Given adequate information, the market theory assumes that consumers know what is best for themselves; hence, they make choices that maximize their total satisfaction. If this assumption is wrong, markets may not efficiently produce. We call this satisfaction consumers gain from consuming a good or service as “utility”. The satisfaction (or utility) depends on the quantity and mix of goods and services chosen by a consumer. The theory holds that consumers get more satisfaction from more goods and services but the increase in satisfaction from consuming additional units gradually diminishes. In health care, how do consumers go about choosing the mix of goods and services which give them the maximum total utility? In places where there are few sources of health care goods and services, do people take into account their tastes/preferences and income when choosing a combination of goods and services which gives the people the highest utility? Do people’s preferences and tastes change in situations where there are very few choices? Or do they develop an acquired taste/preference because of limitations posed by societal inequities?
Thoughts
Bakit tayo ‘baliw na baliw’ sa research?
To our dismay, Senator Cynthia Villar’s comment on the Department of Agriculture’s proposed budget for research reflects many people’s poor understanding of the value of research in policy making and in the country’s quest for sustainable development.
Research produces valuable impact on society. It provides evidence to support or improve practice, in this case, farming. Research offers our policy makers an evidence-based perspective on various aspects of farming and even in addressing societal issues. However, evidences generated by research are often not utilized by the government in the development of policies and standards. This understanding of the current state of policy research in our country warrants us to broaden our focus to include research that addresses problems at the system level.
The problem really lies within the government itself. The government has poor appreciation of evidence gathered through research. Studies can actually help our farmers if the government can translate these findings into polices that support farming in the Philippines. There are many innovations developed through research that are not utilized because the government is not keen on investing in these projects. Our policy makers tend to invest more on projects that are readily palpable to the people, as these projects attract more votes. But for research, it is sometimes difficult to feel its direct impact on society. And this is where the government should step in. It is crucial for the government to recognize and value research by allocating funds for it and creating a mechanism on how to utilize evidence in the development of sound policies supporting the advancement of farming in the country.
Without research, the promises of the 21st century agricultural revolution cannot be realized. And yes, Senator Villar, this is why we’re “baliw na baliw sa research”.
Pen Point 39
The procurement policies and procedures of the government are not flexible which makes them economically inefficient. Sometimes, this inflexibility becomes a barrier given the varied choices now made available to the market, difficulty in standardizing the specifications of materials to be procured, and the fragmented nature of the market. These guidelines are set to standardize procurement rules to eradicate bias and/or fault of human discretion, as well as corruption. The rigidity of these rules renders procurement officers vulnerable to administrative sanctions when one or two of these rules are violated. The rules do not allow negotiations for economically efficient alternatives. Thus, we end up having a scarcity of materials needed to run the government.
In health care, an inefficient procurement process leads to scarcity of essential medicines and equipment. This has direct effect on quality of patient care, and more importantly, on patient outcomes. Sometimes, there is limited attention to the quality of the procured materials which leads to further inefficiency in the provision of patient care. The current procurement process is reduced to a set of guidelines to be strictly followed, with little regard to economic efficiency. While the policy is aimed at reducing corruption, the current mechanism actually increases government wastage in terms of time, money, and procured materials of poor quality, all at the expense of quality patient care.
Reproductive Health in the Philippines: An Ecological Analysis
Faced by the challenges of a growing population and rapid urbanization, the Philippines has inconsistently acted on issues of population control and reproductive health. Some previous policies on reproductive health and population control where “conservative” and reflective of the Catholic Church’s position on family planning. Under the Arroyo administration, government policy on family planning focused solely in mainstreaming natural family planning (NFP) as the only acceptable method of birth control and even leaving local government units (LGUs) with the responsibility of allocating budget for these family planning methods.
More recently, however, the Aquino administration strongly advocated for reproductive health both as a demographic and health intervention. As such, in December 2012, Republic Act No. 10354 commonly known as the Reproductive Health (RH) Law was approved by then President Benigno Aquino III – a battle partly won. The long-standing debate on reproductive health in the Philippines centered on the morality of instituting reproductive rights for all Filipinos, most especially women, putting aside the essence of the RH law which is the “right to reproductive health”.
The RH law seeks to increase the availability of and improve accessibility to reproductive health services such as family planning, prevention of abortion and management of post-abortion complications, prevention and management of reproductive tract infections and sexually transmittable infections, prevention and management of infertility and sexual dysfunction, among others.
A defining element of the law – RH education – sits at its core. Recognizing the need to change perceptions and behavior towards reproductive health, the law mandates that RH education be taught to adolescents by adequately trained teachers in an age-appropriate manner. Moreover, education and counselling on sexuality and reproductive health will also be offered to adults.
Shifting age old mentality and changing acquired behavior is a curse for some public policies. While this is true, the government still recognizes that education and counseling as vital tools in changing perceptions and behavior therefore adequately incorporating them into the core elements of the RH law. Human perception and behavior towards reproductive health, however, are highly influenced by social, political, and cultural contexts. Creating an environment that supports positive behavioral change requires critical analysis of these contexts.
In this paper, I discuss the ecology of reproductive health in the Philippines utilizing the relevant types of human ecology in relation to human life.
Behavioral and Cognitive Ecology
Behavioral ecology analyzes the ecological basis of human behavior and uses behavior to make predictions about ecological patterns. Cognitive ecology, on one hand, brings together cognitive science and behavioral ecology. Thus, in this section of the paper, we discuss the behavior of Filipino women towards reproductive health. We will examine behavior of women as a result of interactions within their environment. Behavior varies with age, and is seemingly associated with level of education and socioeconomic status. As such, behavior of women towards reproductive health is seen as an outcome of the dynamic interplay of several elements in their environment.
Women and their reproductive health
The number of children a woman bears depends on many factors. Postponing first births and increasing the interval between births reduce fertility levels and produce positive health outcomes. In the contrary, short intervals between births can lead to negative health outcomes both for the mothers and their newborns.
Age
According to the 2017 National Demographic and Health Survey, eighteen percent of women age 25-49 years engaged in sexual intercourse before they were 18 years old. By the age of 25, 73% of women have had sexual intercourse. The total fertility rate (TFR) is 2.7 children per woman, a huge decline from the TFR in 1993 which was 4.1 children per woman.
Teenage pregnancy is associated with an increased risk of acquiring complications during pregnancy and childbirth, including neonatal mortality. The median age at first birth among women age 25-49 was reported to be 23.5 years. The percentage of women age 15-19 who have begun childbearing increased from 7% in 1993 to 9% in 2017.
Contraceptive prevalence
Date from the Family Health Surveys (FHS) showed that the contraceptive prevalence rate among currently married women of reproductive age (15-49 years old) exhibited an increasing trend but has not significantly (statistically) changed in the last decade. According to the 2011 FHS, the prevalence rate for modern methods was 2.9% or 13 times the estimate for the year 1968.
For all age groups of currently married women, the prevalence rate of modern methods was higher than traditional methods. Birth control pill was the leading contraceptive method used by 19.8% of currently married women as reported in the 2011 FHS, higher than in 2006 where only 16.6% of women reported using the pill for contraception. Female sterilization and withdrawal were the next two most commonly used methods used by 8.6% and 8.2% of women, respectively. Only 1.2% of women reported using male condom as method of contraception.
Education, socioeconomic status and contraception
Level of education
The use of modern family planning methods was correlated with the level of education and socioeconomic status. The 2011 FHS found that women with higher educational attainment are more likely to be using any form of contraception than less educated women. Regardless of educational attainment, however, women preferred modern over traditional methods of contraception. Ligation was the most popular method among women with postgraduate education. For other women without postgraduate degrees, oral contraceptives were the most common method followed by ligation
Data from the 2017 NDHS also showed that the TFR declines women’s educational level increases. Among women with college education, TFR was 2.0 children per woman while women with no education have a TFR of 4.6 children per woman.
Socioeconomic standing
The same survey found that the overall contraceptive prevalence rate was higher among currently married women belonging to non-poor households than those belonging to poor households at 51.3% and 43.1%, respectively. Regardless of socioeconomic status, modern methods were more widely used than traditional methods by currently married women in 2011. Overall, oral contraceptives were the most popular method of contraception for both the poor (18.7%) and non-poor (20.3%).
The TFR and desire to have more children also declines with increasing household wealth. Women in the poorest households generally want more children than those in wealthier households. In the poorest 20% of household, TFR was 4.3 children per woman. Among those living in wealthiest households, the TFR was calculated to be 1.7 children per woman.
Birth interval (or spacing) and teenage pregnancy have also been also been associated with household wealth. Women in the lowest quintile have the shortest median birth interval (31.2 months) while those in the highest quintile have longer median birth interval of 52.6 months. The percentage of women age 15-19 years and 15-24 years who have begun childbearing decline with increasing wealth.
Women’s fertility preferences
Information on women’s fertility preferences help direct family planning program planners by assessing women’s desire for children, the extent of mistimed and unwanted pregnancies, and the demand for contraception to space or limit childbirths.
In 2017, 15% of women wanted to have another child within the next two years and another 15% wanted to wait at least two years before having another child. However, 60% reported that they do not want another child. The NDHS also reported that 74% of births were planned at the time of conception while 11% were unwanted pregnancies. About seven in ten women reported that they are in consensus with their husbands on the number of children they would like to have.
Social and Molecular Ecology
Social ecology studies the relationship between people and their environment, particularly the interdependence of people and societal institutions. It bridges ecological and social issues. In this section, we discuss the interaction of women and the greater society in relation to reproductive health.
Nominally Catholic
With the exception of the Catholic Church, all other major religions supported the RH law. Although majority of Filipinos (~80%) are (at least nominally) Roman Catholics, surveys showed that nearly eight out of ten Filipinos favored the passage of the RH Bill, supported the provision of RH education and of free RH goods/services to all, especially to the poor.
While majority of Filipinos identify themselves as Catholic, their attitudes and perception indicate rejection of Catholic Church teaching on contraception. In June 2011, SWS reported that 73% of Filipinos wanted information on legal methods of family planning while 82% said the FP was a personal choice. Thus, it can be inferred that the RH fiasco and narrative was controlled mainly by Catholic bishops and some of their loyal followers whilst neglecting the call of majority of the members of the Church to enact a law for reproductive health rights.
RH in PH health system
With the Reproductive Health Law, couples are guaranteed universal access to methods of contraception, fertility control, reproductive health education, and maternal care. Thus, couples can freely utilize these contraceptive goods and services to limit the number of children or space childbirth.
As these goods and services are more readily available to the public through the public health system, one could expect higher rates of family planning utilization among Filipinos. Data from the NDHS showed that 83% of women who are not using contraceptives did not discuss family planning either with a fieldworker or at a health facility. More than half or 56% of women using modern contraceptive methods obtain their method from the public sector. Among women currently using modern methods of contraception, 73% were informed about the potential side effects of the method they were using, while 65% were informed about what to do if they experienced these side effects.
Despite efforts of the government and private sector to make access to and availability of reproductive health goods and services better for most women, some married women (17%) and sexually active unmarried women (49%) reported unmet need for family planning. The demand for family planning among currently married women, however, remains high at 71%.
Politics
We cannot deny how politics influenced reproductive health care in the Philippines. In this section, we examine how politics played a crucial role in shaping perception and cultivating behavior of Filipino women towards reproductive health.
It was during the Marcos regime when the country first recognized the role of family planning in population control. In 1970, the government advocated small family size and provided information and services to reduce the country’s fertility rate through the National Population Program. At the time, the average Filipino family had 6.8 children and the country’s population was 37.8 million.
Post-martial law, the change in government also signaled a change in government stance on population control. Rather than advocating for small family size, the Aquino administration advocated for the right of couples to determine the number of their children. This campaign was supplemented by integrating family planning into the country’s health programs highlighting its role in improving maternal and child health.
It was during the Ramos administration when then DOH Secretary Juan Flavier strongly advocated for family planning and reproductive health to limit family size through the provision of artificial birth control methods. The Ramos administration encouraged the use of male condoms to prevent unplanned pregnancies and the spread of HIV. However, the effort of the Ramos administration was short-lived as it was surpassed by the Catholic Church’s war against modern contraception.
Estrada, on one hand, continued the efforts of his predecessors and introduced other contraceptive methods to reduce fertility rate. Much like the Aquino administration, the Arroyo administration inexplicitly sided with the Catholic Church’s stance on reproductive health and family planning. Thus, the government shifted its focus on mainstreaming natural family planning methods.
Benigno Aquino III’s administration turned the tide when it was finally able to enact a much-awaited law on reproductive health. However, several legal road blocks prevented the full implementation of the RH law. With the FDA certification of contraceptive goods as non-abortifacients, the DOH now freely distributes contraceptives through its regional offices and partner NGOs.
Conclusion
Crucial to the overall perception and subsequent behavior towards reproductive health is the politics surrounding it. Many Filipinos, especially those in the lowest economic quintiles, heavily rely on goods and services provided by the government through its devolved health care system. Thus, improving maternal and child health as well as reducing fertility rate require that the government ensure that reproductive health goods and services are available and accessible at an affordable cost.
Reproductive health, particularly in the Philippines, is a complex health and legislative issue. And in this paper, we have explored the various ecological elements that can influence and potentially predict the behavior of Filipino women towards reproductive health. Reproductive health is a personal choice and the law respects this ‘freedom of choice’ by leaving the discretion to women (and their partners) on how they deal with their own reproductive health while providing options to support their RH needs.
Finally, education and socioeconomic status were seen to have direct influence on how women decide and utilize RH goods and services. Not until we close the gap among the poor and non-poor, educated and not educated, can we truly realize the goal of the RH law which is to improve the reproductive health of women (and men), and maternal and child outcomes.
Urban health in the Philippines: a reflection of poverty-related health inequities
Urbanization is rapidly increasing around the world. Data from the United Nations (UN) estimate that by 2050, the world’s population will exceed nine billion, and 67% of which will live in urban areas. Currently, the World Health Organization (WHO) believes that half of the world’s population live in cities. Sadly, this proportion is irreversibly growing most especially in Asia and in particular, the Philippines. About 60% of the total population of the Philippines live in urban settings, and about 28% live in informal settlements and slum dwellings.
Urbanization fuels the progress of cities. As such, opportunities for individuals and their families flourish. However, rapid and unplanned urbanization can result in many health challenges that are often difficult to address. Poor planning and management of urbanization could lead to several unintended consequences such as urban poverty and health inequities.
Inequities brought about by urbanization affect everyone, most especially the poor. The urban poor often live and/or work in unsafe conditions. Some suffer from discrimination, isolation, and lack of social support. Intergenerational poverty renders these poor individuals and families unable to purchase goods and services. The urban poor is exposed to inequities due to social and economic factors. Therefore, addressing social determinants will help resolve these inequities.
Victor Barbiero (2014) has used the urban crucible to describe the urban environment in low- and middle-income countries. Various ecological elements play crucial roles in forming cultural, social, demographic, epidemiological, economic, and political processes. Problems will arise when there is no policy action taken today.
Paint me a picture! Urban centers in low- and middle-income countries, such as the Philippines, will face an exacerbated triple burden of health in the future. Infectious diseases such as tuberculosis, HIV/AIDS, vector-borne diseases, and even vaccine-preventable diseases will persist and continue to spread in urban settings. Non-communicable diseases (NCDs) such as stroke, diabetes, and chronic obstructive pulmonary disease will also continue to increase. Environmental and social conditions will be at their worst. Air pollution, obesity, depression and other mental health issues, vehicular accidents, and all types of violence will also increase in the future.
On the brighter side, urbanization also present new opportunities. Close proximities of health infrastructure and the availability of health goods and services could facilitate health service delivery. Resources are also often greater (or concentrated) in urban areas. Therefore, urban centers can enjoy greater support that can be used to create pro-poor policies and programs, maximizing the potential to provide both preventive and curative health interventions.
Success stories, although few, provide notable examples that illustrate how certain approaches can be used to address urban health issues. Such as in the case of India when it approved the National Urban Health Mission (NUMH). India’s NUMH seeks to address the needs of the urban poor by integrating national services in urban areas, decentralizing decision-making, and including civil groups in planning and implementation of programs. The NUMH also commits to a program of planned urban infrastructure and human capacity development. While the implementation will be challenging politically and financially, the NUHM promises a practical urban plan and program that considers all ecological factors.
The Philippines can draw inspiration from India as well as other urban centers such as Curitiba, Brazil for its sustainable urban planning, and New York City for Mayor Bloomberg’s Health Legacy. The country’s Urban Health System Development (UHSD) Program is a promising initiative that seeks to help cities address the challenges of rapid urbanization brought about by the interaction of the social determinants of health. The program, however, should be more than just establishing awareness, initiating intersectoral engagement, and guiding local government units in developing sustainable responses to urban health challenges. Rather, UHSD should focus on integrating all systems into a cohesive structure capable of addressing urban health challenges at a system level, or at a societal level.
Finally, the strategy should build on the local urban experience, both positive and negative, to provide a clear vision and programmatic guidance. UHSD should also include the (1) creation of interventions to address the triple burden of health, (2) utilization of resources among and between existing global and national initiatives, and (3) capacity training of urban centers in urban program planning, implementation, management, and evaluation.
Health outcomes of Filipinos living in urban slums are worse than those living in non-slums. Intersectoral action involving all levels and agencies of the government is needed to address the urban health challenge. The country (and the world) cannot afford to neglect the issue regarding urbanization and urban health especially when it’s a matter of life and death.
Sugar taxation: revenue or health?
We have a heavy problem with obesity and taxation isn’t the answer. Obesity is one of the major risk factors for a number of chronic, non-communicable diseases including the top leading causes or morbidity and mortality in the Philippines (i.e. diabetes, cancer, and cardiovascular diseases)1,2. In 2016, 22.3% of Filipino adults above the age of 18 were overweight and 4.7% were obese3. These numbers translate to about 18 million overweight and obese Filipinos. The cost of treating obesity and obesity-linked diseases has a sizeable impact to the public health system. The cost of obesity in the Philippines was estimated between US$500 million and US$1 billion, or between 3.5% to almost 8% of total healthcare spending in 2016. Obesity also reduces life span by an average of four to nine years across ASEAN member states. Among Filipino males, obesity-linked diseases reduce productive years by between eight to twelve years4.
The over-consumption of sugar is associated with weight gain. As such, the consumption of sugar-sweetened beverages (SSBs) has been linked to obesity, as they are unnecessary sources of empty calories (little to no nutritional value). Hence, the recent introduction of SSB excise tax as a health measure, sits on the premise that such tax will curb consumption of SSBs by encouraging individuals to make healthier choices.
Policy Analysis
Given the economic and social costs of obesity, the case for responding quickly is undisputable. Taxation is an undeniably efficient source of public funding. In the Philippines, it has been introduced to address the obesity epidemic and chronic non-communicable diseases associated with it. In October 2018, the government reported that is has collected P30 billion in excise taxes from SSBs. However, this is short from the projected or target revenue of P40 billion5.
- Sugar taxation adds weight to the heavy problem of obesity. The SSB excise tax does not live up to its promise of curbing sugar consumption. Studies have shown that the evidence that sugar taxes improve health is weak6.
- The SSB excise tax is not encompassing; rather it is a ‘discriminatory’ tax. Research does not prove that purchasing fewer SSBs leads to significant weight loss6. Weight loss requires reducing total caloric intake. Therefore, measures to reduce the risks of diet-related, non-communicable diseases should not only focus on altering the consumption of individual food items (i.e. SSBs) but should encompass overall diet.
- Taxation is neither necessary nor sufficient approach to the complex issues of obesity. Evidence shows that such taxes aimed at reducing purchases of SSBs may actually have a short-term impact on sales. In Mexico, it was found that the purchasing behavior of consumers returned to almost pre-tax levels just two years after it imposed tax on sugary drinks7,8.
Combating obesity and the obesity-associated NCDs requires a holistic, multi-sectoral approach. Challenges related to limited knowledge and understanding of nutrition, unbalanced and unhealthy diet, and lack of physical activity should be addressed. Below are more cost-effective strategies on how we can meaningfully and significantly shape a healthier environment to reduce calories and sugar in the diet.
Recommendations
- Reformulate sugar-rich drinks and food, and control portion size
These measures are more cost-effective than taxation in reducing calories and sugar intake9,10. However, government policy is required to set appropriate food and drink standards allowing companies to operate on the same footing. The policy should be developed on the basis of a national quantitative study on major sources of sugar in a typical Filipino diet. The initiation of this process will require considerable time and effort as it warrants a comprehensive analysis of sugar sources and involving various stakeholders in the policy process. Moreover, the government can control portion size by restricting the ability of food establishments to offer large single serving beverages.
- Behavioral: Enforce restrictions on marketing, advertising, and sponsorship of sugar-rich food and drinks; and accelerate health information drive
Increased consumption of SSBs and sugar-rich food is often attributed to successful marketing, low cost, and high availability11. As promotion and marketing of these products remain unregulated, policy on responsible marketing and packaging of products can be legislated. The government can restrict marketing of sugar-rich food and drinks especially targeted to the youth at point-of-sale and by using mass media. Warning labels on food and drinks with high sugar content similar to tobacco products can also be considered. The DOH and DepEd can complement responsible marketing with a more intensive health information campaign against obesity in public institutions, schools, and through the use of public information systems. This approach is a necessary background measure to inducing behavioral change; but health education alone is insufficient to achieve the desired outcome.
- Structural: Improve people’s access to and availability of healthier food options, and alter unfavorable retail environment
The government can institute a ban on the sale of SSBs, sugar-rich food and/or products not meeting the desired nutritional requirement on school grounds and inside government facilities. Zoning requirements can be enforced to prevent fast food restaurants from sprouting near schools. Another feasible measure would be requiring vendors (in schools, malls, parks, etc) to place healthier food options in special displays and along check-out aisles while placing SSBs and sugar-rich food in the back of the store. These policies may be initiated by local government units. However, a national policy on the establishment and/or improvement of food environments can better support local change.
Implementation
The recommended measures can be implemented in three phases:
Phase 1: Comprehensive assessment and health education
- Establish a national committee on sugar reduction involving key stakeholders.
- Conduct a national study on Filipino sugar intake and sources of sugar in the Filipino diet.
- Initiate an education caravan at the grassroots level.
Phase 2: Reduction of sugar content and restrictions on marketing
- Enact policy to reduce the content of sugar in SSBs and sugar-rich food.
- Legislate policy to reduce opportunities to market SSBs and sugar-rich food across all media.
- Revisit and revise food labeling criteria and standards.
Phase 3: Establishment/improvement of healthy food environment
- Coordinate with LGUs in the formulation of policies on creating healthier food environments.
Conclusion
What is the real motivation of sugar taxation? Is it about revenue, not health? If we are truly determined to reduce sugar consumption and improve the health of the people, then, we shouldn’t end the campaign against obesity by simply taxing sugar. In fact, there are more cost-effective ways of battling obesity and its associated diseases. Time is up. The longer we wait, the heavier the problem becomes.
End note: This was taken from an academic exercise where we were required to write a policy memo against sugar taxation.
Thoughts on the lowering of MACR
I cannot seem to understand why there is “clamor” among policy makers to decrease MACR in the Philippines when the global trend is to increase it. I stand with the position of professional and civic groups opposing the proposed measure. First, we need to consider evidence that children below 15 or 12 years old may know what is right or wrong but most of the time fail to internalize the consequences of their actions. Rather than putting them behind bars, we should focus on addressing this problem. The government can establish institutions that can assist our children, their families and communities in educating them about responsible citizenship. Or maybe existing institutions can do a better job in bridging the gap. Second, the most common reasons for children being in conflict with the law can be traced back to poor education and poverty. Perhaps, alleviating these children and their families from poverty will not give the motivation to commit crimes. While this solution is far-fetched, the recognition of the root-cause of societal problems will prevent us from promoting backward policies such as that of lowering the country’s MACR.
Why are our policy makers keen on putting these children behind bars especially when the justice system is juvenile? Juvenile in the sense that it is still struggling to cope with the current number of children in conflict with the law. Therefore, it is unjust to subject these children to criminal trials and/or shelter them under dilapidated facilities under a system that clearly doesn’t put these children’s welfare on top of its priorities. Why are we putting much focus on CICL when they account for only 2% of registered crimes? Shouldn’t the focus shift on bigger crime groups intimidating children to do their dirty jobs? What’s happening, clearly, is like the current war on drugs. This government is scratching the surface, targeting the most vulnerable instead of capturing the mastermind.
