© 2009 Reproductive Health Matters. All rights reserved. Reproductive Health Matters 2009;17(34):99–107 0968-8080/09 $ – see front matter www.rhm-elsevier.com PII: S0968-8080(09)34472-9 www.rhmjournal.org.uk
The influence of local policy on contraceptive provision and use in three locales in the Philippines Romeo B Lee,a Lourdes P Nacionales,b Luis Pedrosoc
a Visiting Professor, Department of Global Health and Epidemiology, Graduate School of Medicine, Hokkaido University, Sapporo, Japan. E-mail: [email protected] b Planning Officer, Population Commission, Welfareville Compound, Acacia Lane, Mandaluyong City, Philippines c Programme Associate, Population and Development Strategy Programme, Population Commission, Welfareville Compound, Acacia Lane, Mandaluyong City, Philippines
Abstract: The Philippines has a family planning programme, but modern contraceptive prevalence has been moderate. Among low-income women, fewer are using modern methods, resulting in a fertility rate among them of 5.9. This limited use is due to lack of consistent national and local government support for modern methods because of religious opposition. Following devolution of responsibility for health services to local government in 1991, three local leaders – in Laguna Province and the cities of Manila and Puerto Princesa – passed anti-modern contraceptive policies. This paper analyses the status and impact of these policies, using information from interviews with local government officials and family planning officers, published data and studies, and accounts in national newspapers. In Laguna Province and Puerto Princesa, the policies were ineffectually implemented or short-lived. The strictly-enforced Manila law, however, has severely disrupted the city's provision of free contraception to and method use by low-income women. The great majority of Filipinos (89%) approve of modern contraceptives. There is an urgent need to improve low-income women's access to modern contraceptives through itinerant and community-based distribution, especially in poor neighbourhoods in Manila, but also throughout the country. Strategies for increasing local government support for and provision of modern methods are also needed. ©2009 Reproductive Health Matters. All rights reserved.
Keywords: contraception, family planning services, devolution, unmet need, health policy and programmes, Philippines
HE 1971 Philippines population policy1 tive and a modern method has stabilised at not mandates the implementation of a family more than 50% and 36%, respectively. Lifetime Tplanning programme to promote contra- births among Filipino women have fallen from ceptive use among married women and reduce 6.0 in 1973 to 3.4 in 2003,3 but this is still con- the country's total fertility rate. In nearly four sidered high.4 Among low-income women, who decades, the extent of women's contraceptive comprise a third of the 12.4 million married use and modern method use, a programme Filipino women of reproductive age, the impact impact measure,2 has been moderate. While has been much lower. Fewer low-income women thereweredramaticincreasesinthenumbers were using contraceptives and adopting modern of contraceptive and modern method users in methods in 2005 (45.5% and 32.2%, respec- the programme's first two decades (1973–1993), tively),5 resulting in a total fertility rate among the same level of increase has not been sustained them of 5.9 (national rate: 3.5).3 in later years. Table 1 shows that since 1993, the The lower level of contraceptive use among low- percentage of married women using a contracep- income women is not due to lack of knowledge or
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sidy, health insurance, socialised pricing and/or commercial procurement”.8 In 2000, about US$1.5 million for contraceptive procurement was allocated in the Department of Health's yearly budget, but the amount was diverted else- where due to an abrupt change in the national leadership, in a “people power” revolution backed by the Catholic church in 2001.10 In 2007, the Philippines Congress earmarked US$3.6 million for modern contraceptive pur- chase, but the funds were returned because of “ ” 11 negative attitudes. Low-income women, like the disbursement failure . No funds were approved rest of Filipinos, favour family planning6 and are from 2002 to 2006. Due to lack of funds, the highly knowledgeable about modern contracep- country is currently not meeting low-income 12 tives.3 But about 25% of them have an unmet women's need for free contraception. need for family planning.5 Data from 2003 indi- Presidents Marcos and Ramos both recog- cated that 85.1% of the 28.8% who were not cur- nised the adverse socio-economic implications rently using a method but had a preference to use of rapid population growth and made contra- 13 a method in the future would want a modern one. ceptives available, but the four other Philip- Among current modern contraceptive users, pines presidents, during their terms, have not 98.3% would opt for the same method in future.3 shown strong support for modern contraceptives. While all four of these presidents articulated the development implications of population growth, Contraceptive supply nowhere did they make explicit reference to Lack of contraceptive supplies per se could not family planning as a key strategy for solving have constrained low-income women's modern the country's burgeoning population and pov- contraceptive use. Since 1971, the family plan- erty.13 Arroyo, the incumbent president, regards ning programme has received a steady level of population as a social justice and economic deve- supplies from the United States Agency for lopment issue and addresses it through anti- International Development (USAID), the United corruption and resource management measures Nations Population Fund (UNFPA) and other rather than through fertility control.14 The Arroyo international organisations. Before 1999, the administration's 2001 National Family Planning Philippines had never had to purchase con- Policy at the Department of Health seeks “to help traceptives, but only pay the import taxes on couples and individuals achieve their desired donated commodities.8 In 1999-2001, the main family size”, but fails to stipulate family plan- donor, USAID, supplied pills, male condoms, ning as a strategy.13 injectables and intrauterine devices worth Modern contraception is unmentioned because US$40 million, covering 80% of the country's many presidents, including the incumbent, are requirements.9 These contraceptives were dis- highly identified with the Catholic church, with tributed free through the public health sector its anti-choice stance, including against modern at provincial, municipal, city and village levels, contraception. While it promotes natural meth- which at that time was funded and managed by ods, the Church rejects artificial contraceptives,15 the Department of Health.3 and seeks to scuttle any public procurement of USAID decided to reduce its donations gradu- contraceptives, including the 2007 Congress- ally, however, and announced that in 2008 it approved local funds.11 Currently, the Church is wouldstopitsdonationsentirely,inorderto at loggerheads with many congressmen who are foster contraceptive self-reliance in the Philip- pursuing the passage of House Bill 5043, the pines. Having been informed well in advance Reproductive Health, Responsible Parenthood that this was coming, the national government and Population Development Act of 2008, which promulgated a 1999 Contraceptive Independence aims to promote, among other things, modern and Initiative Policy “to ensure the availability of natural means of family planning, and contra- commodities for all segments through direct sub- ceptive supply purchases by national and local
100 RB Lee et al / Reproductive Health Matters 2009;17(34):99–107 government hospitals.16 If this bill is approved, Laguna, the city administrators for Puerto Princesa the Church would likely try to derail its imple- and Manila, and local government family plan- mentation through its own national network of ning programme field operations officers. We allies at local level, whether or not the national looked for prior studies and found only one leadership is pro-choice. qualitative study of the impact of the policy in No one has calculated how many local leaders Manila.20 And we collected accounts in reputa- support the Church's actions against modern ble national newspapers. General background contraceptives, but they are a concern because information on the three locales was gathered they can sabotage programmes by telling from their official websites, and relevant family people only about negative side effects and the planning survey data were derived from the “immoral” repercussions of using them.17,18 Philippines National Statistics Office website and They can also instruct their service providers publications. Manila City's field operations data not to inform women about or recommend on new contraceptive acceptors and contraceptive these methods.6 Such actions have been part prevalence are for married women rather than of the landscape in which the family planning low-income women. However, as 75% of public programme struggles in the Philippines and health sector contraceptive users are low-income are a continuing challenge. women,5 these data will reflect their experiences. In 1991, the Local Government Code man- dated the devolution of health service delivery responsibilities and financial management, Findings including for contraceptive delivery, from career Laguna civil servants in the Department of Health's Located 30 km from Manila City (2000 popula- regional, provincial and district offices, to tion: 1.97 million), Laguna Province is a highly elected officials in provincial, city and municipal modernised agro-industrial economy with 28 governments. Within two years, some 95% of municipalities, two cities and 674 villages. the Department's facilities, 60% of its personnel Laguna is led by a publicly-elected governor and 45% of its budget were transferred,12 giving for a maximum of three three-year terms. In local leaders primary control of local health pro- 1992, anti-choice Governor Lina was elected. vision. However, the lack of institutional capac- In 1995, Lina, a nephew of the mayor of Manila ity to fulfil these devolved responsibilities has who later instituted a similar law, issued a one- exacerbated rather than alleviated inequities in page memorandum in a local language through health service access, including as regards con- the provincial population officer addressed to traceptive delivery.12 Although some local exec- all family planning clinic heads. Entitled “New utives have made initial outlays for modern Order of Provincial Head”, it reads (translated): contraceptive delivery, in compliance with the To adhere to the new order of the Provincial Head, terms of devolution,19 some anti-choice leaders I order you to stop providing all artificial contra- have failed to do so, and some of these have ceptives (oral pills, DMPA, IUD, ligation, vasec- further constrained low-income women's access tomy, and condom) except natural family planning to contraception through anti-choice policies. In methods. This order shall take effect starting today 2001, the Laguna provincial governor and the until it is changed or voided. Your prompt adher- mayors of Manila and Puerto Princesa issued ence and cooperation are expected.21 such policies. Published information on these poli- cies is scarce. This paper reports what is known The memorandum was in effect for six years about these policies and their consequences. until Lina's term ended in 2001. Lina was imme- diately appointed Philippines Department of the Interior and Local Government Secretary. In Methods and respondents 2003, he issued Memorandum Circular 204 We obtained hard copies of the local policies (in English) calling for the integration of the from the governments of Laguna, Manila and standard-days method in all the country's local Puerto Princesa. We also carried out brief phone, family planning programmes and enjoined pro- mail, e-mail or face-to-face interviews with the vincial governors, city and municipal mayors, head of the provincial population office for and the Department's regional directors to invest
101 RB Lee et al / Reproductive Health Matters 2009;17(34):99–107 resources to promote this method, though the Atienza himself actively campaigned against memorandum did not ban modern methods.22 modern contraceptives and regularly awarded Although the Laguna law lasted for six years, cash prizes to women with large numbers of chil- its implementation was confined to the provin- dren during medical missions and at other venues, cial capital of Sta. Cruz. In an interview, the cur- especially during election periods.20 Overall, the rent provincial population officer explained that city's family planning programme operations Sta. Cruz was the sole area in Laguna in which were severely disrupted. The study led by Likhaan contraceptive supplies were not available. Her reported the following disruptions in 2007: office, being directly under the governor, had • removal of contraceptive supplies and ser- no recourse but to implement the order there, vices from city health centres and hospitals, but Laguna's other cities and municipalities • closure of non-government organisations that had no such prohibitions. Hence, contraceptive had been providing family planning informa- supplies and services at public health centres tion and services, and several non-government organisations in • harassment and labelling of health care those areas were uninterrupted. “Women who workers in such institutions as “abortionists”, lived in Sta. Cruz who wanted to obtain modern • the cessation of occasional philanthropic methods only had to go to a neighbouring area to medical services to offer modern methods of get them.” The local law was repealed by Gover- family planning.20 nor Lazaro upon her election in 2001.23 In 2006- 2008, Lazaro allocated US$24,000-US$79,000 Consequently, modern contraceptive supplies for contraceptive supplies (Personal communica- were officially effectively nil from 2000 on, and tion, Ma. Corazon Colisara, Provincial Health contraceptive use rates for new and current Office, 16 March 2009). users decreased dramatically, as did the con- traceptive prevalence rate (Table 2). However, Manila interestingly, the birth rate did not increase. The capital Manila has 897 villages (2000 popu- Atienza completed his three terms in 2007. lation: 1.58 million). In 1998, a staunchly anti- Currently, the city is led by Mayor Lim who, also choice Mayor Atienza was voted into office. In anti-choice, has maintained the Executive Order 2000, following in the footsteps of his nephew, (Personal communication, Criselda Coroza, City Governor Lina, Atienza issued Executive Order Health Office, 17 March 2009). In his 2008 speech No.003, entitled “Declaring Total Commitment at the Manila Cathedral School, referring to the and Support to the Responsible Parenthood pending Reproductive Health Bill 5043, Lim said: Movement in the City of Manila and Enunciat- “If the bill is passed and approved to become a ing Policy Declarations in Pursuit Thereof”.24 law, the City of Manila will not follow its provi- Among other things, the Order expresses a “pro- sion wherein local government units buy contra- life” stance on family and motherhood, respon- ceptives using taxpayers' money.”26 sible parenthood, the life of the “unborn”,and natural family planning “notjustasamethod but as a way of [developing] self-awareness Puerto Princesa in promoting the culture of life”.Itcondemns Puerto Princesa, capital of Palawan Province, “criminal abortion, euthanasia, divorce and same- has 66 villages, the majority of which are rural sex marriages as amoral and deplorable practices (2000 population: 0.162 million). that weaken the basic unit of family and society”. Upon his 2001 election, anti-choice Mayor It calls for “discouraging the use of artificial Socrates passed a six-page Executive Order methods of contraception like condoms, pills, (No.36, in English) entitled “Implementing intra-uterine devices, surgical sterilization”.24 Rules and Guidelines for the Implementation of And it mandates the city's health and social ser- Resolution No. 79-2001, Declaring the City of vices to establish responsible parenthood and nat- Puerto Princesa as a Pro-Life and Pro-Family ural family planning programmes and activities. City”.27 Its first section highlighted the sanctity For seven years, the law was effectively imple- of human life; the inviolable right of every mented by city officials, who were ordered not to human to life and of every person to live with recommend or provide modern contraceptives.20 dignity, exercising freedom with responsibility
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in the fulfilment of his destiny; and the impera- the previous title and still lists the “morally illicit” tive to protect all human life. It defined the practices of induced abortion, euthanasia, clon- family as a man and a woman joined in lawful ing and other genetic manipulation, prostitution marriage, together with their children, and and drug abuse. However, it differed in one major human sexuality as primarily for procreation respect; it clearly favoured family planning: within the family.27 “While Puerto Princesa is a Pro-life and Pro- The second part described 11 “morally illicit” family City, it nonetheless recognizes the right practices: induced abortion, divorce, same-sex of its constituents, particularly its women and marriages, euthanasia, artificial insemination, men, parents, and families, to have several artificial birth control, cloning and other genetic informed choices as far as responsible parent- manipulation, death penalty, prostitution, por- hood, family planning, and reproductive health nography and drug abuse. Of contraceptives, it are concerned… The City Government of Puerto stated that: Princesa thus recognises and supports the “The use of artificial birth control methods…not National Government's programmes on family only prevent[s] the transmission of life but also planning, population control, reproductive reduce[s] the conjugal act into a selfish act and health, responsible parenthood, and such other is therefore intrinsically morally unacceptable. similar programmes. Consequently, in the inter- The production, promotion and sale of such est of promoting public health and safety, and items also constitute a grave offence to God.”27 thegeneralwelfareoftheCity'spopulace,the City Health Office, Satellite Clinics, and all other The other sections covered natural family plan- concerned offices and units of the City Govern- ning and implementing agencies, and banned ment are directed to coordinate and cooperate “artificial” contraceptives: with concerned national government agencies “Concerned personnel of the City Government are in the implementation of such national pro- hereby ordered to refrain from further procurement grammes in the City of Puerto Princesa.”28 and distribution of contraceptive drugs and other Mayor Hagedorn and his Executive Order are paraphernalia and to dispose of any such materi- still in place today. als in their inventories for morally harmful.”27 The Order was ineffectually implemented because after less than a year in office, Mayor Socrates Discussion was subjected to a recall election in July 2002, President Arroyo does not support modern con- and lost to returning pro-choice Mayor Hagedorn traceptives due to church pressure. However, in (Personal communication, Agustin Rocamora, the Philippines Congress, although opposition City Administrator, 11 March 2009). Hagedorn to such methods exists, many legislators sup- immediately amended Executive Order No.36. port their provision to reduce poverty.29 These His Executive Order No.9 (in English)28 retained pro-choice lawmakers, e.g. Senator Pia Cayetano
103 RB Lee et al / Reproductive Health Matters 2009;17(34):99–107 and Congressman Edcel Lagman, work extremely The Laguna experience shows that there are hard to pass family planning-related bills, with many local leaders, health officers and service support from women's groups such as Gabriela providers who are willing to defy an anti- with its 200 institutional members (Personal contraception policy, and the Catholic church, communication, Emmy de Jesus, Secretary- in order to provide family planning services General, 14 March 2009) and the academe.30 In and help low-income women control their fertil- August 2009, after years of advocacy, the Magna ity. Protestant religious groups have expressed Carta of Women, a law ensuring woman parity unequivocal support32 and the local govern- with men, which includes responsible, legal, ments of Quezon City,33 Bohol and Aurora,34 safe and effective family planning methods for along with the current Puerto Princesa City gov- women, became law.31 Its approval shows that ernment, have passed pro-contraceptive laws. religious opposition can be surmounted through The Manila City policy remains a serious chal- effective advocacy, which may help to pass lenge. For more than seven years, and enforced Reproductive Health Bill 5043, now 12 votes by two succeeding mayors, its law (as far as our away from approval.16 limited data can suggest) has severely disrupted Women's groups expanded their advocacy to the city's free contraceptive provision and method local level due to the unprecedented action in use among low-income women.35 However, the Laguna, Manila and Puerto Princesa to prevent city continues to record new and continuing users women from accessing modern contraceptives. of modern methods and stable birth rates despite Fortunately, two of the three policies were ineffec- the apparent absence of modern contraceptive tual, and the Puerto Princesa one short-lived due supplies. This may be because women are getting to the recall election. The Laguna memorandum contraceptives from nearby cities, such as Quezon was in effect for six years (1995-2001), but its City, where no prohibition occurs, or are being enforcement was confined to the provincial capital. served by ambulant providers, which have been CHRIS STOWERS / PANOS PICTURES Rural family planning clinic, Mindanao, Philippines
104 RB Lee et al / Reproductive Health Matters 2009;17(34):99–107 introduced by some groups.20 Or, more women operations show that contraceptive use overall could be having illegal abortions, which have was only 35–39% in 2004-2006,37 while in been and remain common.36 poorer regions, where no such support exists, Women's groups have lodged a case against such as in Bicol, a family planning survey found Manila's executive order, on the grounds that it that modern method use was 25% in 2006.7 constitutes an abuse of power on the part of the Women's groups could invoke the Magna Carta mayor. They argue that the city cannot violate of Women along with national population poli- the right of couples to regulate the size of their cies and Constitutional rights as legal platforms family, which is guaranteed in the country's on which to advocate for better services. More- Constitution,13 and that the city is obliged under over, they can publicise the approval of modern national government policy to offer family plan- contraceptives by the overwhelming majority of ning services (Personal communication, Junice Filipinos (89%)38 as another compelling argu- Melgar, Executive Director, Likhaan, 28 August ment. Modern contraceptives are highly effective 2009). But the Manila City administration con- and their benefits greatly outweigh the risks of tends that the policy is within the limits of the frequent pregnancies and unsafe abortion. Testi- Mayor's executive powers.20 monies from satisfied users would be useful.6 While legal recourse and pressure on the part To win local support further, women's groups of women's and other pro-choice groups may should advocate for improving local institu- succeed in the long term against such a policy, tional capacity,12 developing an understanding there is an urgent need to improve contracep- of women's reproductive health and rights, tive access for Manila's low-income women. In and a commitment from local leaders to provide tandem with medical missions and community modern contraceptives. The Laguna govern- service outreach programmes, more women's ment's 2006-2008 contraceptive budget allo- groups must station mobile clinics and ambulant cation is laudable but it covers less than 10% service providers in cities nearest to Manila's low- of the estimated cost of contraceptives needed income communities. Some groups, such as the by local women.39 Under devolved government, Family Planning Organisation of the Philippines, localfundsarecriticaltoservelow-income have already initiated these moves (Personal women's modern contraceptive needs. The communication, Roberto Ador, Executive Director, phasing out of USAID's donations, Catholic 25 August 2009). Other innovative solutions are church advocacy against contraception, and needed to address access until local anti-choice the absence of adequate national government executives conclude their term in office, such as funding has led to a greatly worsened situation in Puerto Princesa. Since there are increasing for low-income women who seek contraception. reports of low-income women in Manila with A safety net guaranteeing access to contracep- complications due to incorrect use of self-abortion tives is needed.40 methods (Personal communication, Junice Melgar, Executive Director, Likhaan, 28 August 2009), Acknowledgments better post-abortion care is needed. We thank Irma Asuncion, Centre for Health Advocacy and better family planning service Development-Metro Manila; Josefina Yanesa, delivery are likewise needed in locales that do Laguna Provincial Population Office; and Junice not have anti-contraception policies, to improve Melgar, Likhaan, for supplying data. For his contraceptive prevalence. In Quezon City, even professional advice, we thank Professor Hiko with local government support, data from field Tamashiro, Hokkaido University, Japan.
References 1. Republic Act No. 6365. At: Setting. Madison: University of 4. Pernia EM. Population, Economy
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Report. Manila: National bill talks. Philippine Daily Total Commitment and Support Statistics Office, 2005. Inquirer. At:
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Standard Today. At:
Résumé Resumen Les Philippines possèdent un programme de Aunque en Filipinas existe un programa de planification familiale, mais la prévalence de la planificación familiar, la prevalencia del uso de contraception moderne est modérée. Peu de anticonceptivos modernos ha sido moderada. femmes à faible revenu utilisent des méthodes Menos mujeres de bajos ingresos usan métodos modernes, ce qui aboutit chez elles à un taux de modernos, por lo cual la tasa de fertilidad entre fécondité de 5,9. Ces limitations sont dues à un ellas es de 5.9. Este uso limitado se debe a la falta manque de soutien suivi des autorités nationales de apoyo sistemático del gobierno nacional y et locales aux méthodes modernes, en raison de local para métodos modernos debido a la l'opposition religieuse. Après le transfert de la oposición religiosa. Tras la devolución de la responsabilité des services de santé aux autorités responsabilidad de los servicios de salud al locales en 1991, trois dirigeants locaux, dans la gobierno local en 1991, tres líderes locales – en province de Laguna et les villes de Manille et la Provincia de Laguna y las ciudades de Puerto Princesa, ont adopté des politiques contre Manila y Puerto Princesa – aprobaron políticas les méthodes contraceptives modernes. L'article contra los anticonceptivos modernos. En este analyse la situation et l'impact de ces politiques, artículo se analiza el estado y el impacto de esas en utilisant les informations tirées d'entretiens políticas, usando información de entrevistas avec des fonctionnaires et des responsables de la con funcionarios del gobierno local y agentes planification familiale, de données publiées de planificación familiar, datos y estudios et d'études, ainsi que d'articles de journaux publicados, e informes en periódicos nacionales. nationaux. Dans la province de Laguna et à En la Provincia de Laguna y en Puerto Princesa, Puerto Princesa, la mise en œuvre des politiques las políticas fueron aplicadas de manera inútil o a été peu efficace ou de courte durée. À Manille, de corta duración. Sin embargo, la ley de Manila, l'application stricte de la loi a profondément quesehacerespetarestrictamente,hainterrumpido désorganisé les services municipaux de marcadamente el suministro de anticonceptivos contraception gratuite pour les femmes à gratuitos a mujeres de bajos ingresos. La gran ressources modestes. Lagrandemajoritédes mayoría de filipinos (el 89%) aprueba los Philippins (89%) approuve les contraceptifs anticonceptivos modernos. Existe una necesidad modernes. Il est urgent d'élargir l'accès des urgente de mejorar el acceso de las mujeres de femmes à faible revenu aux contraceptifs bajos ingresos a los anticonceptivos modernos modernes par la distribution ambulante et mediante la distribución ambulante y communautaire, particulièrement dans les comunitaria, especialmente en los vecindarios quartiers pauvres de Manille, mais aussi dans pobres de Manila, pero también en el resto del le reste du pays. Des stratégies doivent aussi país. También se necesitan estrategias para accroître l'offre de méthodes modernes et le aumentar el apoyo del gobierno local para los soutien des autorités locales. métodos modernos y su suministro.
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