlenecks. This is a key bottleneck with regards to seeking treatment for acute malnutrition in early childhood.
- Inadequate supply chains for health and nutrition. Bottlenecks throughout the health sector supply chain remain an important challenge. These include bottlenecks in the financing, procurement, delivery, and storage of medical supplies. The lack of reporting on supply usage was also reported to be a major issue, which leads to issues of tracking procured commodities for health and nutrition.
- A lack of technical capacity among rural populations to carry out social development programmes such as health promotion activities, including around topics of nutrition in early childhood. These programmes and activities rely heavily on local participation. While this is positive in improving the localisation of social development initiatives, it has also been identified as a key bottleneck. Local populations are often engaged in the implementation of programmes without being given the necessary skills and knowledge needed to effectively carry out their responsibilities, which leads to inefficiency.
- A lack of assistive technology limits access to health care for those with disabilities. There is a lack of trained, specialist staff and technologies to ensure those with disabilities are effectively included within health care services and facilities. Additionally, public hospitals have stringent processes which mean it is hard for PhilHealth to accredit them under the Z-Benefit scheme for those with disabilities. To resolve this bottleneck, some actors are seeking to work more closely with private hospitals to supply these skills and staff, as it is easier to accredit these hospitals and their staff tend to have more capacity.
- Limited coordination between national and local levels of government. The provision of health and nutrition services is devolved in the Philippines, and thus requires robust coordination and coherence between different levels of government. While the introduction of policies and passing of laws happens at the national level, LGUs are the main duty bearers for implementation. Although a range of policies and laws have been introduced, there are major gaps in implementation due to issues of capacity, financing, human resources, and motivation at the LGU level. At the root of these issues is the overarching bottleneck of a lack of coordination between national and local levels of government. As reported by one key informant, “there is a major disconnect in what the national government tells LGUs what they should do, versus what they can do.” Another key informant, a national government stakeholder, noted that knowledge and capacity-transfer from the national to the sub-national needs to be a top-down process with national government agencies leading these efforts. It was, however, also noted that national agencies lack the budgetary requirements to do this widely and therefore rely on LGUs to seek technical assistance as and when needed.
- Limited coordination between different agencies at the national and local level. This was found to be a bottleneck for the nutrition sector in particular. Unlike the health sector which is primarily under the purview of the DoH, issues of nutrition rely on coordination from a range of national agencies including DepEd, DoH, DSWD, NEDA, and the NNC, among others. While there is a coordination mechanism at the national level composed of NGAs, there is a lack of clarity on what are and how to track nutrition-sensitive interventions among key NGAs. For instance, while DepEd is mandated to ensure nutrition in schools, learners at the ECE level are often overlooked as they fall out of the purview of the centralised education system. This bottleneck is thought to extend to CSOs as well, which reportedly often have overlapping or unclear mandates at local levels.
- Varying LGU capacities and appreciation at sub-national level limits LGUs’ capacity to implement nutrition and health laws. LGUs are the main duty bearers for the implementation of national laws and policies on health. However, some LGUs suffer from a lack of capacity in terms of the human resources, technical skills and the necessary budgets for adequate implementation. A commonly cited bottleneck across KIIs conducted under this situation analysis was that decision making on focus areas within LGUs relied heavily on the LCEs. As such, LCEs’ willingness, motivation, and ability to prioritise health and nutrition issues is a major determinant of the realisation of an LGU’s prioritisation of health service delivery. Additionally, Executive Order 138 on devolution does not define a specific budget allocation or percentage for nutrition at the local level, which also means the extent to which it is prioritised varies. While it is difficult to ascertain the extent of this bottleneck, it was suggested that LCEs often make decisions on these matters based on political factors rather than population needs. Furthermore, as LGU elections are held every three years, there are regular changes in health staff and leadership. This is reportedly a significant bottleneck, as knowledge and expertise around health at LGU level fluctuates regularly. For partner organisations, this turnover also requires the rebuilding of relationships to carry forward collaborative endeavours. Additionally, in some LGUs there are more limited capacities to support the role out of the BNS profession; this is particularly a challenge in BARMM, which has fewer BNSs than other regions.
- Inadequate progress indicators being measured and a resultant lack of robust data being collected to inform policy making. This is a critical bottleneck, as without the right data, it is difficult to determine where challenges lie and how they should be addressed. For instance, it was stated that wasting was previously excluded from the DoH indicator list, until advocacy efforts from a range of organisations led to eventual inclusion. Furthermore, there is a lack of child protection-related nutrition data (pertaining, for example, to violence and low birth weight). It is essential that data be disaggregated in order to inform more targeted policymaking.
- A lack of regulation on food and beverage advertising. The prevalence of unhealthy eating habits is a major problem in the Philippines. A significant bottleneck is the lack of regulation on the advertising of unhealthy foods. A 2021 study of digital food marketing in the Philippines found that almost all of the social media posts for marketing from the country’s top 20 most popular food and beverage brands were deemed unsafe for children due to having too much sugar, salt or high levels of trans fats. It is further felt that key actors like schools have not taken on enough responsibility to tackle this issue. A lack of regulation on advertising has also given way to widespread ‘health-washing,’ wherein packaging and advertising for unhealthy foods give a false impression of healthy benefits. It is noted that industry reportedly has some influence in policy making, which may be contributing to this bottleneck.
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