Overview
Malnutrition has short-term and long-term consequences on a person’s health and overall development. Children who are malnourished are more vulnerable to diseases such as diarrhea, measles, and other communicable diseases increasing risk of morbidity and developing chronic diseases when they get older and mortality. Malnutrition may also affect children’s psychosocial and economic wellbeing.
Early detection, prevention and treatment of malnutrition are therefore necessary to child survival and nutrition, including the achievement of relevant Sustainable Development Goal targets toward zero hunger by 2030.
The Philippine Plan of Action for Nutrition (PPAN) provides for the country’s key policy and program priorities to address persistent problems in nutrition especially among children, adolescents, and pregnant women. The Republic Act No. 11148 or the Kalusugan at Nutrisyon ng Mag-Nanay, also known as the First 1000 Days Act, of 2018 further fortifies delivery of nutrition services in tandem with relevant health programs to ensure proper nutrition and health care of women before, during and after birth up, and of children from conception to up to two years old.
Another recent law is the Republic Act No. 11037 or the Masustansyang Pagkain para sa Batang Pilipino Act of 2017, which is essentially a supplemental feeding program for children, including those in day care centers.
While some milestones have been achieved in reducing prevalence of low birthweight, stunting, and wasting among children, and nutritionally-at-risk among pregnant women, there remains key challenges of public health significance.
Stunting, wasting, and underweight among children under 5 years old have decreased in the last decade or so. However, stunting prevalence continues to be of high public health concern while wasting and underweight remain at medium level of public health significance. Stunting and being underweight tend to worsen when children reach one year of age while wasting mostly affects infants less than one year old.
Underweight prevalence is markedly higher among girls of this age group than boys and much worse among children in rural areas.
Overweight prevalence among pre-school children has increased generally stayed at low levels.
Exclusive breastfeeding has increased significantly, and while prevalence of breastfeeding initiation has declined slightly, it is still significantly higher than the global average. Iron and Vitamin A deficiencies among young children have both been reduced.
The PPAN 2023-2028 is designed to address remaining and persistent bottlenecks toward further reduction of all forms of malnutrition across all age groups with concrete targets by 2028.
Child Rights Situation Analysis
Nutrition in early childhood or among children aged under 5 years old is monitored through the prevalence of stunting, wasting, overweight, underweight, and micronutrient deficiencies, and includes coverage of screening and admission for treatment for moderate and severe acute malnutrition; minimum dietary and recommended energy intake of children; and recommended energy intake and food insecurity of the household.
Prevalence of children under five years old experiencing stunting, wasting, and being underweight declined from 2018/2019 to 2021.
Stunting among children under five years old has declined from 29.6 per cent in 2018/2019 to 26.7 per cent in 2021 but remains a high public health concern. Stunting rate among children aged 1 year to 23 months at 28.6 per cent was more than triple that of children aged 0-5 months with only 8.9 per cent. Prevalence is quite high among children aged 3 to <4 years at 32.1 per cent, which falls under the 'very high' public health category, and highest among pre-school age children in the poorest quintile at 42.2 per cent. Wasting rate on the other hand is highest among children aged 0-5 months at 11.2 per cent, which is double that of children under 5 years old and breaches the 'high' level of public health concern. All other children under 2 years old have prevalence rates higher than children under five years old but remain at medium public health level. There are more underweight children among girls and among those in rural areas.
Prevalence of anemia (or iron deficiency) among children 6 months to 5 years old has decreased but not quite so, from 13.8 per cent in 2013 to 12.5 per cent in 2019. Vitamin A deficiency among the same age bracket on the other hand has significantly been reduced, from 20.4 per cent in 2013 to only 14 per cent in 2019. In 2022, 7 of 10 children aged 6-59 months received iron-containing supplements — iron tablets or syrup and multiple micronutrient powders, and 8 of 10 children received vitamin A supplements. BARMM has the lowest proportion of children that received micronutrient supplements, only 5 of 10 children receiving iron-containing supplements and 6 of 10 children receiving Vitamin A supplement. Micronutrient supplementation in children increases with mother’s level education.
More newborns and infants are being breastfed in 2021. The number of children aged less than 6 months exclusively breastfed has increased from 5 of every 10 children in 2015 to 6 in 2021. At 60.1 per cent, the proportion of exclusively breastfed children is higher than the global average of 44 per cent, although still much lower than the global target of 70 per cent by 2030. Breastfeeding within the first hour of birth also increased from 65.1 per cent in 2015 to 72.4 per cent in 2021. The number of children aged 6-23 months receiving the minimum acceptable diet dropped from two in ten children in 2015 to just 1 in 2021 on account of considerably lower number of children meeting the minimum dietary diversity.
Food insecurity among households is on the decline and so is recommended energy intake (REI). The prevalence of moderate to severe food insecurity households based on the food insecurity experience scale decreased by 22 per cent, from 42.8 per cent in 2018/2019 to 33.4 per cent in 2021. The highest drop in food insecurity was observed among male-headed households, those in rural areas, and among those in the richest quintile. Interestingly, there was considerably a smaller proportion of households meeting the recommended energy intake in 2019 at 19.5 per cent than in 2013 with 31.7 per cent.
At least 8 out of ten children aged 6 months to 5 years did not meet the REI for individuals. The proportion of children not meeting the REI ranged from 76.7 per cent among those aged 6-11 months to 88.2 per cent among preschoolers.
Quick notes
- Recent Trends (Children under 5): Decline in stunting, wasting, underweight.
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Stunting Prevalence (2018/2019 to 2021): Decreased from 29.6% to 26.7%. Highest in children 3 to <4 years (32.1%) and poorest quintile (42.2%).
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Wasting and Underweight: Highest wasting in children 0-5 months (11.2%). More underweight girls and rural children.
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Micronutrient Deficiencies: Anemia decreased slightly (13.8% to 12.5%). Vitamin A deficiency reduced (20.4% to 14%).
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Breastfeeding (2021): Improved rates, exceeding global averages.
Equity
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In 2021, among children under five years old, stunting and overweight tend to affect boys than girls while wasting and underweight were likely to be observed among girls.
In 2021, among children under five years old, stunting and overweight tend to affect boys than girls while wasting and underweight were likely to be observed among girls.
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This situation analysis has not been able to determine disaggregated data by disability for this subdimension.
This situation analysis has not been able to determine disaggregated data by disability for this subdimension.
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Rural areas registered markedly higher rates of stunting and underweight among children aged under 5 years than urban areas in 2021, while urban areas recorded slightly higher rates of wasting and overweight among in the same age group.
This suggests that children from rural provinces may be more exposed to the effects of longer-term food insecurity and malnutrition factors, such as poor dietary diversity. BARMM falls significantly behind other regions in terms of micronutrient supplementation.
Rural areas registered markedly higher rates of stunting and underweight among children aged under 5 years than urban areas in 2021, while urban areas recorded slightly higher rates of wasting and overweight among in the same age group.
This suggests that children from rural provinces may be more exposed to the effects of longer-term food insecurity and malnutrition factors, such as poor dietary diversity. BARMM falls significantly behind other regions in terms of micronutrient supplementation.
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 matters like the prevention and treatment of chronic malnutrition in those aged 0-5 years. For instance, Super Typhoon Goni in 2020 damaged rice, corn abaca and other crops which served as a primary source of nutritional intake for families. Additionally, the typhoon was also reported to have halted the provision of supplements, and washed away LGUs’ stores of supplements and other medical supplies, further threatening vulnerable people’s nutrition.
- Another risk for nutritional outcomes is the global economic and food crisis, which is reportedly affecting the Philippines, and which is seeing food prices rise. 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 early childhood.
- 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. The impact of this in the Philippines’ context is the reversal of gains made for stunting and wasting.
- 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 matters like the prevention and treatment of chronic malnutrition in those aged 0-5 years. For instance, Super Typhoon Goni in 2020 damaged rice, corn abaca and other crops which served as a primary source of nutritional intake for families. Additionally, the typhoon was also reported to have halted the provision of supplements, and washed away LGUs’ stores of supplements and other medical supplies, further threatening vulnerable people’s nutrition.
- Another risk for nutritional outcomes is the global economic and food crisis, which is reportedly affecting the Philippines, and which is seeing food prices rise. 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 early childhood.
- 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. The impact of this in the Philippines’ context is the reversal of gains made for stunting and wasting.
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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 the early detection and treatment of malnutrition. Areas with higher conflict incidence, like Mindanao and Masbate, are particularly affected by this risk.
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 the early detection and treatment of malnutrition. Areas with higher conflict incidence, like Mindanao and Masbate, are particularly affected by this risk.
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Health-related crises lead to significant challenges for child nutrition. During the COVID-19 pandemic, for instance, treatment of malnutrition was disrupted, which is one of the key secondary impacts of the pandemic for children. Additionally, food aid distributed during the pandemic was found to be often nutritionally incomplete.
Health-related crises lead to significant challenges for child nutrition. During the COVID-19 pandemic, for instance, treatment of malnutrition was disrupted, which is one of the key secondary impacts of the pandemic for children. Additionally, food aid distributed during the pandemic was found to be often nutritionally incomplete.
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- Changes in personnel and leadership within the Department of Health affect the delivery of child health services in the Philippines, including those pertaining to the early detection and treatment of malnutrition. New senior official or representative appointed or elected may introduce new structures and priorities, which can make partnership work more challenging as they need to rebuild connections, networks and relationships, particularly for advocacy work, and retrain new staff/personnel. A similar risk with personnel movement and leadership change is present at the local level.
- At the LGU level, the short, three-year election period means advocacy and programming at the LGU and LCE level may generally need to be reviewed and revised periodically, and new relationships built. Newly elected LCE’s can have new and different priorities, some of which may not always align with efforts 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.
- Changes in personnel and leadership within the Department of Health affect the delivery of child health services in the Philippines, including those pertaining to the early detection and treatment of malnutrition. New senior official or representative appointed or elected may introduce new structures and priorities, which can make partnership work more challenging as they need to rebuild connections, networks and relationships, particularly for advocacy work, and retrain new staff/personnel. A similar risk with personnel movement and leadership change is present at the local level.
- At the LGU level, the short, three-year election period means advocacy and programming at the LGU and LCE level may generally need to be reviewed and revised periodically, and new relationships built. Newly elected LCE’s can have new and different priorities, some of which may not always align with efforts 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 & Policy Analysis
The Philippines has developed the Philippine Plan of Action for Nutrition (PPAN) 2023-2028, which provides a road map to address stunting as a development and economic emergency and end malnutrition and all its forms in the Philippines.
The plan recognizes the Philippine’s international commitments under the 2030 Sustainable Development Goals, the 2025 Global Targets for Maternal, Infant, and Young Child Nutrition and the 2014 International Conference on Nutrition. Within the plan there are “8 nutrition-specific programmes, an initial list of 10 nutrition-sensitive programmes, and 3 enabling support programs”.
Among other objectives, the PPAN aims to give increased attention to the first 1,000 days of a child’s life, recognizing the developmental importance of this period. The plan also lists influential nutrition-linked policies, including the Healthy Lifestyle Policy Administrative Order 2011-0003 on Strengthening the Prevention and Control of Chronic Lifestyle Related Non-Communicable Diseases.
The law started implementation through DoH MC 2019-0027, its implementing rules and regulations. The law aims to codify good health and nutrition of mothers and their babies starting from conception until the child reaches two years of age. It is implemented through health and nutrition programmes which include counselling and consultations on various health issues concerning the mother and the child, especially for nutritionally-at-risk populations such as: pregnant women; lactating mothers; teenage mothers; and low birth weight infants. The law identifies nutrition-sensitive interventions and critical roles and contributions of national and local government units.
The PPAN 2023-2028 targets stunting and malnutrition in the Philippines, emphasizing the crucial first 1,000 days of a child's life. It integrates nutrition-specific and nutrition-sensitive programs, underpinned by key policies and laws like the Healthy Lifestyle Policy and the First 1000 Days Act.
The law institutionalized “a national feeding program for undernourished children in public day care, kindergarten and elementary schools to combat hunger and undernutrition among Filipino children.”
Under the law, funds have been freed up for the Department of Social Welfare and Development to implement a supplemental feeding programme for day care children, while the Department of Education has been given the resources to better implement the school-based feeding programme. The Act also has provision for milk feeding, micronutrient supplements, health examination, vaccination, vegetable gardening, WASH facilities and hygiene and nutrition education.
Executive Order 51 also known as the ‘Milk Code’ was passed in 1986, and the revised implementing rules and regulation (DoH AO 2006-0012) was signed in 2006. It is the adoption of a national code on the marketing of breast milk substitutes, breast milk and related products.
The code aims to contribute “to the provision of safe and adequate nutrition for infants by the protection and promotion of breastfeeding and by ensuring the proper use of breastmilk substitutes and breastmilk supplements”. This is done through applying restrictions on the marketing of such products. Also of relevance is the Philippines Multisectoral Nutrition Project, which will support the delivery of nutrition and health care services at the primary care and community levels.
Executive Order 51, the 'Milk Code', reinforces the Philippines' commitment to infant health by regulating the marketing of breast milk substitutes and promoting breastfeeding.
- Republic Act No. 8172 (An Act Promoting Salt Iodization Nationwide and for Related Purposes 1995).
- Republic Act 10611 (the Food Safety Act of 2013).
- Republic Act 7600 (the Rooming-In and Breastfeeding Act of 1992).
- Republic Act 8976 (the Philippine Food Fortification Act of 2000), which sets out provisions to address nutritional deficiency in the Philippines, including, energy, iron, vitamin A, iodine, thiamine and riboflavin.
- Republic Act 1161 or the Social Security Law of 1954 (as amended by Republic Act 7322 on Increasing Maternity Benefits in Favor of Women Workers in the Private Sectors, which provides for 60 days of paid leave following a child’s birth). This enables mothers to breastfeed their babies at least for the initial 60 days.
The Department of Health has issued administrative orders on nutrition services, including Administrative Order 2015-0055 which provide National Guidelines on the Management of Acute Malnutrition for Children under 5 years.
Bottleneck Analysis
- A lack of finances to travel to health care 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.
- Insufficient household income to afford nutritious food. This has been identified as a major bottleneck affecting the realization 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, and limited corresponding skills and behaviours to put knowledge into practice. At the household level, lack of knowledge around good health and nutritious diets is considered to be a bottleneck affecting realization 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 which focused on families participating in the 4Ps programme 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 the early detection of malnutrition. 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.
- 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 subnational 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. As such, effective coordination between these agencies is vital. 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 centralized education system. This bottleneck is thought to extend to civil society organizations as well, which reportedly often have overlapping or unclear mandates at local levels.
- Varying LGU capacities and appreciation at subnational 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 inadequate capacity in terms of 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 prioritize health and nutrition issues is a major determinant of the realization of an LGU’s prioritization 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 prioritized 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 organizations, this turnover also requires the rebuilding of relationships and capacities 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 and data being collected to inform policymaking. 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 organizations led to eventual inclusion. Furthermore, there is a lack of child protection-related nutrition data (pertaining, for example, to violence and low birth weight), and a lack of data on nutrition of those with disabilities. It is essential that data be disaggregated in order to inform more targeted policymaking.
- A lack of regulation on food and beverage advertising targeted at children specifically. As stated elsewhere in this section, 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 policymaking, which may be contributing to this bottleneck.
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