Undernutrition in the Philippines Scale, Scope, and Opportunities for Nutrition Policy and Programming Nkosinathi V. N. Mbuya, Gabriel Demombynes, Sharon Faye A. Piza, and Ann Jillian V. Adona INTERNATIONAL DEVELOPMENT IN FOCUS INTERNATIONAL INTERNATIONAL DEVELOPMENT IN FOCUS Undernutrition in the Philippines Scale, Scope, and Opportunities for Nutrition Policy and Programming NKOSINATHI V. N. MBUYA, GABRIEL DEMOMBYNES, SHARON FAYE A. PIZA, AND ANN JILLIAN V. ADONA © 2021 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW, Washington, DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org Some rights reserved 1 2 3 4 24 23 22 21 Books in this series are published to communicate the results of World Bank research, analysis, and operational experience with the least possible delay. The extent of language editing varies from book to book. This work is a product of the staff of The World Bank with external contributions. 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Contents Acknowledgments ix About the Authors xi Executive Summary xiii Abbreviations xxiii CHAPTER 1 The Country Context 1 Introduction 1 Population and demography 1 Climate 4 Economy 5 Objective and organization of the report 6 Limitation of the study 6 References 7 CHAPTER 2 The Face of Child Malnutrition in the Philippines 9 Patterns of nutrition in the Philippines 9 Nutrition in the Philippines in international perspective 15 Intrauterine growth retardation and low birthweight 16 Micronutrient malnutrition: The “hidden hunger” 18 Implications of COVID-19 for nutrition in the Philippines 21 Some pathways for impacts of COVID-19 on nutrition 23 Discussion and conclusions 23 Notes 25 References 25 CHAPTER 3 Why Nutrition Matters 27 Consider the lives of two Filipinos 27 Nutrition and economic growth 28 The economic returns from investing in nutrition 31 Notes 33 References 33 CHAPTER 4 Why Are So Many Children Undernourished in the Philippines? 35 Introduction 35 Conceptual framework 36 “Plus”: Prenatal health and nutrition 37 Postnatal risk factors 38 Stunting risk factor trends in the Philippines 40 iii iv | UNDERNUTRITION IN THE PHILIPPINES Multivariate analysis 42 Discussion 48 Notes 50 References 51 CHAPTER 5 Agriculture, Diets, and Nutrition 55 Importance of agriculture in nutrition 55 Agriculture in the Philippines 56 Diversification of agricultural production and market access 61 Diets of Filipino households 62 Diet of households engaged in agriculture 65 Cost of a nutritious diet in the Philippines 66 Cost of less nutritious diets 69 Household agricultural practices, dietary diversity, and nutritional outcomes 70 Conclusions and recommendations 72 Annex 5A. Methodology for calculating the cost of recommended diet 75 Annex 5B. Detailed explanation of the calculation of price per calorie 76 Notes 77 References 77 CHAPTER 6 Knowledge, Beliefs, and Practices of Health Workers and Caregivers on Child Stunting in the Philippines 81 The importance of knowledge, beliefs, and practices on child nutrition 81 Knowledge, beliefs, and practices of caregivers and health workers 82 Other beliefs: Consequences of stunting and monitoring growth 85 Beliefs about weight gain during pregnancy 85 Findings from a quantitative survey with health workers 86 Interpreting mental models of health workers through response patterns 88 How knowledge and beliefs relate to service delivery at local health centers 90 The implications of different beliefs and levels of knowledge on child stunting 90 The way forward 92 Notes 94 References 94 CHAPTER 7 Synergies and Opportunities for Nutrition in the Health Sector 97 Nutrition governance 97 Synergies between health and nutrition 98 Nutrition-specific interventions and approaches 99 Nutrition-specific interventions and approaches in the Philippines 100 Nutrition-sensitive programs 110 Discussion and conclusions 114 Note 115 References 116 CHAPTER 8 Optimizing Pantawid for Nutrition 119 Can Pantawid improve nutrition? 119 What are the impacts of Pantawid on nutrition to date? 122 Contents | v Why is Pantawid not having a greater impact on nutrition? 125 How can Pantawid strengthen its impact on nutrition? 129 Annex 8A. Impact of Pantawid Program on Health and Education 131 Notes 132 References 133 CHAPTER 9 Local Governments as the Key to Tackling Malnutrition 137 Background 137 Results for Rizal Province 139 Results for Zamboanga del Norte Province 143 Results for Albay Province 145 Conclusions 147 Recommendations 150 Note 150 References 151 CHAPTER 10 Opportunities to Improve Data for Nutrition Policy and Programs 153 Introduction 153 The National Nutrition Survey 153 Operation Timbang Plus 157 Comparing anthropometric results from ENNS and OPT Plus 161 Field Health Services Information System 164 Conclusions and recommendations 167 Annex 10A. Features and indicators of the NNS, OPT Plus, and FHSIS 168 Notes 171 References 172 Boxes 2.1 What exactly is malnutrition? 10 2.2 Why do we focus on stunting and what does it mean? 11 3.1 The Human Capital Index 31 5.1 Aflatoxin exposure and childhood stunting 73 5.2 Policy recommendation to support production diversification 74 7.1 Evidence-based nutrition-specific interventions 100 Figures 1.1 Population pyramid of the Philippines, 2015 3 2.1 Malnutrition trends in the Philippines for children under age five, 1989–2019 10 2.2 Rate of stunting, underweight, and wasting in children under age five in the Philippines, by wealth quintile, 2019 12 2.3 Rate of stunting, underweight, and wasting in children under age five in the Philippines, by age group, 2019 12 2.4 Rate of stunting, underweight, and wasting in children under age five in the Philippines, by setting and gender, 2019 13 2.5 Rate of stunting in children under age five in the Philippines, by region, 2015 13 2.6 Rate of stunting in children under age five in the Philippines, by provincial poverty rate, 2015 15 2.7 Prevalence of stunting worldwide, by region and country 17 2.8 Prevalence of stunting in selected countries, 2000–19 18 2.9 Prevalence of anemia in the Philippines, by selected population groups, 2019 19 vi | UNDERNUTRITION IN THE PHILIPPINES 2.10 Relationship between malnutrition and other consequences