TWURD WP #8

URBAN DEVELOPMENT DIVISION TRANSPORTATION, WATER, AND URBAN DEVELOPMENT DEPARTMENT

ENVIRONMENTALLY SUSTAINABLE DEVELOPMENT THE WORLD BANK

The Philippines in the 1980s: A Historical Review of Social Policy and Urban Level Interventions

July 1993

WORKING PAPER .

The TWURD Working Papers present preliminary research findings and are intended for internal review and discussion. The views and interpretations in these Working Papers are those of the author(s) and should not be attributed to the World Bank, to its affiliated organizations or to any individual acting on their behalf.

@ 1993 The World Rank Washington, D.C.

All Rights Resewed First Printing July 1993

This is a document published informally by lhe World Bank. In order that lhc information contained in it can be presented with the least possible delay, the typescript has not been prepared in accordance with the procedures appropriate to formally printed texts, and the World Bank accepts no responsibility for errors.

The World Bank dots not acccpl rcsponsibilily for the views cxpresscd hcrcin, which are those of lhe author and should not be attributed to the World Bank or to its affiliated organizations. The tindings, interpretations, and conclusions are results of research supported by the Bank; they do not necessarily represent official policy of the Bank. The dcsignationemployed, the presentation of material, and any maps used in the document are purely for the convcnicncc of the rcadrr and do not imply lhe expression of any opinion whatsoever on the part of the World Rank or its afftliates concerning lhc legal stalus of any country, territory, cily, area, or of its authorities, or conccming the dclimilalions of its boundaries or national afliliation.

This paper was prepared by Ms. Carolyn Mad&Anonucvo, Ms. Roselle Rivera, Center for Women’s Resources, The Philippines and Ms. Alicia Herberl, consultan lo the Urban Devrlopmcnt Division, The World Bank, Washington D.C.

THE WORLD RANK

-The Philippines in the 1980s: A Review of Social Policy and, Urban Level Interventions

WORKING PAPER

ABBREVIATIONS

APD ARI BDC BHS BFD BHC BHS BHW BLISS BNAP BNS BSP BSPO CBHP CEDAW

CEDP CMP CPO DBM DDB DECS DOH DOLE DOST DGTC DILG DPO DPWH ECC EDL EDPITAF EO EPI FIES FLS FNRI FTOW Gos GSIS HDMF HIGC HIS

Areas for Priority Development Acute Respiratory Infections Bliss Development COrpOrdOn

Barangay Health Station Bureau of Food and Drugs Barangay Health Committee Barangay Health Service Barangay Health Worker Ba&ng Lipunan Improvement of Sites and Services Barangay Nutrition Action Plan Barangay Nutrition Surveillance Barangay Service Point Barangay Service Point Officer Community Based Health Programs Convention on the Elimination of all forms of Discrimination Against Women Community Employment Development Program Community Mortgage Program Central Project Office Department of Budget and Management Dangerous Drugs Board Department of Education, Culture and Sports Department of Health Department of Labor and Employment Department of Science and Technology Department of Transport and Communications Department of Interior and Local Government District Population Officers Department of Public Works and Highways Employees Compensation Commission Essential Drug List Educational Development Projects Implementing Task Force Executive Order Expanded Program on Immunization . Family Income and Population Survey Forward Looking Strategies Food and Nutrition Research Institute Full Time Outreach Worker Government Organizations Government Social Security and Insurance Service Home Development Mutual Fund Home Insurance Guarantee Corporation Health Intelligence Service

HLURB HSMS HUDCC IDA IDD IMC IPI KKK LGU LRT LWUA MCRA MDP MMA MMC MMTA MMETROPLAN MOF MCH MDF MMINUTE MHS MTDF MWSS MECS

. NCEE NCRFW NCR NCSO

NGO NEDA NHA NHC NHMFC NIP NNC NSP NSO NWRB OECF OPT ORT PCHRD PCUP PDPW

Housing and Land Use Regulatory Board Household and School Matching Survey Housing and Urban Development Coordinating Council Iron Deficiency Anemia Iron Deficiency Disorder Instructional Materials Corporation Implicit Price Index Kilusang Kabuhayan at Kaunlaran Local Government Unit Light Rail Transit Local Water Utilities Association Married Couples o Reproductive Age Municipal Development Project . Metro-Manila Area Metro-Manila Commission Metro-Manila Transport Authority Metro-Manila Transport, Land use and Development Plan Ministry of Finance Maternal and Child Health Care Municipal Development Fund Metro-Manila Infrastructure, Utilities and Engineering Program Ministry of Human Settlements Medium Term Development Plan Metropolitan Water and Sewerage System Ministry of Education and Culture and Sports National College Entrance Exam National Commission on the Role of Filipino Women National Capital Region National Central Statistical Office Nutritionist-Dietitian Non-governmental. Organization National Economic Development Authority National Housing Authority National Housing Corporation National Housing Mortgage Finance Corporation Nutrition Intervention Program National Nutrition Council . . National S he1 ter Program National Statistics Office National Water Resources Board’ Overseas Economic Cooperation Fund (Japan) Operation Timbang Oral Rehydration Therapy Philippine Council for Health Research and Development Presidential Commission on Urban Poverty Philippine Development Plan for Women

PFPP PFNP PHC PO POPCOM PMCC PNR PPO PRODED ’ RHU RCDP

RPTA SEA SEDP SDHA SIF SIR sss sue TFAP UHLP ULRTF UP UP0 UTDP WD WHO VAD ZIP

Philippine Family Planning Program Philippine Food and Nutrition Program Primary Health Care Peoples’ Organizations Population Commission Philippine Medical Care Commission Philippine National Railway Provincial Population Officers Program for Decentralized Educational Development Rural Health Unit Regional Cities Development Project Rural Missionaries Real Property Tax Administration Self-Employment Assistance Secondary Education Development Project Subdivision Housing Authority State Insurance Fund Slum Improvement and Resettlement Social Security System State Universities and Colleges Targeted Food Assistance Program Unified Home Landing Program Urban Land Reform Task Force University of the Philippines Urban Poor Organization Urban Transport ‘Development Plan Water Districts World Health Organization Vitamin A Deficiency Zonal Improvement Program

TABLE OF CONTENTS

INTRODUCTION

I. NATIONAL DEVELOPMENT PLAN AND THE URBAN POOR Urbanization and the Urban Poor in the Philippines National Development Plan and Urban Poverty Reduction

II. SECTORAL INITIATIVES 15 Housing 15 Water, Sewerage and Sanitation 20 Transportation Infrastructure and Service 23 Education Infrastructure and Services 29 Health Infrastructure and Services 37 Nutrition 46 Population 51 $xial Security 56

OVERALL CONCLUSION .’

REFERENCES

TABLES AND FIGURES

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V

1

9

61

63

69

ANNEX I 87

INTRODUCTION

This social policy paper was written collaboratively by World Bank and local consultants during January through April 1992. It is one of a number of economic and social policy background papers written as part of the research project on “Urban Poverty and Social Policy in the Context of Adjustment”. The Urban Development Division of the World Bank is undertaking this research project, with case studies in Budapest, Guayaquil, Lusaka, and Metro Manila. This research project is concerned with the coping strategies of urban low-income households in the past decade. Its purpose is to identify the capacity of households to respond to the conditions created by macro-economic change and policy reform. Understanding household coping strategies has important implications not only for the design of specific poverty alleviation strategies but also for the formulation of coherent social policy consistent with economic reform.

In this research project social policy is defined holistically and inclusively. Its broad objective is the development of a just, equal and prosperous society. Its concern is more equitable wealth distribution and poverty reduction through the active participation of different social groups in the satisfaction of both their economic and social rights. This definition means that not only is it concerned with sectors usually defined as ‘social’, such as Education, Health, Social Welfare and Social Security, but also includes sectors more commonly identified as ‘economic’, such as Employment, or *infrastructure’ such as Housing, Water, Transportation Infrastructure and Services, and Electricity.

This social policy review paper, which uses both Bank and non-Bank sources, has two purposes. First, to describe the national level policies and plans for the period 1987-1992. Second, to review sectoral level policies,‘.programs and projects and assess the extent to which such interventions affect the welfare of the urban poor. This includes an examination of relevant initiatives that have been identified as directly or indirectly targeted to assist in ‘poverty alleviation’ and consequently are intended to contribute to urban poverty reduction.

The paper is divided into two parts. Part One provides a brief examination of the overall policy framework at the national level. This includes a description of current national development plans as outlined in the Philippine Medium Term Development Plan (MTDP) and an assessment of its social policy objectives from a poverty reduction perspective. Part Two is concerned with sectoral initiatives and describes the various policies, programs and projects being designed or undertaken in the Philippines during this plan period. Where data is available, an assessment is made of the extent to which current sectoral initiatives assist urban poor communities, households and individuals to meet their needs.

I. NATIONAL DEVELOPMENT PLAN AND THE URBAN POOR

1.1 This section is intended to serve two purposes. First, it contextualizes the study by summarizing the urbanization process in the Philippines and profiling the characteristics and plight of the urban poor. Second, by detailing the national development plan and alternative plans, it provides the broad framework within which the sectoral policies, programs and projects which are described in Section II are discussed.

Urbanization and the Urban Poor in the Philippines

1.2 Urban growth in the Philippines has averaged about 4 percent over the last two decades and is expected to decline only marginally, adding 2.5 million households by the year 2000. About 40 percent of the Philippine population now resides in cities. This ratio is expected to rise to about 50 percent within 15 years. Growth, however, has not been evenly spread across all cities and has only been prevalent in some urban centers particularly the Metro Manila area whose primacy is a phenomenon akin to other cities in the Southeast Asia. Its population is four times that of the combined total of the next four largest cities and in 1990 Metro Manila’s population constituted 14 percent of the national population and represented about one-third of the total urban population.

1.3 One of the consequences of rapid urbanization has been the proliferation of slum and squatter settlements. Although at the country level there are no accurate statistics of the slum and squatter population, it is believed that the squatter population has tripled from 3.35 million in 1985 to 11 million in 1989 (IBON, 1991). Metro Manila contains the largest number of slum and squatter settlements. In fact, over 45 percent of the slum and squatter population is concentrated in that area.

1.4 Slum and squatter areas are anticipated to grow as the pace of urbanization continues to accelerate in the coming decades. Unless effective policies and programs are designed and implemented to minimize poverty in the entire country, problems of the urban poor will become more acute as they continue to compete for limited resources and space in the cities and other urban areas.

Urban poverty profile

1.5 Urban poverty is widespread in the Philippines. The highest incidence of urban poverty occurs in Eastern Samar, followed by the Visayas, Bicol and Western Mindanao. In terms of the absolute number of poor households, the National Capital Region (Metro Manila) accounts for the highest proportion with over 20 percent of the urban poor’. Next is Southern Tagalog with 12 percent and the Visayas with approximately 10 percent each (Hakim 1991).

1.6 The population in slum areas has been uniformly described as young with at least

* For a fuller discussion of poverty in the Philippines, .see Annex I.

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half below twenty years of age. The typical family in urban depressed areas is reported to have six members. The majority of households are nuclear rather than extended in structure. In the urban areas, the dependency ratio for the bottom 10 percent of the distribution is 4.2 and declines continuously down to 2.5 for the top tenth decile. Thus, in terms of the number of people to support, the financial burden for the poor urban worker in the lowest decile is 70 percent higher than that for a worker in the first decile. The higher dependency ratio among the poor results from the combination of two factors: poor families tend not only to be larger but also show a smaller absolute number of employed family members (see Table 1). .

1.7 The poor do not constitute a homogeneous group. In Hakim’s study, they have been ranked from low to high per capita income and then divided into four groups of equal size, with the .first quartile representing the poorest households. Table 2 shows the differences in urban areas. First, there are large differences in mean per capita across quartiles. Second, the poverty level is related to family size and dependency ratios. The larger the family the higher its dependency ratio, the poorer it is. Third, wage income is inversely related to poverty level, the poorer the family the smaller the share of wage income and the larger its share of self- employed income. Fourth, for the poorer families, it is less likely that they live in the NCR. Finally, there is a clear inverse relationship between the degree of poverty and the. amount of schooling. In the first quartile, household heads with the level of education up to complete high school represented 92 percent of the total. In other words, only 8 percent of the household heads had an education above high school. The proportion increases continually with the level of income and in the fourth quartile becomes 18 percent. (Hakim 1991)

Housing

1.8 Low income urban families live in precarious housing in congested conditions. Slum houses are mostly of the temporary type, built with light materials consisting of one room and on average last for about. five years. Many of these shelter two or more households with an average of 6.6 persons per household. A 1983 Manila Health Department study revealed that household density was 11 to 12 persons per house. A number of squatter houses and rooms were found to be subleased. Also, very few owned the land on which their houses were standing (10 percent in Manila), the rest either rented or squatted on government and private land.

Basic services

1.9 The delivery of basic services is primarily the responsibility of local governments. Basic services usually include the provision of water, electricity, sanitation facilities. Although local governments exercise autonomy in the provision of such services they usually link up with provincial, regional, and national ministries in drawing up their plans and strategies for delivering these services to their constituencies.

1.10 While access to portable water supply appears to favor the urban sector, a considerable number of urban poor do not have access to this facility. Early and recent studies

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conducted in low income communities as well as in resettlement sites have revealed that availability of a sanitary water supply is a continuing problem. A 1981 study by Laquian and others in Manila showed that less than one third of slum households had piped water facilities. This proportion was much smaller than the 1979 national average of 50 percent (NEDA 1981). A later survey conducted by IRC in 1983 in low income communities in Manila, Cebu, and Davao showed that only 16.7 percent of the households had direct water lines. Due to the inadequate supply, a large number of the urban poor depended on public faucets, artesian wells and open deep wells. Households that depended on public faucets also pay a high price in terms of queuing time-from one to four hours daily. This problem was more acute in the summer months when the water level is low.

1.11 Sewerage and dminage facilities in urban areas in the Philippines need improvement and expansion. Due to the absence of well maintained and well planned.drainage systems, the low lying sections of urban areas experience floods every year. The communities that are heavily affected by the floods are the slums and the squatter settlements which are usually located in the low lying areas (IRC 1983; Jimenez et al 1986).

1.12 Toilet ownership among low income households is not very widespread. As shown in a three city study of basic urban services, over one fifth of all surveyed households did not own toilets. Many of the urban poor used open-pit toilets i.e. the type of toilet consisting of an entirely or partly open pit which was not usually connected to a depository structure, wastes were also channelled to bodies of water or canals (IRC 1983). Another strategy is the sharing of facilities among families. (Jimenez et al 1986)

1.13 According to the IRC study (1983) garbage disposal appears to be a serious problem. Only 34 percent of the households reported that their garbage was regularly collected by the government facility. The worst off households in the survey were in Davao city where only 3.1 percent availed ‘of the government service, the majority of whom disposed of their garbage by dumping it into open pits and vacant lots.

1.14 The urban sector has benefitted from the increase in electricity supply and today . a majority of the households in slum areas and in resettlement communities have availed themselves of lighting. The IRC 1983 three city study reported that 78.4 percent of the urban poor households that were surveyed had access to electricity. Although most of the households had direct connections about one fourth had tapped lines. Households with no electricity utilized kerosene, wood and charcoal.

Employment

1.15 Slum communities are not uniformly disadvantaged in terms of employment, although it is the case that the urban poor are limited to low paying jobs of the unskilled or semi-skilled types. In a recent study of four low-income communities in Metro Manila, Jimenez found that 83.9 to 91.8 percent of fathers and from 28.8 to 44.7 percent of mothers were

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engaged in gainful employment. Fathers were more often found in transport-related work while mothers tended to be in sales or,production process work (Jimenez et al 1986). The urban poor often have to devise means of survival other than the usual wage employment. Alternative means of livelihood include hawking, peddling, sari-sari store vending.

Income

1.16 The purchasing power of the peso has declined over the years because of high inflation rates and the decline in real terms of legislated wages. A city-wide survey ‘of Metro Manila in 1982 found that 76 percent of households earned below P1720 per month, the poverty line as defined by the National Wages Council. A 1986 four community survey likewise revealed that the median total monthly income of sample households was P2100, way below the 1983 last- quarter poverty line of P2500 per month. Only those few families with fathers as overseas contract workers regularly received P5000 and more monthly (Jimenez et al 1986).

Expenditure

1.17 Poverty studies have consistently found that food is the single largest expenditure among poor households, taking from 63 to 76 percent of family budget. Shelter (rental, electricity) is the second highest priority, with much less allocated to education, transportation, medical care, clothing, business investments and recreation. In the case of resettled households, the bulk of their expenditure go to transportation, housing and food expenses, in that order (Ruland 1982, Barrios 1983).

1.18 Another consistent trend found in poverty studies is the tendency for low income households to spend more than they earn. Poor families depend on the extension of credit and material aid from their relatives, friends and employers. Households also rely on usurers, which can further exacerbate the spiral into deepening poverty.

Health and Nutrition

1.19 Mortality rates for all ages and for infants are higher in regions with a higher incidence of poverty. Data on differential mortality show that, in general, the poor have higher mortality rates than the economically better-off. The major. causes of death and of morbidity, particularly of infants are associated with poor environmental sanitation, crowding and congestion arising from inadequate housing and poor quality child care arising from the low education of mothers and child carers. All these characteristics are commonly found in low- income households.

1.20 Because of the proliferation of health providers in the city, the urban poor have a number of options open to them. Though the reasons vary with the particular choice, health centers are chosen usually for their accessibility, and free services, private doctors for the perceived better quality of services (e.g. faster) and hospitals for convenience and fast services

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, ;

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(Manila Health Department 1983). However, traditional healers such as hilots are consulted for such illnesses as sprains and tooth extractions respectively. While traditional healers tend to be consulted as frequently as health centers and private clinics, there seems to be little overlap between these two types because they provide different services. For example immunization is given only by health centers and clinics). Private organizations including religious groups, medical/dental students and the military occasionally render free medical and dental services.to the urban poor.

1.21 An important preventive health measure is immunization. However, Jimenez’s study in 1986 showed that only six out of every ten mothers had at least one child immunized. Furthermore, only 25 percent of the children had received the initial doses. The two major reasons given for non-participation or incomplete immunization were the mother’s lack of time to bring the children to the doctor/nurse and worry over the inoculation effects. Urban poor pre- schoolers therefore continue to be threatened by preventable and contagious diseases despite the availability of countermeasures.

1.22 Poor urban children ,are also at risk in terms of undernutrition. This is borne out by the weight for age data in the FNRI survey in 1984 and Jimenez study in 1986. Forty three to forty 6 percent of children were classified as first degree malnourished. The Jimenez study found higher incidences of second and third degree malnutrition in preschoolers in Metro Manila than in the FNRI survey (24.6 percent vs 14 percent and 3.9 percent vs 2.8 percent)-a finding which suggests that the severe economic downturn in the interim period had a negative impact on poor urban children.

Street Children

1.23 As the economic crisis deepened in the early 198Os, the number of street children in the urban centers in the Philippines increased phenomenally. An increasing number of children had begun to adopt the streets, markets and public spaces as regular haunts and in some cases as their permanent abode. By the late 1980s the number of street children was estimated at between 1 and 3 percent of cities’ child and youth population. Most are in Metro Manila: between 50,000 and 75,000; regional urban centers like Davao and Iloilo contain 2000 to 3000. Many work as vendors of newspapers, cigarettes and flowers, scavengers or in sweat shops. Being minors they are often abused and exploited, receiving .only about one third of the legally legislated wage and no social security and other work benefits. Some are also forced into prostitution. The number of child prostitutes reached 20,ooO in 1986.

Social and political organization

1.24 Different poverty studi,es show that the degree of social and political organization varies considerably in urban low income communities. What accounts for this ? One factor may be the stability of slum areas, where the most established and cohesive communities (e.g. Tondo) have a higher incidence of organizational participation. In contrast, newly resettled squatters may

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not be greatly involved in their community because of the tasks of rebuilding and adjustment facing them.-A second factor could be the long working hours of household members which reduces time to attend meetings. Other factors listed by Civilize that are positively correlated with increased participation in neighborhood committees among squatter relocatees include higher level of education, fewer years of residence at the relocation site, high aspirations for the family, geographic mobility and the presence of relatives and family members who could substitute for lost housework time (Civilize 1975).

1.25 it is important to note that where active local communities exist, there is.a greater degree of consultation and the provision of basic services. This is the experience of such disadvantaged areas such as Dagat-dagatan, Navotas and Dasmarinas. Unless the people affected by the relocation and other development schemes are organized at the community level, they cannot be adequately represented in any form of consultation with the government and the objectives of the consultation may not be achieved.

1.26 With regard to community leadership, Angeles’ 1984 study indicated that the typical community leader in Agdao, the research area, was a married male catholic who had at least some secondary education. He was a senior member of the community both in age and the length of residency. He earned an income slightly higher than the poverty threshold from the ownership of a sari-sari store and from dealing in lumber or fruits and vegetables. More in depth analysis of five leaders showed that they had overlapping influences, specifically in barangay politics, situations requiring mutual assistance and community projects. The dominance of a politically-based leadership was reflected in the finding that all the five nominees had formal political positions. To a lesser. extent these individuals also hold key positions in religious associations (Angeles 1984).

1.27 Similarly, the Jimenez 1986 study of Metro Manila showed that the barangay captain/chairman wielded considerable influence in the community. More than half of the respondents (55 percent) said that they turn to the barangay captain for the latest news in the community; 68 percent reported consulting him or her about day to day community problems. The barangay captain was also the most consulted person for personal family problems. The Block or Purok leaders were the second most often mentioned leaders in the community in terms of community information and problems. These studies suggested that the barangay captains and other barangay officials were a viable group that mobilized community involvement because of the fact that “they can initiate projects, coordinate internal resources as well as link up with external institutions in obtaining the basic services that are needed” by their constituents (Jimenez et al 1986). Angeles noted, however, that the nature of activities taken to solve community wide problems were peripheral and temporary (for example informal campaigns on the need for cleanliness) (Angeles 1984).

1.28 However, community organizers have pointed out that the barangay officials do not always represent the best interest of the people. Organizers also therefore deal with the natural (informal) leaders of the community (Bishop-Businessmen’s Conference 1983). In fact

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in some instances, the formal community leaders become tools of government for example in carrying out evictions and demolitions.

Macroeconomic changes and the poor

1.29 The 1983-85 stabilization process resulted in a sharp increase in underemployment and the real drop in ,GDP to 1975 levels. Where increases in underemployment had a larger effect on those workers that had the least specific skills, there were high social costs. Table 3 shows that an increase in underemployment had a negative impact on the share in total income of the lowest two quintiles in the Philippine economy. Underemployment was not found to be significant for the highest 60 percent income earners. Both the rural and urban poor benefitted from the drop in inflation since it was found to be a regressive tax. Devaluation could have a negative effect on the urban consumers since they have a larger imported component in their consumption basket and are employed in import substituting activities. The stabilization period, during which output and government expenditures contracted, affected all parts of society but had a greater impact on the poor.

1.30 The limited evidence available suggests that the welfare improvements of the seventies may have been eroded since 1983. There has been an increase in poverty in the form of. lower energy intake and higher malnutrition rates. For example in Metro Manila, the adequacy of mean one-day per capita intake of energy declined from 88 percent in 1982 to 85 percent in 1985; for protein it declined from 101 percent to 95 percent. This was more .pronounced in depressed areas. Similarly the proportion of children below weight-for-height standards which had declined in the seventies, increased from 10 percent in 1982 to 14 percent in 1985.

1.31 A strong recovery started in the third quarter of 1986 and its impact on poverty alleviation has been significant. While in both rural and urban areas there was a drop in poverty incidence, poverty alleviation was much stronger in urban areas. The average rate of decline in the number of poor households in the urban areas was almost 7 percent per year, while in the rural areas it was less than 2.4 percent. Among the urban areas, the National Capital Region showed the largest rate of decline of poor households, almost twice the national average. Economic growth during the recovery meant that more poor families were relying primarily on wages as their main source of income. Among the urban poor, wage income increased faster than total income, thus increasing its share of total income from 50 percent to 54 percent, with self-employment income stable at around 25 percent and “other income” falling from 26 to 21 percent. (Hakim 1991)

1.32 The shift towards wage income among the poor came mainly from increased participation in casual and seasonal labor markets and to a lesser extent from regular employment. For instance, in the urban areas, the bottom three deciles taken together increased the share of wage income from seasonal employment from 35 percent of total wage income in 1985 to 40 percent in 1988. On the contrary, for the top 20 percent of the distribution, the share

a

of seasonal wages on total wage income increased from four to 5 percent in the same period. The importance of seasonal employment in urban areas is largely due to the involvement of workers in non-agricultural activities. It appears that firms rely on hiring workers on a temporary basis as a means of responding quickly to an uncertain environment (Hakim 1991).

1.33 The importance of wage employment among the urban poor suggests that access to labor markets is .not beyond their reach. However, it is important to focus on the kind of labor market participation performed by poor families. From the FIES, Hakim concluded that in the urban areas, poor families are generally employed in small-sized, low-paying firms. Urban poverty and low wages go hand in hand, low wages are determined by low levels of skill and productivity, which is in turn related to low levels of capital per worker.

Conclusion

1.34 The Philippines experienced rapid urban growth over the last two decades, and today over 40 percent of the Philippine population resides in cities. However, the socioeconomic benefits that accompanied urbanization were not evenly distributed across regions and different segments of the urban population. Thus among the urban centers, Metro Manila emerged with increasing primacy and within urban societies, wealth was concentrated in the hands of a few while poverty flourished among many.

1.35 Though the urban poor are not a homogeneous group, they have been . characterized as having large families with high dependency ratios. Total family income is

usually below the poverty line and its .purchasing power has declined over the years. The presence of more than one income earner per family has therefore become imperative. These additional workers tend to be women and children. In terms of expenditure patterns, the urban poor spend a disproportionate amount of their income on food. The next priority is shelter while other needs such as children’s education, medical care and clothing are lesser priorities.

1.36 ‘The communities of the urban poor in the Philippines as elsewhere are characterized by dilapidated housing conditions, and a lack of basic infrastructure and social services. Living under these conditions has taken a heavy toll on many, particularly children, as reflected in the high incidence of mortality, malnutrition and morbidity among them.

1.37 Except in communities with highly organized and politicized groupings, the recognized leaders in the urban poor communities are the barangay leader captain or other officials. they are responsible for solving community-wide problems, however, this tends to be limited to peripheral and temporary activities which have minimal impact on the communities.

1.38 The participation of urban poor residents in community organizations is related to a number of factors, namely, long duration of community residence, better working arrangements, level of education and the availability of child care assistance. The mandate of urban organizations has changed over the years. In the past, they dealt primarily with land tenure

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issues, however, many are now engaged in activities such as job training, and infrastructure development with the assistance of government and non-governmental agencies.

National Development Plan and Urban Poverty Reduction

1.39 The two key documents which detail the national development plans of the Philippine Government are the Medium Term Development Plan (MTDP) !987- 1992 and the Philippine Development .Plan for Women (PDPW) 1989- 1992. The PDPW was drafted two years after the MTDP was announced, essentially in response to the progressive women’s groups which have been consciencitized to women and development issues and felt that official development policies must take the gender perspective into serious consideration. Also, the government’s response coincided with the international impact that the UN Decade of Women in 19751985 had generated globally.

1.40 In terms of responsibility, the National Economic and Development Authority (NEDA) is in charge of the coordination and monitoring of the implementation of the MTDP, while the National Commission on the Role of Filipino Women (NCRFW), in coordination with NEDA, is responsible for the monitoring of the PDPW and it is implemented by various government agencies. In addition, the NCRFW is tasked with monitoring and updating the PDPW, with the assistance of non-governmental organizations (NGOs).

The Medium Tei-m Development Pla’n: Objectives and Priority Areas of Concern

1.41 The MTDP identifies the “fundamental problems of the people as persistence of poverty and income inequality, high unemployment and underemployment, and urban/regional and regional disparities. * In light this, the major objective of overall policy is to “fight against poverty from the commitment to the prin+ple of upholding the human right of every person to a decent life...within a system which emphasizes equity, efficiency and social justice. n

1.42 The Philippine government development efforts from 1987-1992 are therefore directed towards poverty alleviation, generation of more productive employment opportunities, promotion of equity and social justice, the attainment of sustainable economic growth.

1.43 The MTDP states that sustained economic growth and a reduction in population growth are essential pre conditions for the attainment of these objectives (“goals”). It also identifies the creation of productive employment opportunities for the unemployed, underemployed and new entrants to the work force as the key factor in poverty reduction and as the principal springboard in the social transformation of the poor.

1.44 In addition, the MTDP underscores the need for policy reforms to be undertaken to bring about structural changes through a demand-led, employment-oriented, and rural-based strategy. This is intended to stimulate economic growth and create rural based productive

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employ men t opportunities to reduce poverty.

Short-term strategies.

1.45 Poverty alleviation will be addressed in the short-term through an inducement of demand via increased incomes. For this purpose, the government launched the Community Employment and Development Program (CEDP) targeted at generating some one million jobs in an l&month period beginning July 1986. It is expected that jobs will be generated. through labor intensive schemes such as the construction of feeder roads and communal irrigation systems and school buildings. These projects will be framedby other programs such as agrarian reform, natural resources management and social development. It is believed that the generation of these job opportunities would create expanded demand for industrial goods, improving equity and population welfare particularly for the poor.

1.46 In order to achieve these goals, regional development councils and community-based organizations will be involved in the identification, implementation and monitoring of specific projects under the employment generation program. The expanded economic activities are expected to provide a wider base for financial resource mobilization, while continuing to tap foreign grants and official development assistance and at the same time provide an environment of a less restrained monetary policy towards the stimulation of investments and reduction of financial intermediation costs.

Medium-term strategies.

1.47 The medium term strategy, however,. is rural focussed and aims to increase employment through export expansion in this sector. The role of price and non-price incentives to export producers in the realization of this goal is also identified. Hence, attention will be given to the exchange rate regime, and export procedures.

1.48 A public investment program which supports employment in the rural areas will be developed to raise agricultural productivity and with it incomes and the demand for goods and services. These changes in consumption patterns are expected to stimulate demand for products of labor-intensive industries and small and medium-scale enterprises.

1.49 Industry is expected to respond to the rural-based stimulus through the provision of specific industrial needs in rural development. As a consequence, appropriate industries that are competitive and supportive of employment and export programs would be revitalized, increasing capacity utilization rates. Domestic industrialization and commercialization of Philippine agriculture are the twin impacts expected to proceed from such a strategy.

1.50 However, the emphasis on the mobilization of the rural sector through the modernization of agriculture and the development of small- and medium-scale industries would be a temporary strategy. Through demand-led recovery stimulus, the correction of biases against

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agriculture and labor use, the country’s unemployed and underemployed would increasingly be absorbed into productive employment. In the long run, the economy’s potential is expected to shift to skill- and capital-intensive production, with industry contributing progressively larger shares in total employment and income.

Institutional implications

1.51 Privatization and decentralization are the two key policies identified to achieve the country’s short and medium-term economic plans. As such, the main role of the government is to encourage and provide support to private institutions. To. this end, the MTDP identifies the following policies. First, decentralization which will require the devolution of powers from central units, strengthening of regional and local units as focal points of development efforts and more active people’s participation in community-based and non-government organizations. Second, reduction of scope of government through the abolition of and the merging of redundant offices in line with government priorities, the abolition, divestment and reprivatization of government institutions. Supportive of these policies would be the implementation of accountability mechanisms, structures of effective political and administrative checks and balances, greater participation in decision-making processes, and a policy of transparency or openness.

1.52 The MTDP identifies the private sector as the “initiator” and “prime mover” of development. Non-government organizations are expected to develop and implement low-cost, innovative approaches, community-based participatory development projects. Private voluntary organizations are expected to participate specifically in service delivery and more importantly in mobilizing available human resources through economic-based mobilization and training especially in the marginalized sectors of the population (e.g., children and working mothers).

1.53 NGO and com.munity advocacy is targeted towards the identification of problems and possible solutions to development problems. Thus, community organization is identified as a key approach to people mobilization towards the promotion of the participation of the organized sectors, and the mobilization and organization of the unorganized sectors. To this end, the government intends to establish extension services, programs and other necessary support services. The democratization and decentralization of communication and information processes is expected to be undertaken along with increased and .expanded structures for feedback mechanisms from the people.

The Philippine Development Plan for Women (PDPW)

1.54 The Philippine Development Plan for Women 1989-1992 (PDPW) is the product of collaboration among government, women’s groups and other NGOs which sought to mainstream women in development efforts. Furthermore, “it addresses programs/projects and mechanisms to ensure that women participate on the basis of equality with men, both as active change agents and beneficiaries of programs and services.”

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1.55 The PDPW is expected to contribute to the attainment of the MTPDP’s goals as well as embody a comprehensive program of action for the advancement and development of Philippine women. The rationale for the formulation of the PDPW is:

0 to institutionalize the integration of women’s concern in the development process;

0 to substantiate in more concrete terms the macro statement in the. MTPDP which flows from the gender equality provision of the Philippine constitution;

l to comply with international conventions and agreements such as the UN Convention on the Elimination of all Forms of Discrimination (CEDAW) and the Forward Looking Strategies (FLS) up to the year 2000.

In terms of the implementation, the following strategies are important:

l Prioritization and allocation of funds to programs and activities for women.

0 “Piggy-backing”, that is, making use of approved programs and projects which various agencies are scheduled to implement.

Urban Poverty Policy

1.56 Initially government treated slums and squatter areas either as a legal problem involving the unauthorized use of public or private land. or as a housing problem. They responded therefore by clearing these areas and relocating their inhabitants. This strategy did not work since it failed to consider, among other things, the reason that drove the slum dwellers and squatters to the cities and its depressed communities. In addition to relocation, the government tried to stem the slum and squatter problem by providing low cost housing with basic amenities. The earlier projects involved the construction of high rises in Metro Manila while the later BLISS projects addressed the provisions of both housing and livelihood projects. However, there was a considerable amount of leakage and these projects ultimately benefitted the middle classes rather than low income groups.

. . 1.57 Unable to solve the problem through both relocation and the provision of public housing, the government developed an alternative strategy of upgrading the slums and squatter settlements in the 1970s. The strategy called for (a) the decongestion of the slums through reblocking; (b) the provision of core housing units and basic services; (c) reliance on residents’ self-help efforts; (d) provision of livelihood opportunities; and (e) granting a land tenure system that leads to ownership. The Tondo Foreshore became the first slum to be upgraded while the nearby Dagat-Dagatan was the first resettlement site provided with sites and services. The upgrading program was known as the Zonal Improvement Program (ZIP) in Metro Manila and as the Slum Improvement and’ Resettlement (SIR) program in other urban centers. In order to

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facilitate these programs, the government restructured and controlled the acquisition, ownership and use of urban land through the Urban Land Reform Program.

1.58 The livelihood components of projects also became more important over the years. It was also pursued independently of shelter provision through such as the Kilusang Kabuhayan at Kaunlaran (KKK) and the Self-Employment Assistance (SEA). Of these two, only the SEA program which is part of the Ministry of Social Services and Development’s package of social services emerged as relatively beneficial to low income groups but its limited scope. enabled it to serve only a small proportion of the urban poor (UNICEF 1986).

1.59 The most recent articulation of urban poverty policy by the government came with the establishment of the Presidential Commission on the Urban Poor (PCUP) in 1988. PCUP is mandated by law to direct the atte.ntion of the government to the plight of the urban poor and serve as a direct link in policy formulation, program planning and implementation. A 1989 progress report outlined that PCUP had made significant strides in its efforts to establish its coordinative mandate in mobilizing government and private resources for the urban poor and to effect change in their lives throughits involvement in interagency programs like the Community Mortgage Program, the Urban Basic Services Program and the PRO-POOR Program.

1.60 The NGO community has also outlined specific measures to alleviate urban poverty in “The People’s Agenda”. These include in the short term, the formulation of an urban development and housing framework that will treat the urban poor’s need for land as an integral concern and in the medium term, the establishment of strong cooperatives towards increased productivity, higher profit margins, better marketing techniques, and a stronger capacity for democratic participation. In addition, capacity building programs for the urban poor should be intensified.

II. SECTORAL INITIATIVES

2.1 The purpose of this section is to enable a better understanding of the sectoral initiatives being undertaken in the Philippines to assist the urban poor. First, background information on the major issues and challenges facing the sector are detailed. Second, the sectoral policies, programs and projects that are presently being designed and implemented and the institutions involved are described. Finally, an analysis of the effectiveness of current sectoral initiatives is made and the constraints in implementation are assessed.

Housing

2.2 By way of background information, this section describes the urban housing stock and conditions, particularly for low income groups. In addition, it summarizes past and present government housing policies and assesses current programs and projects.

Housing stock and conditions

2.3 The growth of new housing stock has not kept pace with the rapid urban increase. New stock needed to accommodate,urban growth alone averaged about 114000 units per annum from 1976-81 while supply through public assistance averaged about 1 l-13 percent. Private and informal efforts were still housing the majority of people. Publicly assisted production rose to about 20 percent in the early eighties with most of these units built by private developers and financed through public institutions. Thereafter the economic downturn brought a sharp decline in housing production leaving the industry largely stagnant in 1986.

2.4 Private production under ‘the expanding financial system was heavily skewed toward high income groups. Though direct production by the National Housing Authority (NHA) was targeted to the poor the authority focused on upgrading and associated resettlement schemes which made’almost no net new contribution to the housing stock. As a result, despite improved conditions in many squatter areas through upgrading, uncontrolled growth has not beencurtailed. The backlog of dwellings requiring upgrading was estimated in the mid- 1980’s at about 440,000 units in Metro Manila alone. Of these only about 10 percent have been upgraded. At this pace about four decades will be required to deal with the existing backlog (World Bank 1988).

Past and Present Policies

2.5 The government’s housing policy in the Philippines can be traced from the laissez faire policy of the 1930s which was limited to infrastructure and regulation, to the transitional interventionist policy of the post war period of providing subsidies and assistance, and finally to the developmental housing policy of the 1970s when the government was directly involved in low income housing provision, relegating the provision of housing for middle and high income groups to the private sector.

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2.6 The new government policy identifies an increasing role for the private sector particularly in the provision of low income housing. This is in recognition of the fact that the Philippine population cannot be housed exclusively through funding from public revenues, and that only through combined public and private efforts could the problem of inadequate production volume be addressed. Incentives and controls will, therefore, be introduced to redirect private production to low income groups. Increased amounts of mortgage finance will be available at lower cost ranges, and funding will be restricted at higher cost levels. Direct public production will be expanded for slum upgrading and serviced sites for the poorest half of the population that private dwellers are not expected to service; some resettlement will be continued. Policies to improve the efficiency of resource use and cost recovery for the individual agencies are being developed through a Bank project (see description below) and a long term program between the NHA and the Finance Corporation is being established. Parallel steps have been taken to improve the construction industry’s efficiency and a further review of current bottlenecks is underway (World Bank 1988).

2.7 Urban land reform is also an important component of housing policy in the Philippines. In fact, the Constitution attests to the government’s promotion of urban land reform as the approach to provide the much needed but much speculated urban lot to the millions of homeless people (Housing and Land Use Regulatory Board (HLURB), 1986). This was reinforced with the passage of House Bill 34310, also known as the Urban Development and Housing Act of 199 1.

2.8 At this point, it is important to note that many of the progressive features of the Urban and Development of Housing Act are due to the sustained lobbying of urban poor organizations (UPOs) and non-government organizations (NGOs). To be more effective, they formed the Urban Land Reform Task Force (ULR-TF) with the following functions: 1) to study the bill; 2) to draft the desired amendments; 3) to conduct information campaigns at base group levels; 4) to coordinate with allies in the Church and the Bishops-Business Conference; and 5) to oversee mobilizations. The passage of the Bill was an initial success of the coordinated efforts of UPOs and NGOs involved.

2.9 The ULR Act was passed into law in January 1992. A recent newspaper article questioned the validity of the ULR law i.e. its ability to protect the poor, since squatter settlements continue to be demolished and the necessary pre:conditions set out in the ULR Act were not adhered to (Manila Inquirer March 29 1992).

2.10 With respect to implementation, the Presidential Commission for the Urban Poor (PCUP) is assigned the task of designing a system for the registration of qualified program beneficiaries ‘while the local government units (LGUs) shall be charged with the implementation of this Act in coordination with the Housing and Urban Development Coordinating Council (HUDCC), the national housing agencies, the PCUP and other agencies concerned.

2.11 Tasked with a more crucial role is the HUDCC which “shall within one year after

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the approval of this Act prepare the national urban development and housing framework and the implementing rules and regulations” after consultation with the concerned sectors. The composition of HUDCC shall be increased to include the secretaries or heads of duly designated representatives from NEDA, the National Central Statistics Office (NCSO) and the PCUP. The framework to be drafted by HUDCC is critical since implementation by the LGUs will be based on this. Until this is made available, the LGUs will not be able to proceed with the required land use plan. It is therefore estimated that the LGUs will be able to start work on this only in the second year after the law is put into effect.

Women and housing

2.12 The PDPW has also outlined a housing policy framework which states that the housing sector shall pursue the overall recognition of women’s participation particularly those at the community level. The Plan shall aim to enhance the role of women in housing in relation to policy, housing production, finance, and estate management. Three specific policies and strategies are outlined in the PDPW: increased access to housing, improvement of information generation and dissemination related to women and housing, participatory and responsive housing programs.

2.I3 Four major programs are likewise outlined in the PDPW: consciousness raising-gender sensitive education, popular information dissemination on housing programs and women organizing on education and training in housing, organization development and institution building for housing, cooperatives, housing loan guarantee groups, data improvement on women and housing.

Programs

2.14 The National Shelter Program (NSP) seeks to confront the housing problem of the lowest 30 percent of the population by providing assistance to this group. The standard projects are development of sites and services for resettlements and site improvement of slum areas. It targets 91,000 housing units for the year increasing through the years to reach 240,000 units by 1991. Of these, 56,000 will be built for the lowest 30 percent, 20,000 for the middle 30 percent and 15,000 for the top 20 percent. Only P837 million has been allotted by the national government for the construction of the 240,000 units. .

2.15 To operationalize this goal, the following are identified as the key agencies:

l National Housing Authority (NHA) is directly involved in the production of housing units and is responsible for approximately 40 percent of government’s shelter production.

l Housing and Land Use Regulatory Board (HLURB) is the main regulatory board in housing and land development. It is charged with encouraging the

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private sector to participate in low cost housing.

Home Insurance and Guarantee Corporation (HIGC) assists private developers going into production of mass dwelling units. It not only sets the standards for low cost housing but also grants licenses to those who market them.

Since ftnancing packages are important, the government rationalized funding sources and lending mechanisms for home mortgages by integrating housing funds of Home,Development Mutual Fund (HDMF), Government Service and Insurance System (GSIS) and the Social Security System (SSS).

The Housing and Urban Development Coordinating Council (HUDCC), which is mainly a policy-making and programming entity. As it a coordinating body, the HUDCC does not have executory functions. This lie mainly with local governments, and to some extent, the NHA. Figure 1 provides an overview of the agencies involved in the housing problem and their respective functions (see Figure 1).

2.16 To acquire the lots, the Community Mortgage Program (CMP) of.the National Housing Mortgage Finance Corporation (NHMFC) provides financing for communities intending to purchase currently occupied lands or possible relocation sites. Under this program, the community, not the individual, is the borrower. It offers a loan package in three stages: land acquisition, land development, and house construction/improvement. Launched in 1988, it was allocated a budget of P200 M for full implementation. ,.

2.17 For the first five months of 1990, the Community Mortgage Program extended loans amounting to P 97 million. Site development has been done only on four of its 60 projects for the year,indicating a slowdown in the government’s mass housing program. Meantime, in terms of site development, 77 percent of the overall number of 316 slum communities spread out in 13 municipalities and 4 cities of Metro Manila had been proclaimed Areas for Priority Development (APD) by 1988. Of these, only 9.8 percent have been developed completely. A large percentage of the APDs or 64 percent remain untouched. It has been estimated that at the rate of implementation by the NHA, it will take not less. than 15 years for APDs to fully develop. ’

Program effect.iveness and problems

2.18 Previous discussion points to the fact that despite laws passed and agencies created, government has not been effective in addressing the housing problem. The National Housing Authority pointed out that land acquisition is a major stumbling block in project implementation. It also considers local government units (LGUs) as another problem area as they usually do not have the political will to deal with the squatting problem. Resolving land tenure

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problems in their respective boundaries has always been a dilemma for many local politicians. Even if NT-IA is vested with the right of eminent domain, without the agreement and cooperation of the local government, it can not proceed.

2.19 Urban Poor Organizations (UPOs) and NGOs have also pointed out flaws in the government’s housing program. One fundamental criticism is that policy remains at the rhetoric level. An examination of the programs and structures will show that they are not as responsive to the needs of the urban poor. Experiences of the urban poor themselves prove that the procedural requisites for demolitions are often oriented against them. This is aggravated by the lack of awareness of the urban poor about their rights: The critics also point out the basic assumptions under which the Program was conceptualized can be questioned. For example, it is believed that the urban poor are capable of apportioning 18 percent of their income to monthly amortization,however, the NCSO 1.985 survey of family expenditures shows that the five lowest income groups only spend from 6.7 to 8.75 of their income on rent of their dwelling unit. The program also assumes that the private sector will be interested in supporting low-cost housing. Experience has shown, however, that this is not an attractive venture for them because of its low profitability. ,’

2.20 Government has also failed to allot the necessary funds to get the program going - the NSP covers less than 40 percent of the urban poor population. Its P 4.1 billion budget is

only one-fourth of the 16 billion needed to finance the country’s housing requirement of 256,000 excluding the backlog of 100,CKKl units (IBON, 1987).

2.21 In terms of implementation, several charges have also been hurled against government’s inefficiency in handling the program. Some point out that the housing officials do not have the perspective and management skills to undertake the program. Despite the creation of HUDCC, there is still lack of coordination among agencies concerned. In fact, the HUDCC is “reduced to a non-visible agency during implementation” because government and public organizations deal directly with the concerned housing agency. “In the final analysis, while the HUDCC receives monitoring reports submitted by its Council member agencies, it has little power, and has limited coordinating functions in the implementation phase of housing programs or projects”.

2.22 On the other hand, the Subdivision Housing Authority (SDHA) praised the Aquino administration for its achievements in the area of housing.The Housing program is said to have benefitted 400,000 people in the last six years. The SDHA claimed that while the housing program of the last administration benefitted the upper 30 percent of the population, their records show that under the present program, 30 percent of those who gained from the program are below the poverty line (Manila Bulletin April 3, 1992).

Projects

2.23 The Bank has helped finance four demonstration projects over the last decade to

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establish the acceptability of low cost approaches involving slum upgrading and services sites. The first and second projects have been completed (Loans 1272-T/1282-l-PH), The completion reports concluded that both projects were successful in achieving their basic objective of demonstrating the social acceptability of low cost, self help approaches but encountered serious delays and difficulties in pricing, sales documentation and cost recovery .of units built. The Third Urban Development Project (Loan 182 1 -PH) and the Regional Cities Development Project (Loan 2257-PH) contained shelter components which expanded regional operations and experimented with private sector production of services sites. These projects have provided valuable lessons in handling private low.cost mortgages and highlighted problems inherent in complex cross subsidies. Simpler, clearer policies and tighter managementof cost recovery are needed in future to ensure replicability of these demonstrations.

2.24 The most recent Bank housing project has six major objectives, which imclude a) improvement in the institutional and policy framework; b) greater efficiency in the use of public resources; c) mass housing stock expansion by redirection of private production to low income groups; d) introduction of greater prudence into the sector’s financial and risk management with strengthened sectoral monitoring, coordination and control; e) elimination of key bottlenecks to recovery in the construction industry; and f) stimulation of the domestic economy and direct employment generation.

Conclusion

2.25 Successive administrations in the Philippines have attempted to address the issue of low income housing through a number-of approaches ranging from direct production, sites and services and upgrading to encouraging private sector participation. In spite of these varied attempts, there is still a vast housing deficit, a large percentage of the urban poor live in squalid conditions and housing remains a pressing social and political issue in the Philippines.

Wat.er, Sewerage and Sanitation

2.26 By way of background information, this section describes the availability and accessibility of water, sewerage and sanitation infrastructure and services particularly for low income groups. In addition, it summarizes the institutional framework for the provision of these services and the current policies, programs and projects.

Water supply

2.27 Between 1972 and 1980 water supply services were extended to an additional 3 million people bringing the total population with access to safe water to around 22 million or about 45 percent of the population. By the end of 1987, about 63 percent of the population had access to safe water, including 86 percent of the population in Metro Manila and its adjoining areas, 55 percent in other urban areas and 62 percent in rural areas. Overall some ,31 percent

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of the population was served by piped systems. In 1987 World Health Organization (WHO) estimated that 75 percent of urban communities in the Philippines had access to safe water, defined as piped in water supply within 200 meters and that less than 40 percent of urban communities live in dwellings directly connected to public sewerage or a septic tank. However, despite the improvement in overall service levels, the quality of the service in the areas covered was poor, with low water pressures throughout and rationed service in some areas.

Sewerage and sanitation

2.28 The 1980 census estimated that only 56 percent of the population had access to satisfactory sanitary facilities in the form of septic tanks/pits or water borne sewerage for excreta disposal. By the end of 1986, about 69 percent of all households had safe excreta disposal facilities, about 15 percent had unsafe facilities and about 16 percent had no facilities at all. In terms of population served, about 62 percent of the rural and 80 percent of the urban populations had access to sanitary facilities with Metro Manila having the highest level at 93 percent.

2.29 In Metro Manila, the dominant disposal facilities are septic tanks, many of which are not well maintained and are inefficient in treating the wastes which they discharge to service water drainage systems. The only urban areas with water-borne sewerage systems are Metro Manila, where about 75,000 people are served and three other cities where service is provided exclusively to the central areas. Because of the limited public sewerage systems and inefficient private sanitary waste disposal facilities, untreated or poorly treated domestic sewerage is a major source of urban and river pollution.

Institutional arrangements

2.30 The Department of Public Works and Highways (DPWH) is responsible for the development of integrated water supply plans and programs consistent with national policies. it also performs engineering functions, provides technical assistance and grants from the national government for the construction and major repair and rehabilitation of water systems.

2.31 The Metropolitan Waterw,orks and Sewerage System (MWSS). This agency provides the potable water supply and sewerage system for the Metro Manila area. It is responsible for planning, design, construction, operation and maintenance of water supply and sewerage systems in this area.

2.32 The Local Water Utilities Association (LWUA) is a specialized lending institution for the promotion, development and financing of local water utilities. It provides loans to the Waster Districts (Wds) at concessionary terms and also extends engineering services to them.

2.33 The Department of Health (DOH) is responsible for promoting safe water supplies and exercising surveillance of water quality. The Department’s major functions include the certification of potability of drinking water, the development and implementation of the

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sanitation program nationwide and the administration of a health education program.

2.34 The Department of Interior and Local government (DILG) undertakes the development, operation and maintenance of water systems outside the Water Districts (Wds) and the development of local government units in planning and implementing water supply projects. Local government imposes water charges to finance the water system’s operation and maintenance.

2.35 The National Water Resources Board (NWRB), organizationally attached to DPWH, is responsible for the management, coordination and integration of all activities related to the development of water resources.

2.36 As mentioned earlier, The Metropolitan Water Works and Sewerage System is responsible for the development, operation and maintenance of water supply and sewerage systems in and around Metro Manila. The operation and maintenance of urban water supply systems in the provinces is the responsibility of local government, often acting through Water Districts (Wds), which are semi-autonomous public utilities, serving one or more municipalities. Wds are formed on the initiative of the city or one or more municipahties and are financially and administratively independent of local government.

2.37 Due to the duplication of certain activities and conflicting policies of several government agencies involved in water supply, a bill to redefine the powers and functions of the

. Local Water Utilities Administration (LWUA) was tabled. It sought the transfer of functions of the water resources project management office of the Department of Public Works and Highways (DPWH) to the Department of Local Government.

2.38 A number of NGOs are also involved in water and sanitation, namely, Tulungan sa Tubigan, Philippine Business for Social Progress, Bigay Puso Foundation, 24 Hour Television for Charity Foundation, UN Ladies Association.

Current Policy

2.39 The government has prepared a Water Supply, Sewerage and Sanitation Master Plan for the Philippines 1988-2000 (The Master Plan), which provides a well integrated, ambitious package of policies, programs and projects to be implemented in two stages, i.e. from 1988 to 1992 and from 1993 to the year 2000. The Master Plan is aimed at accelerated development of the sector, especially in depressed areas, through an equitable mobilization of resources and institutional reforms. It was formulated in the context of the updated Medium-term Philippine Development Plan for 1988 to 1992 and provides a comprehensive framework by which sector agencies are guided in preparing their long-term plans, using a sectoral approach.

2.40 The targets of the Plan during the first phase are to increase water service coverage in Metro Manila in line with population growth but keeping the service level at about

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87 percent, increase coverage in other urban areas to 77 percent and increase coverage in rural areas to 92 percent. Targets for sewerage and sanitation are 14 percent in Metro Manila and 77 percent in rural areas respectively. The quality of service will also be improved.

2.41 Investment requirements for the first stage of the Master Plan’s implementation are estimated to total about P 25,022 million for water supply P 2857 million for sewerage and P 473 million for sanitation (in constant 1988 prices).

Projects

2.42 The Bank’s involvement really began in 1977 with the Provincial Cities Water Supply Project (Loan 141%PH, US$23 million) to improve water supply in five provincial towns in Luzon. A Project Performance audit Report (No. 6422, September 1986) found that physical works and studies included in the project were carried out satisfactorily;however, training of government staff working in small communities was poorly planned and had no effect. Project objectives for institutional development and financial performance would have been better pursued through projects focused, on these not easily attained goals. Six other loans were subsequently made; four for the expansion of water supply and sewerage in Metro Manila; another for water supply in provincial towns and a national program of rural water supply and sanitation in 1982 (World Bank 1986).

2.43 The Project Completion Report for the Second Manila Water Supply Project found that despite a four-year project delay ‘due to under estimated technical complexities and the economic financial crisis of 1983-86, the.project achieved its objective of improving the piped water service to Manila, thus benefitting the health of the population. It also contributed to the institutional development of MWSS.

Conclusion

2.44’. Though the provision of water supply and sanitation services in the Philippines has improved over the last two decades, a large proportion of the urban poor do not have access to these basic services. Significant investment in the sector is still needed in view of the rapid urban population growth, the low levels of coverage,the poor quality of the existing services in many locations and the need to prepare for future growth and economic expansion.

Transportation Infrastructure And Service

2.45 This section briefly describes the urban transportation system, particularly in Metro Manila, the institutional arrangement for the delivery of transport services and finally the policies and projects which have been framed and implemented in order address the major issues in this sector.

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Urban transportation system2

2.46 Based on the recent estimate, the total number person trips per day, in 1989;was about 16.3 million as compared to 8.3 million in 1974, or an annual growth rate of 4.6 percent. About 65 percent of this demand is served by public transportation modes. The predominant mode of public transportation is the jeepney, with a 75 percent share.

2.47 Bus and railway services, including the recently i+duced light rail system (LRT), along two major corridors account for 16 percent and 1 percent, respectively, of the public transportation trips. The share of private transportation modes (cars, taxis and trucks) has increased significantly from 26 to 35 percent, from 1980 to 1989. This has been attributed to the pent up demand for private vehicles since the recession up to 1986.

2.48 Another indicator of the overall transportation demand in Metro Manila is the number and type of road vehicles in use. From 1980 to 1989, the number of motor vehicles registered in Metro Manila has increased at the rate of 3.1 percent per annum. Since 1987, total motor vehicle registration has been, growing at an annual rate of close to 10 percent.

2.49 Public Transportation in Metro Manila is predominantly road based, consisting largely of jeepneys and buses for primary and secondary routes and tricycles and pedicabs for feeder routes. On the railway system, The Philippine National Railway (PNR) provides commuter services, within Metro Manila on a very limited scale with a current patronage of about 20,000 passengers daily.

2.50 The latest addition to the mass transit system is the LRT No. 1 which started full operation in 1985 and currently serves close to 400,000 passengers per day. Another elevated LRT line has been approved for implementation; this will run along the heavily trafficked east- west corridor of central Manila in Divisoria, while a mass transit line (either a busway or an LRT) is under evaluation by the government for the EDSA corridor. . .

2.51 Car ownership and usage in Philippine cities, particularly Metro Manila, has increased rapidly since the economic recession ended in 1986. In Metro Manila alone, where more than 40 percent of the national motor vehicle fleet and 60 percent of total cars are concentrated, per capita vehicle ownership is more than three times the national average. Private cars are increasing at the rate of 13 percent per annum. Its share of daily commuter trips has risen dramatically from 25.6 percent in 1980 to 35.2 percent in 1989.

2.52 Recent traffic surveys indicate that private cars are the major causes of congestion in city roads due to their sheer numbers (72 percent of all traffic during the morning peak period in 12 critical Metro Manila intersections) and low occupancy ratios (average 2.3 passengers in

2. Most of the information in this section refers specifically to Metro Manila.

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1990). In the new People’s Car Program, a component of the Car Development Program, the enthusiasm of car manufacturers to participate to bring down the prices to around P 200,000 (approximately US$ 7,700) and make them affordable to the general public, indicates the likelihood of an increased motorization level in the years to come.

2.53 Recently, the government has decided to totally withdraw oil price subsidies and allow upward adjustment of the prices of petroleum products, as a result of the gulf crisis. The ensuing fluctuating oil prices may have some dampening effect on private car use. (Esguerra 1990).

Institutional arrangements

2.54 The Department of Transport and Communications (DOTC) is the principal policy and coordination arm of the government in transportation planning, management, management and regulations. The Department of Public Works and Highways (DPWH), on the other hand, is responsible for the planning, construction, improvement, repair and maintenance of public roads and bridges. .’

2.55 The are also a number of agencies under each respective department which are responsible for the various urban transportation and traffic functions in Metro Manila. However, the existence of these agencies and their overlapping responsibilities in the delivery of urban transportation services have led to piecemeal and often times fragmented efforts to improve certain situations. A certain degree of success has been achieved in Metro Manila. Specialized units, for example T’he Metropolitan Police Command, with the police drawn from the different police districts in metro Manila. Also, there is the Task Force on Traffic for Metro Manila which is headed by the DOTC Secretary (Esguerra 1990).

Policies/Programs

2.56 Since 1983, the government has been guided by the principal recommendations of the sector review missions including the recently devised Urban Transport Development Project (UTDP). To the extent socially and politically acceptable, these strategies for action have been adopted. More specifically, the policy directions followed include:

l Increase the traffic carrying capacity of the existing road system through improved traffic management and enforcement. Current efforts involve the close collaboration of urban traffic management units, the police and local authorities in undertaking traffic improvement measures with sustainable enforcement.

l Demand management through public policies favoring high occupancy vehicles. Bus and jeepney priority lanes have been developed in Metro Manila and there are serious discussions on traffic restrictions for private cars.

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Selective investments in urban road construction and maintenance. Programmed expenditures on urban roads have been directed toward improving road maintenance and selective upgrading and construction of new roads.

Minimize investments in the provision of public transport services. In spite of initiatives to take over certain transport concerns, in 1990, the government had slowly started divestment through the slow sale of employee-cooperative mechanism.

Reform the public transport regulatory process. The LTFRB has simplified its procedures and eased up its regulatory controls, particularly in Metro Manila and Cebu, As of 1990, there was a proposed loan to focus on policy reforms in public transport regulation, particularly on truck deregulation and fare range for both urban and inter-urban services (Urban Transport Report 1990).

Projects

2.57 Since 1976 under the Manila Urban Development Project (First Urban Loan), the Bank has assisted the Philippines in developing policies and programs in the urban transport sector and low cost solutions. The project which concentrated on slum upgrading in Tondo included traffic management (US 6.4 million) and road construction (US$ 14.8 million) components. It also funded the conduct of the Metro Manila Transport, Land Use and Development Planning project (MmetroPLAN, 1977), a comprehensive study which dealt with transport strategies and priorities for future urban development of Metro Manila and identified and prepared transport regulatory measures, improvements in traffic management and public transport services and various road projects for implementation.

2.58. From 1979, the Bank has expanded its involvement in the sector by adding the concept of low cost infrastructure support in its slum upgrading programs in Metro Manila by including intermediate and medium sized cities outside Metro Manila under its Bank financed urban services improvement projects. Past and current initiatives include:

l Metro Cebu Cum Transport St&y: A comprehensive urban transport planning study, initially financed by Australian aid was carried out from 1978-80; this was later assisted by the Bank’s Urban Engineering project for the preparation of feasibility studies and detailed engineering works. This study included the formulation of long term urban development strategies and transport investment programs.

l Regional Cities Development Project: This is the first major urban intervention outside of Metro Manila covering the country’s largest regional

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centers namely Bacolod, Cagayan de Oro, Davao and Iloilo, started in 1983. RCDP comprises the following interrelated components: sanitation and drainage,municipal enterprises, shelter, livelihood pilot project, urban transport and technical assistance and training. The US$ .27.6 million transport component involves the upgrading and construction of city streets, improvement of road maintenance capability, limited traffic engineering measures and construction of bus terminals.

l Municipal Development Project; This was designed to address the imbalance of development between Metro Manila and secondary cities and municipalities of the country. The Bank provided US$ 36 million assistance for the development of basic infrastructure and services in these areas and for the strengthening of local technical and financial capacity for project implementation and service management. The infrastructure component includes the improvement to sanitation, drainage and slum areas, solid waste management, roads, traffic management and bus terminals and upgrading markets and slaughterhouses. _

l Road Transporr Industry Study: With the technical assistance from the Fifth Highway Project and RCDP, the NEDA/DOTC led National Transportation Planning Project carried out from 1986-87; a study of bus passenger and freight transport nationwide. The study concluded that purpose built common bus terminals are at best marginally feasible in economic terms and very unsound financially and.freight coordination and clearing houses should be left to the private sector to develop. These findings have influenced the government’s view on urban transport terminals and the Bank’s lending policy for similar undertakings in the future.

2.59 Despite the government’s regional development strategy, Metro Manila continued to dominate the national scene. Cognizant of the influence of urban transport to its efficient functioning and therefore to the national economy, numerous planning, policy and engineering studies were further undertaken to address the array of transport problems in the metropolis. Notably, the following works were carried out with Bank support:

l Metro Manila Urban Transpon Strategy Planning Project: A set of basic studies dealing with policy issues and investment proposals were undertaken in 1983-85;previous urban road feasibility studies of DPWH were updated in 1985.

l Study of Urban Public Road Transportation Regulation: This study has presented a thorough review of public transport problems in Metro Manila and put forward recommendations on traffic improvements and reforms to the existing regulatory framework.

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l Metro Manila Urban Transport Development Plan Project (Ui’DP): The main objective of the UTDP is to develop a ten year capital investment program for urban transport in Metro Manila.

2.60 A total of 91 projects have been identified by the related transport agencies. Fifty three are already committed and thirty eight others were tested. The implementation program including the annual investment of megaprojects included in UTDP is shown in the Figure 2.

These projects are:

l capacity expansion of the LRT Line 1; 0 construction of LRT lines 2 and 3; 0 construction of Metro Manila expressway; and l construction of urban expressways and busways.

2.61 The total investment over the years 1990 to 2000 is estimated to be about 64 billion pesos at constant 1990 prices. Total investment in megaprojects is 50.7 billion pesos; about 60 percent of this amount is suggested to be invested by the private sector. Of all investment, 31 billion pesos (49 percent) would be funded by the public sector by means of the government budget, loans and grants, the rest would be invested by the private sector (Ratchapolsitte 1991).

2.62 The involvement of other did agencies. Other bilateral agencies of the governments of Australia, Belgium and Japan have made significant contributions to the sector. Australian assistance focus mainly on traffic engineering concerns. Belgium participation is limited to the requirements in the introduction of the First Light Rail Transit line along the two main corridors and in the study of future extensions. Japan’s development assistance through JICA and OECF cover mainly road improvement and construction, traffic management, bus and railway operations. The geographic focus of their technical assistance and lending has been the metropolitan areas of Manila and Cebu (World Bank 199Ob).

Conclusion

2.63 As the population of the Metro Manila and the other major urban centers continue to grow, so will the demand for urban transport. The last few’ years have witnessed a dramatic increase in car ownership and this has exacerbated the traffic congestion problems, particularly in Metro Manila. If the needs of the urban poor are to be adequately addressed then more explicit policies and programs which reduce the use of private cars and promote efficient modes of public transport should be implemented.

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Education Infrastructure and Services

.’

2.64 The following section characterizes the Philippine education sector, particularly as it relates to the urban poor. It then details and assesses the past and present policies, programs and projects and their implications for the urban poor.

Introduct ion

2.65 The Philippines has attained a relatively high level of educational development. Almost 90 percent of the population is considered literate. More than 90 percent of primary students were already enrolled twenty years ago. Besides continued high primary enrollment, the Philippines currently enroll 70 percent at the secondary level and 30 percent at the higher level (World Bank 1988). Another noteworthy achievement of the Philippine education system is the exceptionally high representation of female students at all three levels of education. Enrollments at the elementary level are about equal for both boys and girls but female enrolment exceeds that of boys at the secondary and tertiary levels (see Figure 3).

2.66 However, the quality of education has been seriously compromised by rapid expansion and underfinancing. Though this sector received a significant proportion of the national budget in the 196Os, as much as one-third, subsequent expenditure dropped steadily, declining from 2.8 percent in 1960 to 1.5 percent in 1983. Education programs deteriorated in the early and mid 1980’s when adjustment programs called for restrained expenditure. The resulting cuts in both capital and recurrent expenditures led to critical shortages in textbooks, classrooms and physical facilities.

2.67 The education sector has since received a boost and the level of expenditure stood at 2.7 percent of GNP in 1989. Salaries for teachers which had declined in real terms over the years increased from the 1985 level of the lowest paid P1446 to the 1990 rate of P3 102. For the highest paid public schools, the increase has been from P2392 to P7478. In addition, a constitutional ‘provision for the implementation of free secondary education has been implemented. The government has undertaken to the protect the private sector through a series of measures including increased funding for students attending private universities and colleges and approved subsidies for students of private secondary schools (World Bank 1990~).

Characteristics of the education system

2.68 There are two main divisions of school based on the types of control or ownership. The first is the government supervised public school sector composed of public elementary -and high schools and state colleges and universities. The private school sector is subdivided into private sectarian and private non sectarian.

2.69 The public sector which is responsible for 95.2 percent of elementary education and 60.8 percent of secondary education, services 12.9 million of the 16.6 million school-going

30 . .

population, and employs about 350,000 teachers and other education personnel. Almost one-third of total enrollments in secondary education are concentrated in barangay, provincial and municipal schools; they cater to the poor, have low costs and low quality, Average tuition .fees are P261 which is high relative to other types of public schools.

2.70 At the tertiary level including post-secondary, non degree vocational and technical courses, there is a complete reversal of government participation-it is only 25.3 percent. There are approximately 341 state colleges and universities all over the country, located primarily in urban areas. The operations of these institutions are largely dependent on government subsidy. Unlike public elementary and high schools that are directly supervised by the Department of Education and Culture and Sports (DECs), a number of them enjoy some degree of autonomy.

2.71 The tuition-quality structure of tertiary ‘level education is regressive. State universities and colleges tend to offer a higher quality of education, but charge lower tuition fees than private institutions. Most colleges, private and public require a minimum score in the National College Entrance Exam (NCEE) as a condition for entry; this requirement is higher for the better state universities and colleges. On average the poor tend to have a lower probability of being admitted to the State Universities and College (SUC) system since they do not perform very well on the NCEE. This is partially a result of the accumulated differential of the quality of the education received by the poor at the elementary and secondary levels.

2.72 The private sector plays a significant role in the Philippine educational system. At the elementary level, there is a small high quality private sector mostly in Metro Manila. At the secondary school level, 42 percent ofstudents are enrolled in private schools whose fees are regulated by the government. At the tertiary level, the private sector accounts for 78 percent of enrollments.

2.73 Private sector education has been a lucrative business because of the large population of youth who migrate to the urban areas to study. Aggregate profits .of eight big private non-sectarian schools amounted to P8.28 million in 1972, shooting up to P14.6 million in 1975, 176 percent increase in profits (Quejada, 1986). Two private education institutions, Far Eastern University, University of the East are among the top 1000 corporations in the Philippines.

Enrollment mtes

2.74 An analysis of enrollment rates by income deciles was carried out by the Department of Education using a 1982-83 Household and School Matching Survey (HSMS). Approximately 5000 households were interviewed in this survey that matches for each child, household school and community information. In addition, students were given tests to compare their attainment to national standards. Although almost every 7-10 year old attends school in the Philippines, enrollment starts to decline after that age, particularly for the urban poor. At age 13-14, the enrollment of the urban poor declines to 70 percent. The differences in attendance

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become more acute for ages 15-16 with 89 percent attendance for the upper three deciles and 66 percent for the lower three deciles (see Table 4).

2.75 The enrollment rates at tertiary level are high by international standards, with a 33 percent enrollment ratio. Although enrollment distribution by income is unknown, it is believed that students from poor families are under-represented. High tuition is also a major barrier, particularly since less than 1 percent of students receive scholarships (World Bank 1988).

The quality of schooling

2.76 With regard to quality of schooling, clear income related differences were found in test scores, particularly in urban areas (see Table 5). The distribution of textbooks per pupil is similar to the distribution of attainment tests with students from high income deciles having access to a greater number of textbooks (see Table 6).

2.77 This is particularly worrying since the experience of the Philippines shows that access to textbooks has a positive effect on the performance of students from lower income families. Textbooks were distributed in the Philippines in the 1977-78 school year as part of the National Textbook Project funded by the World Bank. An evaluation in terms of the general achievement changes and who benefitted most from the introduction of these books was done as part of the project. It revealed that national achievement was raised considerably. The intervention was more effective for children who came from low income families. The study concluded that “the effect of the. school .quality intervention appears to be most pronounced among the children who are the most impoverished and whose home backgrounds are the most underprivileged” (Hyneman et al 1984).

Evidence on efficiency .

2.78 Evidence suggests that government’s investment in education thus far have been profitable. Estimates on the social rates of return in 1985 were approximately 12 percent to 13 percent which exceeds the normal 10 percent yardstick used for investing in physical capital. It should be noted, however, that important’differences exist between those who do and do not complete each cycle of education. The difference is particularly significant for elementary education.

2.79 The rates of return are comparable at all three levels suggesting that there are no serious distortions and inefficiencies in the intrasectoral allocation of public resources to education-a situation greatly aided by the public-private division of responsibility. Unlike many other countries, the Philippines allocates a large percentage of the education budget to elementary education. The 1988 estimates of government expenditure reflects this; 61 percent, 23 percent and 17 percent for elementary, secondary and tertiary education respectively. This pattern of spending is considered to be socially efficient since the elementary level generates the

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highest externalities. These features of large government support for elementary education and the high share of private involvement in the secondary and tertiary levels contribute to structural equity in the system-this will be discussed in greater detail below (World Bank 1988).

Evidence on equity

2.80 Three characteristics contribute to structural equity in the system: a) there is broad access at the base of the education ladder; b) the share of enrolment in private secondary and tertiary education is substantial indicating a significant proportion of students paying their own way at those levels; and c) the difference is small between government spending per student in the first and third levels.

2.81 Though the system is structurally equitable, there is inequality of opportunity. Within the elementary system it stems mainly from the variance in quality within the public system. Inequality at the secondary level reflects both inequality within the public schools and lack of access to the private system. In the public system, local schools catering to the poor, have lower expenditure per student, lower quality and higher tuition than national and city schools. Access to the higher levels is limited by high tuition. The regressiveness of tertiary education stems from its tuition-quality structure.

2.82 There is also adverse social selectivity i.e. not all socioeconomic groups have equal opportunity for education. For example, 89 percent of students with an annual household income exceeding P30,OOO complete elementary education compared to 57 percent with an annual household income of less than P, 10,000. Using another indicator of socioeconomic status,cohort survival rates in elementary education by father’s education, students whose fathers received a college education rarely dropped out but nearly 50 percent of those whose fathers had only an elementary education leave school without completing the cycle (World Bank, 1988)(see Figure 4).

Past and Present Education Policies in the Philippines

2.83 Equity, quality, efficiency and relevance are the constitutionally mandated thrusts of the educational system in the Philippines. Although stated differently, the Philippine Constitution of 1935, 1973 and 1987 require that all educational institutions shall teach the duties and obligations of citizenship, inculcate patriotism and nationalism, foster love of country, strengthen ethical and moral values, develop moral character and personal discipline, encourage critical and creative thinking, broaden scientific knowledge, and promote vocational efficiency.

2.84 In 1969, the Presidential Commission to Survey Philippine Education, formulated the guiding principles for the reorientation of the Philippine Educational system, ,which included the provision of broader general education, training in middle-level skills for national development, development of high level professions to provide national leadership and the systematization of educational planning and evaluation for more effective response to national

33

needs.

2.85 This served as a basis for the objectives and reforms in elementary and secondary education from 1970 onwards. Two major education Acts were adopted during this period, namely the Educational Development Act of 1972 or Presidential Decree 6-A and Education Act of 1982. The Decree fashioned the parallel Guiding Principles of a ten- year national education development program in the pursuit of the above aims by undertaking several development projects. An Educational Special Committee (DECS, Dept of Finance, Commission on Budget) was formed to implement these projects. The National Board of Education’s task was to formulate education objectives and policies and to provide policy guidelines. An EDPITAF (Educational Development Projects Implementing Task Force) was established to directly carry out foreign funded education projects. To fund these integrated projects, President Marcos was empowered by the Decree to contract foreign loans and “credits of indebtedness up to one hundred million US dollars as may be necessary to meet direct and indirect foreign exchange requirements of authorized projects.

2.86 The goal of universal primary education has been a main thrust of elementary education since the 1935 Constitution. Free public elementary education became a constitutional mandate under the 1973 Constitution while free public secondary education became mandatory under the 1987 Constitution.

2.87 In 1990, a new document was drafted, Education for All: A Framework for a Philippine Plan of Action. It provides the framework for policy and program development of the education sector for the period 1990-99 which has been proclaimed the Decade of Education for All. This document defines basic education as the empowerment of individuals with fundamental learning for their own being, which is a life long process in and out of the classroom. The two approaches included to achieve this goal are: 1) good quality primary education for children of school age; and 2) literacy and adult education for developing essential knowledge, skills and attitudes that allow out-of-school youths and adults to improve their quality of life and increase their opportunities to participate in and benefit from social and economic development. These thrusts have been translated into the 1990 battle cry of the Department of Education and Culture and Sports as BAYAN MUNA BAG0 SARILI (Country First Before Self).

Assessment of the education se&or 1970-1985 . .

2.88 An extensive review and assessment of educational policies, objectives and reforms in elementary and secondary education pursued during the years 1970-85 was conducted recently. The study focussed on the extent elementary and secondary education provided service to all with the constitutional right to education, the quality of mobilization of resources during that period as well as student achievement in academic and non-cognitive learning.

2.89 Elementary education. The participation rates in the elementary schools were 89 percent in 1970-71, peaking to almost 95 percent in 1979-80 and then fluctuating between 86

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and 93 percent during the past six years. The period 197080 produced slightly higher participation rates in contrast to the first six years of the succeeding decade. Due to the fact that about 10 percent of school age children were out of school in 1970-85, this group became an additional cost to society and a yearly drain in the national economy.

2.90 It was also found that the National Capital, Region had the lowest participation rates during the period 1970-85. On average, the participation rate over the six year period was approximately 76 percent which is quite low compared to those of other regions. Houjever, the NCR had the lowest dropout rates over the ten year period 197585.

2.91 Over the fifteen year period, the graduation rates of elementary school pupils bordered at 90 percent level. A large percentage of the population of elementary education was found in regions where urban centers are located. Among these are NCR, Region Four (Southern Tagalog), VI (Western Visayas) and I, (110~0s).

2.92 Based on the single performance indicator, the achievement level of elementary school age population falls way .below the target performance of 75 percent. Increases in achievement scores in national achievement tests have been made in some grade levels but in general, such gains underscore the need for better performance of the elementary school age population.

2.93 It was proposed that a more equitable sharing of resources must be instituted in elementary education so that the objectives may be met. Specific recommendations included making provisions for equitable distribution of schools among regions; initiating mechanisms for the maintenance and improvement of participation rates in all regions and providing incentives for more teachers to remain in the profession and better monitoring of the achievement of all elementary school age children.

2.94 Secondary education: In ‘1970, the Philippines had a total number of 3851 secondary schools, 48.7 percent public and 51.3 percent private. Five years later, this number increased to 4,844 with the public schools accounting for the increase. By 1985, approximately 63 percent of the secondary schools in the country were public schools.

2.95 In school year 1979-80, only 560 or 18 percent of 3,223 high schools in the country were nationally funded. The share of the national government in funding public secondary schools remained at 18 percent in 1983-84. The proportion increased to 22 percent in 85-86 (MECS Statistical Bulletin, 1980; 83-84; 85-86).

2.96 Though the number of public secondary schools started to exceed the number of private schools in 1975, the latter absorbed a higher proportion of the total enrollment in this level in 1975 and registered a relatively higher share of the total secondary school enrolment in relation to the number of school,s in .this sector. In 1980, while public schools comprised 60.5 percent of the total schools in this level, the enrollment in this sector was only 55 percent of the

35

total while in 1985 when the public high schools constituted 63 percent of the total schools in this level, their enrollment was only 59 percent of the total enrollment in secondary education. On the basis of these figures, the role of private secondary schools remains significant.

2.97 There are regional variations in participation rates in government secondary schools. The national average for the school-age participation rate in 85-86 was 28.71 percent in public high schools. Only two areas, region IV (Southern Tagalog) and VI (Western Visayas) had participation rates above the national average. This reflects that public high schools are not reaching a large percentage of the secondary school age population. This maybe attributed to the peace and order situation and low socioeconomic conditions. Dropouts and elementary school failures are also additional factors.

2.98 In general, government secondary schools posted a very high graduation rates during the period 1970-85 ranging from 81.5 percent to 95.5 percent. However, the effectiveness of secondary education measured in terms of achievement scores in the National College Entrance Examination and percent qualified examines in the NCEE did not show marked improvement over time. More regions obtained scores below the national mean score in 1975, 1980 and 1985.

Programs and Projects

2.99 Program for Decentralized Educational Development (PRODED). Elementary education has been the focus of a ten year program (198 1 - 1990) which aimed to improve quality, efficiency and reduce disparities in educational provision. This program was implemented with the assistance of the World Bank through a sector project. PRODED introduced policies for financing and management, developed a revised curriculum new with improved instructional materials and created a structure for the in-service training of teachers and school administrators.

2.100 Recent evaluations of the program revealed mixed results. PRODED has constructed 8000 classrooms, primarily for the most deprived schools. The impact of the program, however, has been stymied by two factors. First, the formula for allocating funds proved to be too complicated and the regions applied their own criteria. Second, school location planning criteria were not always clear.

2.101 The Educational Reorientation Program was the main strategy used under PRODED to develop institutional capabilities in DECS and the competencies of education personnel at all levels. Between 1982 and 1988, nearly 200,0 elementary school teachers participated in the Teacher Foundation Program, which included training in classroom instruction and management. The major drawback of the Program is that in-service training proliferate to the extent that they cause serious disruptions to classroom teaching.

2.102 Under PRODED, the curriculum was revised to simplify, update and indigenize the content of basic education. It has been noted, however, that with the introduction of new

36

material and the integration of previously separate subjects, adjustment by teachers will be necessary.

2.103 The production and distribution of textbooks formed an important component of PRODED- million textbooks were targeted for public elementary schools by 1990. The student textbook ratio for elementary school has been reduced from 10: 1 in 1979 to 2: 1 in 1988. The beneficial impact of the textbook program, however, has been weakened by poor quality content and inefficiencies in distribution (World Bank 1988).

2.104 Despite the accomplishments of PRODED, there are a number of outstanding issues to be addressed in this subsector, namely (a) physical inputs necessary for teaching and learning remain inadequate; (b) schooling effectiveness is, limited in limited by weaknesses in teachers’ subject mastery and pedagogical skills; and (c) planning is hampered by inadequacies in the systems for management information and monitoring and evaluation.

2.105 As a consequence, a second elementary school project was proposed. The overall objective of this project would be, to increase efficiency, equity and quality in this subsector through an investment program and action plan for 1990-1992. More specifically, the project would aim to (a) provide essential school infrastructure and other physical resources equitably; (b) improve the effectiveness of teachers and administrators; and (c) increase the basic learning attainment of target groups (d) strengthen DECS institutional capacities in planning and management (World Bank 1990d).

Conclusion

2.106 Despite the achievements of the Philippine education system, it is still highly inequitable. Inequality in the elementary system stems mainly from the variance in quality in the public schools. Poorer communities and students get the poor facilities. The ratio of textbooks per pupil, for instance is higher among low income students than it is for those in the upper deciles. As a result, low income students tend to have higher drop out rates and score lower in attainment tests. In the public sector, local secondary schools which cater to the poor, have lower costs and lower quality.

2.107 However, investment in education has been successful thus far. If the plight of the urban poor is to be improved, therefore, any additional investment should be targeted to finance ways to enhance school quality which in turn could improve learning achievements and raise completion rates.

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Health Infrastructure and Services

2.108 This section describes the health status of the poor and the health care system in the Philippines. It also outlines the health policies of both governmental and non-governmental agencies. Finally it details the major current programs and projects.

Overall health status

2.109 While the health of the Philippine population improved significantly during the 197Os, progress in mortality reduction probably slowed during the 1980s. The following table shows the trends in life expectancy, crude death rate and infant mortality over the period 1970 to 1985 (see Table 7). At the same time there are large regional differences in mortality with less developed regions having higher rates (see Table 8). The leading causes of death for all ages are still infectious and communicable diseases,for example pneumonia, tuberculosis, diarrhea, nutritional deficiencies and measles although degenerational diseases appear to be slowly gaining prominence.

2.110 Mortality rates for all ages and for infants are higher in regions with a higher incidence of poverty. Data on differential mortality show that, in general, the poor have higher mortality rates than the economically better-off. The major causes of death and of morbidity, particularly of infants are generally associated with poor environmental sanitation, crowding and congestion arising from inadequate housing and poor quality child care arising from the low education of mothers and child carers; characteristics commonly found in low-income households. These factors are discussed in more detail below.

D&erminants of health status

2.111 Income relative to the price of medical services is an important determinant of health status. Table 9 shows that the Implicit Price Index (IPI) for Medical Services more than doubled from P296 in 1980 to P781 in 1988. While the costs of medical services have soared tremendously, income growth has not paralleled the rising costs. Average household expenditures .show that the Filipino family has to stretch its budget to cover its food needs (see table 10 for expenditure on health services). The lower the income of a family, the higher a percentage of total expenditures goes to food, with little left for health care and emergencies or serious illnesses.

2.112 Another important determinant is the education of mothers. Survey data reveal significant infant mortality differentials by selected characteristics of mothers: the infant mortality rate varied from 52 per thousand births for mothers with some college education to 118 per 1000 births among mothers with any grade of schooling completed. Environmental sanitation is another important consideration. Indicators of environmental sanitation in terms of the proportion of households with, sanitary toilet facilities and access to safe water supply have shown improvements since 1970. However, in 1985, 33 percent of households still did not have

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sanitary toilet facilities, and 23 percent did not have access to safe water supply.

2.113 Among infants, a major determinant of the nutritional status and infant mortality risk is breast feeding. Survey results on breast feeding show declining prevalence and duration between 1977 and 1983. Moreover, it has declined in all regions except Metro Manila. The information and education campaigns that were conducted seemed to have only reached the older, more educated and more urbanized mothers. Besides breast feeding, the most important preventive child care is immunization. Current immunization rates are still low. The MTDP (1987-92) estimated that in 1986 only 30 percent3 of infants were immunized. A final factor affecting survival is the utilization of health care. The proportion of all reported deaths with medical attendance has been slowly declining. In 1983, only 30 percent of reported deaths had medical attendance compared to 33 percent in 1977. The proportion of births with medical attendance steadily rose from 49 percent in 1977 to 57 percent in 1980, but no progress has OCCUrRd since 1980. In 1983, only 57 percent of births had medical attention, varying from 34 percent in Bicol to 93 percent in the National Capital Region (World Bank 1988).

The health care system

2.114 There is no unified structure of public health service due to the pluralistic strategy of the government towards both the public and private health delivery structures (Bautista, 1989) The Department of Health is the primary government agency responsible for the implementation of the national health program. Other government agencies complement the health program, namely the Department of Education, Culture and Sports (DECS) for health education; the Department of Labor and Employment (DOLE) for the maintenance of the health of workers and the enforcement of safety standards in the work place; the Philippine Council for Health Research and Development (PCHRD) which coordinates the health sector’s research and development efforts. The Commission on Population, (recently placed under the Department of Health) and the National Nutrition Council, are two agencies which the Department of Health also cooperates with on family planning and nutrition concerns which are integrated into the health development program of the Department of Health.

2.115 Health care services are provided through public and private hospitals, rural health units (RHUs), barangay health stations (BHSs), private physicians, various NGOs and traditional

3. At the onset it is sip&ant to note that researchers from the academe. non-government organizations and health advocacy groups have warned that due to financial constraints, there is a tremendous lag in the production of PhilippineHealth Statistics by the Health Intelligence Service (HIS) of the Department of Health. To illustrate, only as recent as 1979 data was available in 1984. While efforts of the leadership of the HIS have been pushed to update the lag, the reality of the lack of updated information still remains. In 1987, the 1980 up to 1983 editions of the yearbooks were available. The Philippine Health Statistics has its limitations mainly because it relies on figures reported from the field and there is strong evidence of under-reporting for births, deaths and the incidence of diseases. Despite these limitations, these yearbooks are the only -source of nationwide health statistics for macro analysis. A case in point is the interpretation of figures with regards to nutritional status because these data are politically sensitive information.

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:,

health practitioners. In 1986, of the 1949 hospitals, 66 percents were private and 30 percent public. In 1990, there’were lO,l51 Barangay Health Stations (BHS) and 2,210 Health Centers with a population ratio of 1:6056 and 1:27 744 respectively. For the same calendar year, there were 549 DOH hospitals with 41,297 beds classified according to the levels of health care. Out of the 15 hospitals which are directly under the Secretary of the Department of Health, 29 percent are primary hospitals, 52 percent are secondary hospitals and 19 percent are tertiary hospitals (DOH Annual Report, 1990). However, statistics for health facilities are somewhat meaningless in that they merely indicate availability. These figures do not tell us whether these facilities are functional or accessible .

2.116 The expansion and upgrading of government hospitals is generally slow-paced. Studies show that the bulk of state institutions were built before 1952. In recent years the government has been building highly specialized medical centers such as the Heart Center and the Lung Center. In contrast, other institutions providing general services/care such as the Quezon Institute and the National Mental Hospital have been under-funded. As a result, the service capacity of government hospitals has been declining in recent years. The number of hospital beds reached a peak of 45., 161 in 1977 but has since dropped to 31, 403 in 1984. This decrease took place even as the number of government hospitals increased. On the contrary, there was a rapid growth of private hospitals in the seventies. This was partially encouraged by a government policy that provided loans for the establishment of these hospitals.

2.117 Both the BHSs and the RHUs are relatively more evenly distributed across the country than hospital beds but are more accessible to the population residing close to major transportation networks and closer to towns. The least accessible of government workers are the nutitionists with a ratio of 1:86,000 population in 1985, followed by dentists with a ratio of 1:48, 000. Physicians, nurses and midwives have ratios of about one per 6,000 population (see Table 11 for the period 1980-1990 and Table 12). Another category of facilities are institutions like sanitaria, mobile and semi-mobile units which care for patients suffering from specific diseases and endemic problems.

2.118 The formal health care delivery system is complemented by various NGOs (approximately 331) which provide mainly maternal and child health, family planning and nutrition services. These organizations have limited national coverage in view of their small size. Traditional health practitioners called helots and herbolarios, and a variety of magico-religious practioners practice mainly in rural areas and in urban poor communities, particularly for maternal care.

Health care expenditure and financing

2.119 Public health expenditures account for only a small proportion of total spending compared to private expenditure. In 1985, government accounted for 26 percent of health care

.expenditure in the forma1 sector as compared to 74 percent for the private sector. Meanwhile, between 1981 and 1985, health care expenditures declined by 9 percent in real terms as a result

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of a cut in overall government spending. On a per capita basis, real health care expenditures dropped to P 40 in 1985, from P49 in 1981 and PSO in 1983 (see Table 13). The government spent PlO per person in 1985, down from Pi7 in 1981 and P20 in 1983.

2.120 These financial constraints can partially explain the poor condition of the hospitals. In addition, interviews with hospital administrators reveal that the price of equipment and supplies doubled between 1983 and 1984. In light of this, a number of cost saving measures have been adopted, these include: reduction in routine laboratory examinations and x:rays, 80 percent of the country’s radiation (x-ray) clinics continue to be rated by the DOH as sub-standard; conservation of water, power and fuel consumption; a freeze on hiring new personnel and filling of vacant positions; reduction in the variety of dishes served to patients and recycling of unconsumed food; reduction in the use of office supplies; discontinuation in the purchase of disposable medical supplies. While some of these measures are energy cutting measures and saving tips, they cripple the delivery of health care services. They are possible only at the cost of cutting back on other items which hit services catering to the low income groups whose low purchasing power makes capital spending for their needs an “unprofitable” exercise. ,

2.121 With regard to composition of expenditure, government spends most of its resources in curative care and since 1982, the proportion spent for preventive care has been declining. Between 1981 and 1985,57 percent of total government spending in the sector went on curative care as opposed to only 33 percent on preventive care; administrative costs accounted for 9 percent of government spending while training activities accounted for the remainder. A large part of curative care spending wentto support public hospitals. Though little data exist on the composition of expenditure by the private sector, it is commonly believed that a large proportion of spending also goes to curative care.

2.122 Data from Family Income and Expenditure Surveys (FIES) for 1981 indicate that a large proportion of total expenditures went to pay for curative care in the form of hospital charges (32 percent), physicians fees (29 percent), and drugs related to serious illness (9 percent). Lower income households who cannot afford expensive curative care are most likely to need it eventually because of under-investment in preventive care. While no information is available on the allocation of expenditures to preventive and curative care by income groups, it is likely that the low-income groups, who spend a smaller absolute amount on health care than higher income groups, spend a relatively large amount on curative care than preventive care than higher income groups. This is because low-income households have to spend on other more pressing needs and due to their lower levels of education, may not be aware of the need for preventive care or where to obtain that care (World Bank 1988).

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Current Policies

2.123 The diseases associated with factors commonly found among the poor are easily preventable and controllable at low cost per beneficiary through immunization,proper hygiene, early detection, and simple cure. Yet the health sector in the past has allocated a substantial part of its resources to expensive urban-based curative care. Moreover, in times of budgetary cut backs, this composition of expenditure was maintained.

2.124 The Aquino government recognized this -problem and adopted policies and strategies for the 1987-92 planning period to address it. The major features of those policies and strategies were a) the emphasis on provision of basic health services for the poor, unserved, underserved and high-risk groups; b) vigorous implementation of preventive and promotive health and measures; and c) increased budgetary resources to the health sector. In addition, the policies and strategies called for the greater integration of efforts among sectoral agencies involved in the delivery of health and health-related services, the increased reliance on individual and collective efforts, greater collaboration with the private sector and greater reliance on indigenous resources and technology.

2.125 These policies can have significant impact on the poor. The DOH increased budgetary resources for health and reversed the declining share of DOH expenditures on preventive care. The share of DOH budget for preventive care increased from 14 percent in 1985 to 31 percent in 1987, higher than the average share for 1981-85 (22 percent). Finally, DOH improved efficiency in drug procurement practices, resulting in savings of at least 30 percent. Such savings were used to expand service delivery.

2.126 The DOH examined a wide range of health issues and has identified several key constraints and solutions. These issues are organized around four key concerns. a) program concerns - issues of direct service delivery; b) interagency concerns--issues of direct impact requiring collaboration between DOH and other agencies; and c) funding concerns d) institutional concerns - issues around DOH’s capacity to implement programs, collaborate with other agencies and properly utilize resources.

Alternat.ive Health Policy

2.127 ’ BUKAS, a national coalition of NGO health organizations, institutions and health individuals working towards a nationalist health care system, has designed an alternative health care policy. After discussions in 1990, BUKAS envisioned a “democratic, nationalist, scientific and service-oriented health care system geared towards the protection and promotion of the people’s right to health and quality life”.

2.128 As the first step towards the realization of this vision, BUKAS proposed changes in the health system with respect to the organization of resources, economic support, and management. With regard to the organization of resources, it is believed that representatives

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from NGOs and Pos should be included in the formulation of the guidelines concerning health services under the new local government code; that measures should be taken to regulate the practice of health and operation of health related industries; and that functionally effective community-level structures such as barangay health committees (BHCs) should be set up.

2.129 On the development and management of resources, BUKAS proposed the creation of a commission on human resource development; the development of a more relevant curricula for the health profession and mechanisms for a rational distribution; maintenance and provision of adequate human resources; training of primary health care workers; the development of health education material for the public; and the nationalization of the drug industry.

2.130 On the delivery of health care, the main tenets of the agenda include adequately equipping the health centers with personnel, facilities and supplies; nation wide campaigns to control the major prevailing infectious diseases; nutrition programs; addressing the specific health needs of women; the integration of environmental concerns in health and education services; and the inclusion of dental care as part of the essential health services.

2.131 Other proposed changes include setting a minimum budgetary allocation to health of 5 percent of GNP; imposing price controls/regulations on health services, pharmaceutical, food and other health supplies and the Central DOH should provide the political and technological leadership to shape and modify the health care system, set priorities and influence actions of relevant sectors on health-related issues (The Health Agenda, 1992).

Programs

Maternal and child health care program

2.132 This program involves a set of interrelated activities which include immunization, nutrition, maternal care, family planning and the control of diarrhoeal and respiratory diseases.

2.133 The immunization component aims to achieve expanded coverage for the population under three years of age from an estimated 25 percent in 1985 to 90 percent in 1990. It involved training personnel, vaccine distribution via a cold chain, communication and education of mothers and thorough monitoring and evaluation. The key issue perceived by DOH is how to assure continued funding support for the program and how to institutionally strengthen the health services to sustain high coverage for full immunization. The DOH recommends provision of support for upgrading and expanding local production capabilities for vaccines (World Bank, 1988).

2.134 An immunization component is executed through the Expanded Program on Immunization (EPI). This is a program that still has to be effectively waged to bring about significant results since in spite of its launching since 1976, health patterns are still recognizable: three immunizable diseases are still in the top leading causes of morbidity, namely tuberculosis,

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whooping cough and measles; two are among the leading causes of mortality (measles and tuberculosis); and one is among the top ten leading causes of infant mortality (measles). In spite of the gains of the DOH program in terms of its coverage of immunization, deaths still remain high due to inadequate provision of support activities such as environmental sanitation, nutrition, child care practices, and maternal education.

2.135 DOH (1990) reported that it had fully immunized 1,383,132 children which was 76 percent of the eligible population. BCG school entrants were given to 1,308,968 (72 percent) while 966,254 AP mothers were given DT2 representing 47 percent. There are indications that the immunization program may be helping bring down the infant death toll from diseases such as diphtheria, whooping cough, polio tetanus and most importantly, measles (see Table 14).

,

2.136 The nutrition component aims to prevent permanent disability of severely and moderately malnourished pregnant and lactating mothers. The DOH planned to increase the coverage of OPT Operation Timbang for planning purposes at local levels, achieve complete coverage of severely and moderately malnourished children and at risk pregnant and lactating mothers and increase coverage of micro-nutrient supplementation and strengthen mallard operations. It faced various operational problems including the inadequate supply of clinical weighing scales, lack of nutritionists-dietitians, and inadequate funds for food and micro-nutrient supplements. The DOH recommended hiring nutritionists-dietitians for every municipality and purchasing equipment. In order to deal with the problem of scarce resources, the DOH recommended better targeting of disadvantaged groups and institutionalization of nutrition information to prevent the occurrence of malnutrition.

2.137 ?%e maternal health care pmgmm covers prenatal, postnatal and birth delivery care. It aims to reduce maternal mortality from 0.9 per 1000 live births in 1985 to 0.7 per 1000 in 1992. The DOH considered the health care delivery system incapable of adequately meeting the need for maternal health care. It recommended improvements in logistics and facilities in health centers and hospitals, establishment of maternal health clinics in every barangay (BHS), and expansion of the health person power ratio to one Rural Health Midwife per 2,500 population. In addition, it recommends improving the quality,of midwifery training and revision of nursing and midwifery laws to authorize nurses to attend to deliveries and midwives to give tetanus injections (World Bank 1988).

2.138 According to the 1990 DOH Annual Report, AP visits to the health facilities were 2,661,539 for normal women and 854,762 for at risk women. A total of 483,069 AP mothers were given iron tablets while food supplementation benefitted 170,448 mothers while 34,623 mothers received iodine supplementation. During the post partum period, 937,275 mothers were visited within 4-6 weeks and 966,886 initiated to breast feeding. Post partum mothers were given food supplements, vitamin A and iron supplementation (DOH Annual Report 1990).

2.139 The control of diarrhea1 diseases is a major component of the program since this is one of the major causes of infant and child deaths and morbidity. Intravenous therapy, anti-

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d&heals and antibiotics were overused, while modem concepts of diarrhea are management, such as ORT were not widely practiced. The DOH, therefore, planned to intensify efforts to promote techniques of diarrhea control, supported by the production of oresol packets. DOH also intended to strengthen non-ORT strategies to control diarrhoea e.g. breast feeding, proper weaning.

2.140 The chief strategy adopted to control diarrhea was the introduction of Oral Rehydration Therapy (ORT). DOH reported that many communities as well as doctors. have not accepted this indigenous technology. A significant factor is the limited access of physicians to the ORT supply of MOH. DOH reported that in 1990,986,525 out of 1,058,219 diarrhea1 cases were given oresol. 778,148 cases were attended at RHU, and 733,150 were given oresol, 197,735 were treated at the hospital’s out patients’ department while only 181,186 were given oresol.

2.141 The control of acute respiratory infections component of the MCH program aims to establish and implement a national targeted program to reduce infant and child mortality from ARI. An on-going pilot project in Rohol offers some important lessons. It has demonstrated that midwives can be taught to detect and treat moderately severe cases of ARI. This can represent a shift from expensive hospital based treatments to simple diagnostic methods. Such innovation not only reduces cost but also expands the coverage of services to those areas with limited access to hospitals.

2.142 The under-five clinic is a special type of clinic geared towards providing preventive, promotional and curative services to preschoolers. The special feature of this service is the involvement of mothers in monitoring growth and nutrition of the O-6 years old through the use of the growth chart and home-based record.The initial impact of this strategy may be gleaned from the fact that 73 percent of mothers who delivered their children in under-five clinics breast fed their children. It was found that more often than not, mothers developed a dependent attitude to the health worker, expecting the latter to assume the responsibility to monitor the child’s growth. For the underfive chic, DOH reports a total of 705,941 (O-59 months) risk children were given medical treatment out of 2,379,984 new registrants. Among the O-83 months children, 538,960 were beneficiaries of the Targeted Food Assistance Program (TFAW.

2.143 The maternal and child care programs have been criticized for not taking into account the health needs of women per se. In their own right as human beings and subject as they are to gender-specific health problems, women need holistic health care and medical treatment.

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Projects

Health development project

2.144 The objectives of the most recently proposed project are a) support government’s priorities to expand and improve public and primary health care, especially to high-risk groups; b) strengthen the efficiency and effectiveness of DOH; c) promote collaboration among the government, local governments and NGOs in meeting community health needs; and d.) establish improved mechanisms for future health policy development.

2.145 The project would be carried out over six years and would comprise four components a) high priority programs for improvements in the control of major diseases and in maternal and child health; b) institutional strengthening of DOH though improvements in management information systems, planning and budgeting procedures, central laboratory support, service delivery capacity, communications, training and evaluation mechanisms; and c) establishment of a program to provide grants for organizing and implementing provincial-level collaboration among the DOH, local governments and NGOs for community health collaboration and d) establishment of a national health policy council and a secretariat within DOH and provision for studies.

2.146 Total project costs are estimated to be US$ 108.4 million net of taxes and duties and a foreign exchange component of US$ 40.6 million. The Bank loan of US$ 70.1 million would finance W percent of total costs, net of taxes. :

2.147 The project is expected to result in reduction of the prevalence of malaria, tuberculosis and schistosomiasis in the areas of the country identified as meeting high risk criteria. The project would also assist in the reduction of mortality among women and children in high risk communities’ targeted under the project and would support lowering of fertility through maternal health services. The capacity of DOH to identify and monitor high risk households within the community will be improved which will increase both equity and efficiency of resource use. DOH planning, management, communication support and evaluation capacities would also be improved which will lead to more effective and efficient delivery of services. Community services would be mobilized through partnerships of local governments and NGOs with DOH, permitting communities to meet their critical health needs better. Finally the project would lay the groundwork for future policy development (World Bank, 1989).

Conclusion

2.148 The major causes of death among the poor are linked to poverty and are preventable. However, if the issues which affect the health of the urban poor are to be adequately addressed, a radical shift from the current focus on specialized curative care to preventive care is required. In addition, other factors like the quality of the urban environment, congestion, availability and access to basic services and health education should also be dealt

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with.

Nutrition

2.149 This section outlines the major nutrition problems in the Philippines, and more specifically provides nutrition profile for Metro Manila. Having provided this contextual information, the policies, strategies and programs are assessed, particularly as they relate to their impact on the nutritional status of the urban poor.

Introduction

2.150 Nutrition problems in the Philippines are primarily those of dietary/nutrient inadequacies among low-income groups and growth failure in preschool children. Available national data indicate that some progress was made in improving nutritional status of the population between 1978 and 1982, however, such progress appears to have been reversed by 1985. .’

2.151 The nutritional problem that has generated most concern is among preschool children. Preschool children between the ages O-6 years constitute about 20 percent of the population. Anthropometric measures carried out by FNRI reveal that the prevalence of malnourished children declined between 1978 and 1982, but appears to have risen after that. In 1985, the prevalence of malnutrition among preschoolers based on weight for height was higher in urban areas (18 percent) than rural areas (11 percent). Moreover, while the prevalence declined in rural areas from 13 percent in 1984, to 11 percent in 1985, it rose’in urban areas from 14 percent in 1984 to 18 percent in 1985.

Metro Manila nutrition profile

2.152 The most common forms of malnutrition in Metro Manila are protein/energy malnutrition, Vitamin A Deficiency (VAD), Iron Deficiency Anemia (IDA) and Iodine Deficiency Disorder (IDD) .

2.153 The latest Operation Timbang (OPT) conducted in 1990-1991 shows that about 1,160,511 preschoolers were weighed representing a 73.27 percent coverage. The prevalence of severely and moderately underweight was 7.6 percent among preschoolers and 17.7 percent among school children. Iron deficiency anemia was found to be 70 percent among infants of 6-l 1 months, 40 percent among pre-schoolers, 45 percent among pregnant mothers and 50 percent among lactating women (FNRI, 1987). The prevalence rate of goiter was 3.5 percent among 7 year old’s and above 14.9 percent among those belonging to 7-17 year old group (FNRI and DOH, 1987).

2.154 Among the school children, prevalence of severely and moderately malnutrition

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increased from 17.3 percent in 1989 to 17.7 percent in 1990. The prevailing prevalence in the region is somewhat higher than the national prevalence which is only 11.7 percent.

2.155 Malnutrition in the region is brought about by an interplay of factors namely health, socioeconomic and environmental conditions. Most of the cities and municipalities with high prevalence of malnutrition are generally characterized by poverty, congestion, poor education, unemployment, large family size and poor environmental conditions such as inadequate water supply, lack of sanitary facilities and poor garbage disposal. These poor conditions bring about increased incidence of diarrhea, respiratory infections, other infections and communicable diseases which affect not only the preschoolers and school children but also the adults as well (see Figure 5).

2.156 As shown in the model, the health and nutrition status of an individual or community contribute to the magnitude of malnutrition problem. Nutrition and health status, in turn, are influenced by several factors such as poverty, food distribution, food beliefs and practices, environmental conditions and utilization of health services. Poor nutritional status lead to high risk of infectious diseasesand poor health status impairs the ability of the body to use and absorb essential nutrients.

2.157 Poverty remains the underlying cause of malnutrition in the region. It affects both the health and nutrition status of certain communities. It leads to uneven distribution of food in the family where the children are given the least priority in the family meal. It is also the result of large family size where more mouths are being fed. Poor access to food, low purchasing power and poor food beliefs and practices are all contributory factors. Unemployment and underemployment also characterize poverty which in turn affects ability to acquire and maintain a healthy status. Congested areas, particularly in slums of Metro Manila, are characterized by poor environmental conditions.

2.158 The health status of an individual is directly and indirectly affected by poor environmental conditions and poor utilization of health services in the area. Again, poverty contributes to the lack of a safe water supply, poor garbage disposal, lack of toilet facilities. Pollution and calamities also are detrimental to health. Poor personal hygiene and sanitation results in high prevalence of infectious diseases such as diarrhea and acute respiratory infections especially among children. . .

Strategies, Programs and Projects

2.159 The various nutrition programs and projects being implemented in the National Capital Region were anchored in the nutrition policies formulated to address the major nutrition problems identified. The approaches emphasized in the nutrition policy statement requires both the direct interventions as well as long term development aimed at tackling the underlying &uses. These plans target the nutritionally depressed segment of the population and are geared towards a lasting impact.

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Nutrition in policy development

2.160 The strategy of integrating nutrition into the development of plans and programs was included in the nutrition in nutritional development orientation of the Philippine Food and Nutrition Program (PFNP). This strategy complements the traditional nutrition interventions in order to achieve a more permanent solution to the problem. It embraces the total upliftment within the targeted beneficiaries and the environment in which they live.

Nutrition intervention pmgmm

2.161 The different strategies being carried out in the Nutrition Intervention Program (NIP), aim to provide direct, immediate or short term solutions to malnutrition problem. However, it has been emphasized that these are part of a longer term plan which complements the development process. This intervention includes food assistance, incremental food production and the provision of nutrition and nutrition related health services.

Nutrition surveillance

2.162 The Philippine Food an Nutrition Program does not end after implementation. It requires continuous provision of information to policy makers, decision makers, program planners, implementors at various levels to affect nutritional improvements through policies, programs and legislation. Information can be provided through the regular conduct of essential and relevant data generation, analysis, utilization and dissemination. The component programs of Nutrition Surveillance strategy are program monitoring and evaluation, growth monitoring, nutrition and nutrition related health services,nutrition advocacy, information and education.

Support strategies

2.163 The support strategies serve as the foundation to carry out an effective planning, management, and implementation of the PFNP. They aim to strengthen and sustain capabilities of the policy makers and planners as well as those involved in the implementation of nutrition programs and projects in their own communities. The three major components of the Support Strategies include person-power development, nutrition research, resource generation and mobilization support strategy. .

Existing Organizations and Resources in the National Capital Region (NCR)

2.164 Governmental and non-governmental organizations continuously support each other in giving proper information, training and assistance on nutrition campaigns in accordance with their line of expertise. In the NCR, there are three times as many NGOs (36) as there are governmental organizations (12) involved in this sector.

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The Urban L.akass program

2.165 The urban LAKASS program which is an action-oriented community based component of the Philippine Food and Nutrition Program (PFNP) is intended to alleviate poverty in the most nutritionally depressed cities and municipalities in the National Capital Region (NCR) by building local capabilities for planning, implementing and managing nutrition and livelihood projects. It combines the delivery of direct nutrition services with effective and sustainable development programs (income generating projects, credit, etc.). that will enhance the nutrition benefits.

2.166 The objectives of the program are 1) to continually improve the nutrition situation in the metropolis, 2) to strengthen capacities of communities to recognize emerging nutrition problems, plans for community level responses and mobilize resources to undertake effective and sustainable nutrition-oriented projects, and 3) to improve growth monitoring. within the nutrition surveillance system for nutritionally-at-risk O-6 years old children.

From these objective, key .features of the programs were identified:

0 The most nutritionally depressed barangays in the municipality are prioritized for delivery of services within these barangays, families who are most affected and at-risk to malnutrition are priorities.

l Programs and projects are identified, implemented and managed by the community itself with’ national government agencies and non-government agencies extending technical, financial and material assistance.

l Programs and projects are identified to prevent or cure malnutrition and promote good nutrition.

l Communities are mobilized and empowered to build and sustain their capabilities to improve their nutritional situation.

2.167 Based on the 1989 Operation Timbang Results of the Department of Health (DOH), six areas have been selected initially namely: Manila, Quezon City, Pateros, Malabon, Marikina and Navotas and from these areas two (2) barangays each were chosen to be the target areas.

. The following activities were undertaken:

l conduct of social mobilization as the community assemblies and C/MNC meetings;

l multi-level training on area based nutrition program especially program

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management training and its echo training and other simultaneous trainings at the barangay level;

0 seminar-workshop on business management and small scale industry both at the municipal and barangay levels;

l conduct of community organization and management seminar workshop for the BNSs;

0 multi-level nutrition action planning. .

2.168 After the training, seed capital of $130,000.00 was granted to each area. 20 percent of this is allotted for the direct services and the remaining 80 percent is for the sustainable development programs which the barangay itself identified and planned from within the framework for the Barangay Nutrition Action Plan (BNAP). Formal launching of the program and turnover of the financial assistance to the recipients were celebrated and to date five areas have already implemented their projects on food assistance, construction of sanitary toilets, varied income generating projects and consumer’s cooperative.

2.169 According to a recent NNC report, thus far, the implementation had been good giving positive results as to the rehabilitation of the malnourished children from second degree and third degree and augmenting the living situation of their families through the income generating projects they engaged in. Regarding the payment scheme, there is a high level of repayment, in fact, a number of recipients. have received additional loans. There were also other areas that have already undergone expansion of the program to other nutritionally depressed barangays and its needy families making a new set or batch of beneficiaries.

Conclusion

2.170 The nutritional problem that has generated the most concern in the Philippines is growth failure among preschool children. This problem is very prevalent in low income urban areas and is growing. A number of national and urban based initiatives including the Urban Lakass Program have been implemented to address this problem in poor urban communities. The evaluations thus far have indicated that though the results vary from region to region, overall, a considerable measure of success has been achieved.

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Population

2.171 This section briefly outlines the history of population policy in the Philippines and details the current policies and initiatives. It also summarizes the women’s NGO perspective on the issue of fertility and population control.

2.172 The Philippine population increased from 36.7 million persons in 1970 to 60.5 million in 1990, making it 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;

2.173 The lack of progress in the reduction of birth rates is said to be directly related to the increase in the proportion of women in childbearing ages, a decline in the mean age of marriage and a slow decline in marital fertility. This slow change in marital fertility is directly related to the slow progress and even decline in the prevalence of contraceptive use during the 1980s (World Bank 1988)(see Table 15).

Fertility and Contraception

2.174 As indicated in Table 16, the poor have higher fertility rates than the higher income groups. Fertility rates are higher in the poorest regions, rural areas, among less educated mothers, agricultural households and manual occupations. The differences in fertility rates are paralleled by differences in contraceptive prevalence rates. As shown in table 17, substantial differences in.contraceptive prevalence rates were found between urban and rural residents, by region, by household income, occupation of household head, and educational attainment of the wife.

2.175 ’ The proportion of women who were not using contraceptives but did not want more children was higher among poor households (Table 18). Data for 1978 show that 40 percent of “exposed women” who did not want more children were not using any contraceptive method. This proportion was higher among rural women with less education and in agricultural occupations. Part of the discrepancy between fertility desires and contraceptive practices may be due to the lack of access to family planning services. One survey reported that 65 percent of women could not afford the cost of contraception (World Bank 1988).

Policies and Programs

2.176 During much of the 196Os, family planning activities were the purview of NGOs. In 1967, however, the Philippines government signed the United Nations Declaration on Population, recognizing population growth as a principal element in long range national planning. In 1969 a presidential declaration established the Population Commission (POPCOM)

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under NEDA and in 1970, under POPCOM’s recommendation, the National Population Program was formally launched. The national population policy and the creation of POPCOM were written into law the following year when the Philippine Congress passed Republic Act 6365.(The Population Act), providing that,

“for the purpose of furthering national development, increasing the share of each Filipino in the fruits of economic progress and meeting the grave social and economic challenge of a high rate of population growth, a national program of family planning which respects the religious beliefs of the individual involved shall be undertaken”

2.177 This Act mandated POPCOM to serve as the central coordinating, planning and policy making body of the government in matters relating to population. From the outset, the state’s policies received substantial financial support from external sources which financed more than 80 percent of the Program expenditures during the first four years, and an average of 57 percent until 1988 (World Bank, 1991).

2.178 During the initial years, the Family Planning Program was integrated into the health service delivery system through the Maternal and Child Health/Family Planning Unit, established in the DOH. By 1975, there were about 2500 clinic country wide. Although this represented approximately one clinic for every 2fKKl married couples of reproductive age (MCRA), there were wide regional variations. The contraceptive prevalence rate was only 13 percent, less than half the rate reported for the urban areas (28 percent). Further, the data suggested that the prevalence rates decreased as the distance from the clinic increased.

2.179 Based upon these findings, it was determined that the Program should go in two directions (a) by extending the reach of planning services to rural areas and (b) by utilizing non- medical personnel in the delivery services.

2.180 In an effort to improve accessibility of services and broaden and deepen local government support for the Program, the Outreach Project was established in 1976. The project was the core activity of the Philippine Family Planning Program until 1986. The Outreach Project essentially consisted of a network of both paid and volunteer outreach personnel. The paid personnel included the provincial/city population officers (PP&/CPOs), district population officers (DPOs), and full time outreach workers (FTOWs). The unpaid community-based volunteers are known as barangay service point officers (BSPOs). The FTOWs and BSPOs’ functions were to motivate and recruit contraceptive acceptors, distribute IEC materials, resupply contraceptives, monitor family planning acceptors and report the number of those acceptors to POPCOM. In 1985, there were 157 PPOsKPOs, 34 DPOs, 2250 FTWOs and 51169 BSPOs.

2.181 Recent data on the Outreach project, based on the 1983 National Demographic Survey indicates that the presence of the Barangay Supply Point and BSPOs were not greatly felt. Only 37 percent of the married women of reproductive age interviewed said that they knew

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of a nearby BSP. Among those who knew, only 29 percent received contraceptive supplies from the BSPO. Part of the problem has been the lack of basic supplies.

2.182 In keeping with the prevailing international views, (which held that family should be a vertical initiative separate from health) and because the development of the DOH rural network was still in its infancy, it was decided to separate family planning outreach from that of the health system. This led to a number of problems. First, two dichotomized family planning service delivery structures emerged. By the early 198Os, POPCOM had effectively become the implementing arm of the Program as its role extended not only to include 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 was increasingly focussed on primary health care and less on family planning (World Bank, 1991).

2.183 In addition, 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’this. It is believed that the Program’s overriding concern to control the birth rate was at the expense of providing q~ulity family planning services. This obscured women’s needs for thorough family planning information,counselling and follow-ups which could have helped sustain the Program’s initial goals. Since the Program was relatively unresponsive to women’s needs, it failed to enlist as many acceptors as previously and in fact suffered a considerable number of drop outs (Miralao 1989). The program had also been characterized by vacillating political support, variable levels of financing from both domestic and external sources, and lack of consensus on program goals.

2.184 In the face of mounting opposition by’ various groups to the Program’s explicit advocacy on population reduction, leadership support for the National Program eroded, particularly within NEDA. This set in motion a series of events that imposed considerable constraints on POPCOM’s management of the Population Program.’

2.185 After the change in government in 1986, institutional development and service delivery continued to decline while new policies were being debated. During 1986 and 1987, POPCOM became more passive and, less focused and its leadership role diminished as its overall program mandate became less clear. Both domestic and external funding declined, imposing financial constraints on POPCOM. By 1989, the Outreach Program had fallen apart. The problems were probably best expressed in the DOH’s Family Planning Service 1988 Report which stated that the Program had made little headway in 1986 and 1987, largely because of “serious political, religious and legislative problems surrounding the on-going policy debate and institutional, financial, manpower and logistical constraints” facing the Program itself.

2.186 The process of formulating the neti policy directions for the Philippine Family Planning Program has been national in scope and has reached the very foundations of the relation

.between the state and society. The central difference between the historical population policy and the new one lies in the constitutionally mandated role of government. According to the 1973

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constitution, it was the state’s task “to achieve and maintain a population level conducive to national welfare.” the new constitution, ratified in 1987, shifted this responsibility from the state to the individual couples, recognizing “the sanctity of family life” and upholding 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.

2.187 The new policy distinguishes between the country’s Family Planning Program on the one hand and its broader population and development concerns on the other. The statement provides a broad framework for addressing the current problems of unmet demand for contraceptive supplies and services particularly among the poor. 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.

2.188 The stated primary goal of the Philippines Family Planning Program (PFPP)( 1990 -1994) is to improve family welfare by providing accurate and timely information and services to support individual couples’ fertility decisions. While this can contribute to curbing population growth,the Program is not focused on this objective nor on fertility reduction as a goal. While it is recognized that the aggregation of such personal decisions and actions has an impact on overall fertility and population growth, the Program views this result as

“a separate issue altogether distinct from the principal program focus of assisting couples for their own benefit and according to their aspirations. The Program intends to respond to the household demand for information and services relative to family planning on the assumption that the satisfaction of individual couples would also mean the achievement of overall social development goals.”

2.189 Specific objectives include increasing the number of acceptors and the proportion of women practicing family planning; decreasing the drop out rate; and continuing services to current users. In order to achieve the stated objectives, the Program expects to establish family planning services in existing public and private facilities with untapped capacity; maintain existing service outlets;train health professionals in basic and specialized skills; and increase the number of acceptors and continuing users (see Table 19).

2.190 The Institutional and operational locus of the Program has shifted from the Population Commission (POPCOM) to the DOH, the country’s major family planning provider. The DOH is charged with establishing policies and standards for its own activities and those of participating Governmental and Nongovernmental 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, The Family Planning Organization of the Philippines and the Population Center Foundation.

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2.191 The POPCOM Board was reinstated as a coordinating and policy making body for the overall National Population Plan, which formed the basis for subsequent articulation of the DOH’s 1990-94 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.

2.192 The New Program is domestically not externally driven. The government has grounded the program in a broad based process of national consensus building. International agencies have been consulted and participated in the process, but the Program’s “ownership” is Philippine and its policies and strategies are clearly those of the government (World Bank, 1991).

Women’s NGOs Stand on Health and Family Planning

2.193 For Women NGOs, fertility management is defined as the regulation of one’s capacity to reproduce, which includes the management of problems of infertility. Fertility management is also taken in the context of reproductive rights which to these NGOs is a basic human right. Given this premise, they advocate that the state must:

l Insure this right is not violated by programs and policies tliat would seek to deny women the right to decide on their fertility. The government must also maintain a separation of the Church and the State.

l Insure that all the necessary conditions and systems are in place that would allow women to exercise this right. These include availability of and adequate information on all safe, accessible and affordable contraceptives, child care support and comprehensive health care for women regardless of age or status.

2.194 In addition, education programs aimed at women, children and men are necessary in order to may informed choices. Also, given women must be made major participants in all phases of policy and program formulation and implementation.

2.195 In terms of policies and program scope, fertility management and health services should be made available to all women and programs designed to help women manage their fertility should address men’s equal responsibility on birth control and unwanted pregnancies.

2.196 Program services should include comprehensive reproductive health services for women throughout their life cycles; access by all individuals of reproductive age to safe, effective and affordable methods to manage their fertility; education programs with orientation and training on gender sensitivity and gender-fairness for all policy makers, program beneficiaries and implementors and the media; objective research on the side effects as well as the safety of different types of contraceptives (Alliance of 21 Women NGOs, July 1990).

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MAJOR EVENTS M THE PHILIPPINES FAMlLY PLANNING PROGRAM

1967 Philippines signs U.N, Declaration on Population

1969 POPCOM created

1970 National Population launched to reduce fertility

’ 1973 Constitution mandates government’s role in fertility reduction

1976 Outreach Pmject launched

1978 Special Committee to Review Philippines Population Program

1981 NEDA eliminates demographic targets from Five Year Plan

1982 POPCOM chair transferred from NEDA to MSSD

1984 ’ POPCOM budget ‘incorporated in MSSD budget; targets reintroduced

1986 Change of Government

1987 New constitution mandates couples’ right to make fertility decisions; New Population Policy issued.

1988 DOH designated lead agency for family planning

1989 New Five year Directional Population Plan

1990 New 1990 - 1994 Family Planning Program Plan

2.197 The efforts thus far to deal with the high population growth rates in the Philippines have not met with much success. However,. the recent attempts to change the institutional and operational framework of the policies and programs and establish them in a broad based process of national consensus building should yield more promising results.

Social Security

2.198 Social security in the Philippines operates through two major systems, the Social Security System (SSS) for private company employees and the Government Service Insurance System (GSIS) for state employees.

57

2.199 This section describes the two existing and related forms of social security which directly affect the urban poor, particularly those formally employed as laborers of companies, factory workers and wage-rate earners. While the majority of the urban poor work as casual wage-rate earners in the service sector, these forms affect them. Since both operate as social insurance institutions, these systems are basically oriented in their current operations towards the wage-based sector, a limitation that should be addressed.

2.200 The first is Medicare, a type of state health insurance system to help shoulder medical expenses. The second is the Employees Compensation Commission, which is a compulsory social insurance scheme that gives tax-exempt benefits to employees (or their dependents) for work-related disability or death.

Medicare

2.201 The Philippine Medical Care (Medicare) Plan was established by 1969 and implemented in 1972 through the Philippine Medical Care Commission (PMCC). Currently, PMCC is administratively under the supervision of the Department of Health (DOH).

2.202 In its policy declaration, Medicare, commits to “gradually provide. . . comprehensive medical care according to the needs of the patient. n Medicare’s objectives include providing medical care to residents of the country in an evolutionary way within our economic means and capability as a nation and to provide our people with a viable means of helping themselves pay for adequate medical care.

2.203 However, the implicit cost-sharing concept in Medicare was qualified by the 1986 Constitution which recognized that there are members of society who are too poor to pay for their health service requirements. The Constitution, apart from identifying priority sectors (i.e., underprivileged sick, elderly, disabled, women, and children) also mandated that “thestate shall endeavor to provide free medical care to paupers” (Article XIII, Section 11).

Organizat.ional structure

2.204 The Medicare Law provides that PMCC shall formulate policies, administer and implement the Medicare Program consistent with the National Health Plan. (PD 1519, section 3) Operationally,’ PMCC translates this mandate by promulgating rules and regulations to implement the Medicare Program, monitoring abuses, conducting information campaigns, undertaking research on prevailing support value of Medicare benefits, and recommending premium payments and benefit packages. The PMCC is governed by a Board of Commissioners and its budget (salaries, for operating expenses, capital outlay) is funded by the national government via the annual Appropriations Act.

2.205 The implementation of the Medicare was divided into two stages: Program I which covers the employed and Program II is intended to cover those in the formal sector. In the

58

implementation of Program I, PMCC serves as the policy- formulating and coordinating body. The Social Security System (SSS) and the Government Insurance System (GSIS), respectively, administer to the needs of private company employees and state employees. As of 1990, Medicare covered 23.5 million Filipinos or 38 percent of the total population. Of this, about 16.8 million were served by SSS while the remaining 6.7 million were under GSIS.

2.206 Program I benefits are financed through a compulsory contribution scheme and is administered through a payroll tax. Contribution is computed at 2.5 percent. of an employees’s salary base, with the employer and employee sharing equally in the cost. The salary base has a ceiling beyond which contribution is the same, regardless of the salary amount of the employee (See Figure 6) However, despite its compulsory nature, Program I reaches only 20 percent of its potential target.

2.207 Program II has not been implemented because of the financial and administrative issues involved. The DOH has lately initiated the basic research to provide the basis for informed decision making in the policy and operational concerns associated with implementing Program II. The coverage of the unemployed and the self-employed is the target of Medicare Program II and serious efforts are underway by DOH to systematically address the numerous and complex obstacles inhibiting the implementation of Program II. There is an existing opportunity to expand Program I coverage to the self-employed who are at the lower end of the income spectrum (ieepney and tricycle drivers, market vendors).

Availment

2.208 From 1972 to 1990, the rate of availment for the total Medicare program averaged 6.45 percent. For the same period, SSS had an average of 5.36 percent, almost half the 10.36 percent experienced by GSIS.

2.209 The differences in availment rates of SSS and GSIS may be due to a number of factors, namely that GSIS has been covering retirees since 1974 while SSS commenced only in 1990, GSIS covers members of the Armed Forces and policemen which are high risk groups, private employers provide their own benefits which may be discouraging their employees from claiming Medicare. and private employers provide pre-employment and annual medical check-ups. .

2.210 From 1987 to 1990, both SSS and GSIS exhibited declining availment rates, indicating that the aggressive measures’against abuses undertaken by PMCC,SSS, and GSIS may be making inroads. In 1990, benefits paid by SSS and GSIS totalled P710 million and P442 million respectively. Annual increases in benefit payments appear to be due to changes in the prices of medical services rather than due to increased availment rates. ’

2.211 Medicare has proven its ability to act as a risk-sharing mechanism. Those in the formal sector as well as sectors of the self-employed have been provided an avenue whereby

59

funds may be pooled for use for hospitalization expenses. Medicare has also introduced the concept of cost-sharing where the member shares in the funding of the cost of treatment.

2.212 The reality is that Medicare has not succeeded in totally covering the employed sector, having reached only 22 percent of the employee population of 1990. The unemployed remain without Medicare coverage. The majority of the urban poor populace are in the informal sector. Medicare has yet to extend its benefits to this informal sector and to a large portion of the self-employed. Also, the support values of Medicare have not been responsive as expected resulting in higher share of out-of-pocket expenses. This has also led to the need for a number of individuals and employees to take out other insurance options.

2.213 Presidential Decree No. 1636 of 1980 allows SSS to cover the self-employed and many have indicated a desire to do so. One impediment to such coverage expansion is an SSS rule that does not allow membership in SSS purely for Medicare .purposes, one has to be covered for the entire gamut of SSS benefits (e.g. retirement, ECC) If this SSS restriction can be eliminated, then the risk sharing mechanism of Medicare can be enhanced in terms of persons covered.

The Employees Compensation Commission (ECC)

2.214 The ECC was established by Presidential Decree No. 626 dated 27 December 1974 and took effect 1 January, 1975. ECC supplanted the old Workman’s Compensation Commission. ECC’s policy (Chapter 1, Article 166) is to promote and develop a tax-exempt compensation program where employees and their dependents, in the event of work- connected disability or death, may promptly secure adequate income benefit, and medical and related benefits.

2.215 ECC benefits come in the form of cash income in the case of disability or death, medical and related services for injury and sickness, rehabilitation services in case of permanent disability. They are provided through medical care, rehabilitation benefits, disability benefits and funeral benefits. .

Organizational structure .

2.216 ECC is the policy formulating body and is supervised by the Department of Labor and Employment. SSS and GSIS serve as the collecting and claims processing/paying agencies. They also separately manage the two State Insurance Funds (SIF); SSS for the SIF of privately- employed workers; GSIS for the SIF of the state employees. Unlike PMCC which obtains its institutional budget from the national government, ECC is dependent on the SIF for its budget which is perceived as a major operational constraint.

60

2.217 Administratively, ECC operates just like the PMCC. The Board is composed of: The Secretary of Labor as Chairman; the GSIS Gen. Manager; the GSIS Administrator, the Chairman of PMCC and two other members (one each representing employees and employers) appointed by the President for a term of six years.

2.218 ECC coverage is compulsory for all employees who are not over 60 years old. An employee beyond 60 years old may also be covered if s/he has been paying contributions before age 60 and has not been compulsorily retired. As of 1987, ECC covered about 12.2 million workers of which 10.9 million are SSS members and 1.2 million come form GSIS. Total ECC coverage for 1987 represents 21 percent of the Philippine population for the same year ( versus 38 percent for Medicare). Medicare has a higher percentage coverage because it benefits not only employees but also dependents, retirees and a portion of self-employed.

2.219 The SSS has a much broader membership coverage and a faster rate of increase in covered employees than the GSIS. Membership in the SSS increased from about 3.8 million in 1976 to 10.9 million in 1987, growing at an annual rate of 6 percent. But membership rates have experienced declines since the start of the program. Peak growth rates ranging from 8 to 10 percent were registered during the early years of inception but the rates have steadily declined to 3 percent in 1987.

Conclusion

2.220 Despite the efforts of the government, overall social security coverage in the Philippines is still very limited and even more so for the urban poor. The two schemes, Medicare and ECC are designed to cover workers in the formal wage earning sector and their dependents, automatically excluding a large proportion of the urban poor who tend to be concentrated in the informal sector. If coverage is to be extended to the latter group, then there must be a concerted effort to overcome the obstacles currently experienced by Medicare in the implementation of Program II and the ECC must broaden its client base to include workers in the informal sector.

61

OVERALL CONCLUSION

2.221 The preceding sections have attempted to assess the various sectoral interventions in terms of their ability to alleviate urban poverty. The results are mixed, with certain sectors performing better than others in this regard. Availability and access to housing and basic services are critical issues for the urban poor. In spite of the efforts of successive administrations and. the shifts in strategies and philosophies over the years, there is still a large deficit of low income housing and inadequate provision of basic infrastructure. Significant gains have been made in the area of education, particularly at the primary level, and the issue at hand is less one of access and more one of quality, particularly in poor communities. Less progress has been made in health and nutrition; still a disproportionate number of Filipinos (especially the poor) do not have adequate assess to basic health care and have poor nutritional status. By and large, the urban poor have had virtually no access to social security, the current system is highly exclusive. If the needs of the urban poor are to be seriously taken on board, then innovative ways and mechanisms should be developed.

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64

8. Philippine Studies Program. Honolulu: University of Hawaii. (June)

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IBON Facts and Figures. 1987 Vol X No. 17

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Makil, Perla Q. 1982. “Social problems research.” Philippines Country paper read at the ACUCA Workshop on Social Problems in Asia. Tokyo: Kwansei Gakvin University. (November 29-December 2)

Mangahas, Mahar. 198 1. “Social well-being in Metro Manila: A final report on the Social Weather Station Project. n Makati: Development Academy of the Philippine; Research for Development Department. (September)

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Manila Inquirer March 29, 1990

MECS Statistical Bulletin 1980 Pp 83-86

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Philippine Business for Social Progress. 1988. Poverty ProJle of the Urban Poor.

66

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Philippine Urban Transport Sector Issues 1990.

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67

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TABLES AND FIGURES

Table 11 Differences among the poor, by qualities, 1988 . ’

Urban Poor lncdme up to No. of

Family No. of Depend. 46 of % of % living HS grad wage wkrs Per Capit Sire Employed ratio wages self-emp. in NCR % % Income

1 st quartile 6.5 1.5 4.2 47.1% 30.1% 10.2% 2nd quartile 6.1 1.6 3.9 51.4% 27.7% 17.9% 3rd quartile 5.6 1.5 3.8 55.5% 23.6% 27.9% 4th quartile 5.6' 1.6 3.6 57.1% 22.0% 33.2%

All Urban Poor 6.6 1.6 3.9 53.8% 25.0% 22.3%

Rural Poor Income

Family No. of Depend. % of 46 of % living Size Employed ratio wages self-amp. in NCR

1 st quanile 6.6 1.5 4.5 24.4% 49.4% NA 2nd quartile 6.1 1.5 4.0 29.6% 47.0% NA 3rd quanile 5.5 1.6 3.4 324% 44.6% NA 4th quartile 5.3 1.6 3.4 35.7% 41.8% NA

All Rural Poor ’ 5.9 1.6 3.8 31.5% 45-o%- N4

92.2% 42.4% 2567 90.0% 48.0% 3947 87.2% 53.3% 5078 82.b% Si.S% 6221

87.9Vo 49.1% 4459

up to No. of HS grad wage wkrs Per Capit

% % Income

98.9% 19.0% 1737 97.9% 25.0% 2610 96.2% 27.6% 3362 95.2% 31.8% 4204

97.1% 25.9% 2978

Sma#e: Hokim 1991

Table 2. Dependency ratios by deciles, 1988

1 II III IV V vl VII VIII IX X

Family Size 6.28 5.98 5.61 5.52 5.35 . 5.21 5.08 4.73 4.56 4.01 . Employed 1.51 1.57 1.54 1.59 1X1 1 .M 1.72 1.69 1.70 1.62 Dependency Ratio 4.16 3.81 3.64 3.47 3.32 3.05 295 2.80 2.68 248

70 .’

Table 3. Earning shares and macroeconomic variables, estimates for each quintile (quarterly, 1980-N)

Variable Lowest Second Middle Fourth Highest Fifth Fifth Fifth Fifth Fifth

Constant 33.64* 14.28* (5.17) (7.61)

12.18* (4.29)

21.18* (4.12)

-2.36 (-1.27)

Productivity (P)

3.92* 0.964< (-4.93) (4.20)

o.s79* (1.72)

-0.361 (-0.725)

-0.393* (-1.79)

-0.009 (-0.58)

Underemployment * (u)

0.12 (1.10)

-0.175* -0.070* (-4.77) (-6.65)

0.229 (0.699)

Real Interest Rate (r)

0.005 (1.26)

-0.002 (-0.345)

-0.004 (-1.51)

0.027* 0.014* (3.31) (5.97) ,'

-5.13* -1.78* -1.27* (-5.S) (-6.68) (-3.15)

Government Spending w

-1.81* (-2.32)

,0.859* (3.24)

Real Exchange Rate (xl

Inflation Rate (xl

-2.14*' t-2.516)

0.061 (0.26)

2.16* 0.437* (2.82) (1.98)

-'0.075* -0.022" (-3.89) (-4.01)

-0.168 (-0.47)

-0.025+ (-2.88)

-0.006 C-0.395)

0.016* (2.73)

Time trend (t)

R2 D.W

0.061* -0.043* (4.20) (10.10)

-0.001" (0.21)

-0.007 (0.457)

0.007* (-1.77)

0.789 0.972 (2.68) (2.78)

0.774 (2.16)

0.761 (1.87)

0.791 (2.24)

Notes:

log Si = C i + a li Log 0 + a2i U + a3i f..+ a4i log 0

+ asi Log X-l+ 06i log n-l+ 07i t

'i = th;:sr;e of the ith quintile in the distribution of income . ..S).

The model specification and the variables are discussed in the methodological appendix. The estimations were performed using the Cochrane- Orcutt Iterative Technique.

71

Table 4. Enrollment rates by age and income decile

Income dccile ‘I-10

1.

AQe 11-u L - la-lb

2 3 4 Total

Urban

Total

0.99 0.97 0.96 0.99 0.99 0.98 0.99 0.99 0.99 1.00

0.98 0.94 0.96 0.97 0.97 0.97 1.00 0.98 1.00 1.00

s. 0.98

0.70 0.71 0.84 0.87 0.90 0.95

x: 0:97 1.00

0.63 * 0.83 0.67 0.82 0.68 0.86 0.74 0.89 0.77 0.91 0.80 0.93 0.87 0.95 0.78 0.93 0.92 0.97 0.97 0.99

0.78 0.91

Sourer: HSMS - special ubulrlions

Table 5. Attainment tests by income decile .for public elementary education*

Income decile Average score Urbpn

1 2 3 4 5 6 7 8

. .

9 10

37.80 38.66 36.12 38.41 43.73 40.39 44.45 42.53 47.76 47.64

a Average of I~SI scores given IO 41h gndc students ia Mathematics. English and Filipino Source: HSMS - special tabulationa . .

72

Table 6. Number of textbooks per public elementary school student, by income decile

Income dccile

1 2 3 4 5 6 7 8 9 10

Smwce: IhMS - speed ubuhtioru

Urban

3.84 3.41 3.64 4.55 3.72 5.00 4.61 6.94 4.25 7.66

Table 7. Selected estimates of mortality 1970-U

Year Crude death rate Li& expectancy at birth Infant mortality rate (per 1,000 population) .’ (ia years) (per 1,000 population)

1970 11.8 58.1

1975 9.2 59.9 74.6

1980’ 8.7 61.6 63.2

1985 7.9 63.1 56.6

Souse: NCSO. Popuhioi~ Studii Division. IS repattcd in NEDA. Cbmpediun o/Philippine Social Smisiu. 1986

73 .?

Table 8. Crude death rate, life expectancy at birth and infant mortality rate by region, 1975-80

Infant Lift expectancy mottality rate

Crude death rate at birth (per 1,000 (per 1,000 pop. 1 (in years) Live births) 1975 1980 1980 197s 1980

Philippines 9.2 8.7 61.6 National Capital Region 8.6 5.7 66.1

I Ilocor 10.6 9.9 63.0 II Cagayan Valley 9.3 10.6 58.3

III Central Luton 9.2 7.1 65.1 IV Southern T~galog 9.2 7.6 64.3 V Bicol 9.3 9.2 61.2

VI Western Virayar 9.5 9.0 62.2 VII Central Virayas 10.0 . 8.7 63.9

VIII Eastern Visayas 9.5.. 10.9 58.3 IX Western lfindanao 8.4 14.3 51.3

X Northern Hindaaao 8.8 12.3 55.0 XI Southern Hindanao 8.5 12.6 54.4

XII Central Hindanao 8.0 14.3 51.5

74.6 *

83.4 98.1 62.3 69.2 63.4 73.2 . 65.6 7s.3

116.0 112.1

91.9 112.1

63.2 44.0 57.0 78.3 48.2 51.6 64.8 60.5 53.3 78.3

112.8 943 97.6

112.8

Now: Dau for 1975 d 1980 YC~ derived from Ibe 1975 4 1980 census mqcctivcly. Sowze: NCSO, Popuhtion Studier Divtion as reponod in NEDA. tosnpmdiyln o/Philippine SodI slodtbct. 1986.

Table 9. Some economic indicators relevant to the Philippine Health Sector (1972 Pesos)

YeU GNP Per Capita Implicit Price Index for Medical Services

1980 1915.14 296.7 1 1981 1932.45 337.86 1982 1920.82 384.61 1983 1894.53 432.63 1984 171.88

. . 560.94

1985 1607.31 648.84 1986 1600.14 695.66 1987 1650.71 737.62 1988 1723.11 781.33

Socme: Solon and Hetin, 1991

74

Table 10. Health expenditures - days of work (average income) needed to pay for

One consultation with a general practitioner 1.1 One consultation with a specialist 3.2 One chest x-ray 3.3 Three days room and board in a public ward 7.2 Three days room and board in a private room 17.3 Simple tonsillectomy 94.2

Sovrrc Philippines lfaltlt Matten. I99 I

Table 11. Department of Health manpower and Ratio to population

Manpower 1980 1989 - 1990 .

Physician 7529 (1:6388) 9546 (1:6151) 7431 (1:8273) NtNS 9426 (15102) 12.170 (1:4825) 10270 (15986)

Dentist

Pharmacists

1027 (1:46834) 1163 (150491)

730 (1:80440)

1550 (1:39665)

565 (1:108814)

Midwives 9320 (15160) 11604 (15986)

Sowee: Philippine Health Matters. 1991 l & Departtnmt of kdtlt Atttttml Repoft. 1990.

75 .,

Table 12. Government medical and selected paramedical workers per person, 1978-M

Physician Nurse Hidvifc Dentist Nutritionist Inspector

1978 7,437 6,132

1979 6,877 5,518

1980 6,656 s,o29

1981 6,714 5,136

1982 6,883 S.265

1983 6,403 5,050

1984 6,560 S,ltb

198s 6,423 5,245

7,437 57,967

s,407 60,537

5,179 46,954

5,230 45,445

9,362 46,S89

s.437 46,333

S,S72 47,507

5,582 47,704

150,146 30’,489

93,700 * 31,379

78,182 30,873

82,697 25,692

84,779 26,339 .

84,09s 27,689

86,189 28,378

86,228 28,282

SOUIW: MOH. Planning Se&cc: mnd NSCO. Pop&ha Scudi Div*ioo. u # ia NED& ti@m O~p~~P~ sorid htisaia, 1986.

Table 13. Per capita health care expenditures, 1981-U (Pesos)

Year Government

Nominr 1 Real Private Philippines

Nominal Real Nominai Real

1981 SS 17 104 31 lS9 49 1982 65 18 118 .!2 183 51 1983 75 20 135 33 210 St 1984 67 12 164 29 231 41 198) 69 10 196 30 265 a0

Sourtr: Tables 7.22 and 7.22 in Chapter 6. Volume 2 of thii sport.

76

Table 14. ImmuniMion coverage of infants 1989-90 (percent)

1989 1990

BCG 89 72 DPT (Diphtheria, Pertussis, T&anus) 1.2.3 79 88 Polio 1.2.3 78 88 MCI&S 83 85

Table 15. Contraceptive prevalence rate, currently married women 15-44 years old. 1968-83

Hethod

All Methods

Modern Program Methods -1iD P 11

St&liz8tioa In jrction

Other Program Hethodr Bhbm co~oal

ls.s 24.4 37.1 32.1

10.4 12,s 17.6 E 6,p n 0.1 4 2.4

Xi s.3 f 3 - - -

E 12.7

%i 2.0

Uon-Program Wthodr w tMr&w8L Other*

.6.0 11.8 s cu Tz G 1.6 2.0 2.3 1.1

tiume: 1968. 1973 and 1903 National Dcmogmphii Survey and 1978 Republic of the Philippinea Fertility Sway.

77

Table 16. Mean number of children born in the past five years to women who have been continuously married, by background variables.

+’

BAckground VrtiAblt HeAn Background variable Hem

Level of Education None Primary Iatcrmcdiate High school Some college With college degree

Region of Residence Ketro Haaila Luzon ViSA)tAS Mind Anao

1.1 1.4 1.2 1.0 0.9 1.0

0.9 1.2 1.3 1.3

Husband’s Occupation Prof l rsional 0.9 Clerical 0.9 SAhS 1.0 Agriculture, self-employed 1.3 Agriculture, aot self-emploped 1.3 Services 0.9 Manual, skilled And unskilled 1.2

Place of Residence Urban RurAl

1.0 1.3

All Women 1.2

SOUIW: 1978 Republic of the Philippines Fenility Survey.

Table 17. Contraceptive prevalence rates accnrding to selected socio-economic variables (married women 15-44 year8 old)

Socioeconomic characteristics Contraceptive prevalence t%)

Residence '-A.)

Urban (b)

Monthly HH Income Less than P 1,000 P 1,000 and over

HH Head Occupatioaal fader 9. Lov High

Educational Attainment Priuury or less Elemeniary High school College andover

.

27.1 40.4

28.5 41.5

31.0 45.4

21.4 20.9 36.0 43.7 .

Sorcrrr: 1983 National Dcmogmphic Survey as reported in J.V. Wigon. ‘Fettility and Contmccption in the Regiona. Philipptu Popdbabn Joumd. l(4): 30.66. December 1985.

78

Table 18. Percentage of women who are not currently using an efficient method of contraception among those who are currently exposed and want no more children, 1978

All 25-34 35-44 All 25-34 35-44 Bac&ouad varitblt ages years ymrr Background varitblt ages years years

Lcvtl of Education None Primmy Intcmrcdiatt High rchool sou colltgt With college degree

Beltion of Btaidtntt Metro Haail

Husband's Occupation 84.9 (100.0) 04.8 Proftrsional .Sl.? 43.5

. 83.a - 80.7 84.0 Cltrical 60.7 38.9 73.6 68.2 75.0 Sales 63.5 58.0 60.6 58.9 59.8 Agriculkart, relf- 49.6 46.7 48.1 employed 82.2 79.8 54.7 49.3 55.3 Agriculture, not self-

tmploytd 82.8 78.0 Strvittr '59.1 35.1

S6.7 so.1 57-&S !fanual, skilled 64.0 sa.7 Luton 71.2 65.4 73.3 Han-l, unskilled 60.0 s7.5 Viray8s 79.6 78.2 78.8 Xinduaao 70.4 68.2' 72.0

Place of Rtridcnct Urban 58.9 63.8 f8.1 Etur81 77.6 73.8 79.5 All Women 70.9 66.5

54.5 58.5 62.S

83.0

85.9 56.5 66.6 60.1

72.1

titme: 1978 Republic of the Phiii Fertility Sunmy:

,’ ,,

79

Table 19. Projected annual accomplishments

totb I Accampiiohunt8 1990 19Bl 1992 1993 1994 lSOO44

1. Now Sorvieo Outlot*.

(b) BON l utloto (b) Othw CO outlots (c) NC0 outlok Cd) N70~;uro

(a) DOH l utloti (b) Other GO outlota (c) NC0 clinics (d) NI?‘o’;“rs

8. Trriring

(a) k;fXhgor&ors on

(b) Neolth profomoionols ;;,;~iblixod R

(c) Hwlth profossionalo on diWwort FP rof n8h.r ~OUIWOS

(d) llDo/RNs/RYo on VSC

148 164 630 261 40 146

I m 6tii

2,244 2,192 10 913

284 328 S

2,zm .' a,sJ

3,6D9 L,328

1,139 1,928

1,RUl a,s47 222 472

167 2t1

81

roi

2,646 EQ4 472

z2 3,894

4,946

2,081

a,faB 416

161

!

26

2,718 1,119

Fsa

4,4ii

4,139

lJ97

4,wa aa9

124 61 16

19:

2,864 1,180

676 23

4,eB

a.739

912 7,266

4,402 172

744 1;trr

a07

2.2%

21,860

4. Aeeootom 1.140.000 1.228.600 1.639.700 1.867.200 2.199.000 7.B74.600

s. 08Ors 2.004.900 ;).012.400 2.283,600 S,t41.000 4,171.000

Sotwee: Dcprnmenr of HmL.

80

Figure 1. Entities involved in the housing problems, their level and main functions (PULSO, 1990)

NATIONAL LEVEL

METROPOLITAN LEVEL

LOCAL LEVEL

Policy-making Planning Programming HUDCC Integrated National

Shelter Program

Financing (HDMF, NH&C) '

Appraisal, insurance (HICC)

Regulatory (ELURB) I

1

Accreditation of urban poor (PCUP) I

Land acquisition,resettlement, production (NKA)

I Delivery of services: garbage collection, flood/fire control (MMA) I

Development Planning (LGU) L Policy-making, Regulatory (LcU)

Implementing, Land Acquisition, Financing, Production (Lou)

4

. .

81

Figure 2. Implementation plan for committed projects

-t i : i -*

I I I

I I i

82

Figure 3. Distribution of enrollments by sex, 1984’

a Teniary enrollment we for degme program8 only.

Figure 4. Cohort survival rates in elementary education by father’s education, 1986

amu1-

t

-- c-.Q. .’ -.- N

--,mgn- --- No-

-

83

Figure 5. Casual model of malnutrition in the region (NCR)

:u ! NALNUTRITIGN p&q . . ! ------j . . t . IHII)LIIIfllUEI’ ,

i LOU PUACHASINii

PQER

i

84

Figure 6. The current medicare system

1 PMCC I

Claims

l&r fees(P) ‘laiy

Premiums

Out-of-pocket(P).

Map of NCR

85

/ \ I . .

ANNEX1

Definitions of poverty

While most agree on the qualitative description of what constitutes poverty, arguments abound on the quantitative criteria for defining a person or a household as “poor”. The following table details three of the main indicators used in the Philippine context.

Indicator

NEDA Poverty Line il’

NEDA Poverty Line 22’

Purchasing Power 2’

Purchasing Power

Poverty Line Based on Subjective Perception of Basic Minimum Needg’

Value YfS

$195/mth 1991.

Incidence

55.8% of families below this line.

$145/mth

Categories A and B

Category C

Category D

Category E

Categories A and B

1991 40.7% of families below this line.

1984 2%

1984 16%

1984 57%

1984 25%

1985 2%

Category C

Category D

Category E

P3OOO/mth2 (Median for Metro Manila)

1985 9%

1985 60%

1985 29%

19851’

1’ Based on the needs of an average family of six.

?’ The “New Poverty Line” - Based on the needs of an avcrapc family of six. Only essentials areconsidcredhenceproducts like cigarettes and alcohol have hcen climinatcd.

2’ This is based on the categorization of households according to purchasing power. These range from class A or the highest income level to class E for the very poor.

*’ This is based on the respondents’ subjective pcrccptions of their minimum basic needs. Rcspondcnts arc asked to give conservative (minimum) estimates of the incomes and various expenditure categories below which they would consider themselves poor.

2’ Based on Bishop-Busincssmcn Confcrcncc Survey. 1985.