Philippines: decentralized approach shows results

In the Philippines several steps have been taken to meet the challenge of increasing population growth. Commencing with the Republic Act 6365, known as the Population Act (1971) program directives focus on achieving and maintaining population levels most conducive to the national welfare. In 1978 a Special Committee was constituted by the President to review the population program. Pursuant to the Committee's findings certain changes were adopted. The thrust is now towards longterm planning to ensure a more significant and perceptible demographic impact of development programs and policies. Increasing attention is paid to regional development and spatial distribution in the country. The 1978-82 Development Plan states more clearly the interaction between population and development. The National Economic and Development Authority, the central policy and planning agency of the government, takes charge of formulation and coordinating the broader aspects of population policy and integrating population with socioeconomic plans and policies. At present the National Economic and Development Authority (NEDA) is implementing a project known as the Population/Development Planning and Research (PDPR) project with financial support from the UN Fund for Population Activities (UNFPA). This project promotes and facilitates the integration of the population dimension in the planning process. It does this by maintaining linkages and instituting collaborative mechanisms with the different NEDA regional offices and sectoral ministries. It also trains government planners in ways of integrating population concerns into the development plan. PDPR promotes the use of population and development research for planning purposes and policy formation. The Philippine Development Plan, 1978-82, recognized that an improvement in the level of 1 sector reinforces the performance of the other sectors. Since the establishment of the National Population Program 12 years ago, population and family planning have been successfully integrated with various development sectors, notably, labor, health, and education. Through the policies of integration, multiagency participation, and partnership of the public and private sectors, the Commission on Population uses existing development programs of government and private organizations as vehicles for family planning information and services and shares the responsibility of implementing all facets of the population program with various participating agencies in the government and private sector.     

Bangladesh

In Bangladesh the Population Control and Family Planning Division of the Ministry of Health and Population Control has decided to delegate increased financial and administrative powers to the officers of the family planning program at the district level and below. Currently, about 20,000 family planning workers and officials are at work in rural areas. The government believes that the success of the entire family planning program depends on the performance of workers in rural areas, because that is where about 90% of the population lives. Awareness of the need to improve statistical data in Bangladesh has been increasing, particularly in regard to the development of rural areas. An accurate statistical profile of rural Bangladesh is crucial to the formation, implementation and evaluation of rural development programs. A Seminar on Statistics for Rural Development will be held from June 18-20, 1980. The primary objectives of the Seminar are to make an exhaustive analysis of the current availability of statistics required for rural development programs and to consider methodological and operational improvements toward building up an adequate data base.     

A fresh look at family planning communication

As a step toward development of a national information, education, and communication (IEC) plan, a reassessment of such efforts practiced by the agencies involved was undertaken. A paper published in 1978 by the Research Utilization Unit of the Population Information Division, Population Center Foundation, reviewed materials used and accounts of experience in conceptualizing and communicating family planning messages by 12 private and public sector agencies. The most common concepts employed by the agencies were small family size, responsible parenthood, family welfare, community and national development, birth spacing, delayed marriage, contraceptive use-effectiveness, "manliness," delayed 1st pregnancy, value and rights of children, human behavior and social environment, and population dynamics. Most of the messages were conceptualized and developed through formal and informal consultation with field staff. The need to consider the specific needs of target audiences was considered crucial, and thus decentralization of IEC production was recommended. Such decentralization has been a goal of the Philippine program since 1976, but the effort has been hampered by lack of local training and resources, and of studies to support successful implementation. Mass and mixed media approaches were found to be used by most of the agencies, although a reliance on interpersonal approaches was found to be most prevalent in rural areas. Among recommendations for policy makers were development of a systematized data base for IEC materials, regional capabilities in research and development, and studies of funding and existing resources.     

Massive drive to reenergize the family planning programme

A massive drive has been launched throughout India in an effort to reenergize the family planning program. The Prime Minister has made a special appeal to the nation from radio and television networks and through the press to adopt the small family norm as a way of life. The Chief Ministers and the Health Ministers in the States have made similar appeals to the people and the doctors. The current drive was preceded by 18 months of concentrated efforts to vitalize the family planning program. The change in nomenclature from "family planning" to "family welfare" created some misunderstanding regarding the government's own commitment to the program, but it is now widely understood that while family welfare aims at the total welfare of the family, family planning is an essential part of it. The government has tried to involve all sectors of society in program efforts. The mass media is now focusing attention on "family welfare" almost continuously. In villages, a large-scale program of organizing education camps of opinion leaders is now underway. The rural health scheme, initiated in October 1977, promises to bring about increased participation of the people in village programs. 54,000 community health workers have already started serving the rural population in their areas. In 2-3 years there will be 1 trained community health worker in every Indian village.     

Cagayan de Oro taps own resources to cope with population problem

In 1972, the Model City Population Planning Project (MCPPP) was begun in the Philippine city of Cagayan de Oro. The MCPPP was an attempt to encourage family planning on the community level. Funding was provided by the Ford Foundation for the program in 1974, for 2 years. There were 5 main objectives of the program: to provide family planning information to parents, to test small scale projects which could be applied elsewhere in the country, to actively involve local government, to reduce the birthrate, and to facilitate, coordinate and strengthen population and family planning services of the different agencies of Cagayan de Oro. While the MCPPP's efforts to reduce the birth rate were mostly concerned with coordinating and facilitating prexisting family planning services, evaluators of the project credit it at least partially, for the cities' declining birthrate. In 1971, the birthrate was 36.5 per 1,000 and in 1975, it had dropped to 29 per 1,000. In mid 1976 the program was incorporated into the nationwide Outreach Program. Although some evaluators felt that private citizens were not sufficiently involved with it, the program has been judged successful in demonstrating a city's capacity to work toward solving it's own problems. Particularly successful were efforts at educating the population and dissemination of family planning information.     

A brief introduction to China's family planning programme

China's family planning program is described in reference to its goals, approaches, and achievements. Between 1949-83, China's population increased from 541 million to 1,024,950,000. The population has a young age structure, and the median age is 22.9 years. 80% of the population is rural, and 90% of the population lives in the southeastern region of the country. In view of this demographic situation, the government recognizes the need to control population growth. China's goals for the year 2000 are to increase industrial and agricultural input by 400% and to keep population size below 1.2 billion in order to ensure that per capita income increases. In accordance with these goals, the government, in 1979, began advocating a 1-child policy. To ensure the survival of single children, the government also launched a program to upgrade maternal and child health (MCH). In some rural areas and among certain minority groups, the 1-child restriction is not applied. Family size goals will vary with time. These variations will reflect the need to maintain a balance between economic growth and population growth. A variety of incentives are used to promote the 1-child family. For example, single children receive medical and educational benefits, and in some rural areas, the parents of single children can obtain additional land contracts. Economic disincentives are also used. The government seeks to obtain compliance with the policy primarily through educating the public about the consequences of uncontrolled population growth. All channels of the mass media are used to deliver the messages, and the publicity campaign is especially intensive in rural areas. A comprehensive plan to provided family planning and population education for middle school students is currently being implemented. Each local area develops its own fertility control plan. This plan is then incorporated into the nation's overall plan and the overall plan is implemented from above. Family planning workers bring free contraceptives directly to the people, and family planning motivators are found in almost all villages, neighborhood committees, factories, and military units. As a result of these efforts, China made great strides in controlling population growth and improving MCH during the last decade. The birth rate declined from 27.93 to 18.62, and the total fertility rate declined from 4.01 to 2.48. 124 million couples were practicing contraception by the end of 1983. 41% used IUDs, 37.4% relied on tubal ligation, 12.9% relied on vasectomy, 5.1% on oral contraceptives, and 1% on other methods. The quality of maternal and child care also improved. 92.7% of all deliveries are now performed by trained midwifes. Infant and maternal mortality rates declined considerablely in recent years. Currently the respective rates are 35.68/1000 live births and 0.5/1000 live births. In 1983 alone, the gross national agricultural and industrial output increased by 46.1%. Since 1979 per capita income increased annually by 18.3% among rural residents and by 10.7% among urban workers. China controls and operates its own population program, but in recent years, it increased its cooperation with UN Fund for Population Activities, other UN agencies, and nongovernment agencies. China recently completed its 3rd national census, and demographic research institutes have been established in 10 universities.     

The marketing of the condom

The Commercial Contraceptive Marketing Program was developed by the Population Center Foundation in the Philippines to increase participatio n of private commercial firms in promotion and distribution of nonclinical contraceptives. The program was started to eliminate ignorance concerning contraceptive methods, to increase contraceptive acceptance, and to decrease dropouts from the program. It is hoped that all 200,000 sari-sari stores in the Philippines will eventually become involved in marketing contraceptives. This will free government personnel for the work of extending family planning services to the rural areas. The history of the development of a plan for commercial marketing of condoms in the Philippines is discussed.     

To the barrios] The new course charted by the national population program

In order to reduce the Philippine birthrate to 2% by 1980, the number of rural women practicing contraception must be trebeled. To facilitate such an effort, a large-scale reorganization and reorientation in all areas of family planning activity--delivery, training, research, information, education, and communication--is proposed, shifting the delivery of family planning services from clinics to the 36,000 barrio bases. A goal of 16,000 extension workers in family planning is set for 1976; these workers will be the ones to make the initial contacts with potential acceptors. Then full-time family planning workers will try to make potential acceptors into bonefide ones, giving advice or prescribing the method and providing follow-up. Family planning workers will be supervised by nurses and midwives in health stations, who in turn will be supervised by the physician in the rural health unit. Acceptability among community residents is the most vital characteristic of a family planning worker, with the country's 27,000 hilots (birth attendents) seen as leading candidates. Attracting and training manpower in the field is a major challenge, as is lack of personnel in the area of research. Several possible avenues for the development of research interest and manpower for the population program are explored.     

Who uses reproductive health services in the Philippines (and who doesn't)?

Data from the 1993 National Demographic Survey and the Safe Motherhood Survey have filled gaps in knowledge about the accessibility and use of reproductive health services in the Philippines. Analysis of the data by the East-West Center's Program on Population has revealed that the number of women using family planning (FP) and maternal health services has risen to 40% in 1993 from 17% in 1973. Modest gains were also seen in the past five years despite disruption to program efforts. Prenatal care showed the greatest maternal care coverage rate increase, but 70% of births occurred at home, with only 51% attended by a trained person, and only 32% of postpartum women received care. Adolescents and women who are over age 40, uneducated, Muslim, and/or live in a rural setting have the most unmet need. In addition, less than half of the women reporting symptoms of a sexually transmitted disease sought treatment from a trained practitioner. Most women use public sector services, including 71% of those using modern contraceptives. While trained midwives provided 58% of prenatal care, traditional birth attendants delivered 52% of all births, and a high incidence of maternal mortality persists (209/100,000). Recommendations arising from this analysis include 1) improving prenatal and delivery care, 2) strengthening postpartum FP services, 3) expanding the program to reach more women, 4) extending the range of reproductive health services offered, 5) integrating traditional practitioners into the reproductive health system, and 6) balancing cost and service variations between the public and private sectors.     

Outreach: helping achieve coordination in the field

The outreach officials of the National Population Program of the Philippines, with its 4 basic functions of research, training, information-education-communication, and clinic services, are trying to solve pressing problems which have been an outgrowth of developments of the early 1970s when population and family planning concepts were integrated into other government programs. Given the task of attacking these problems and coordinating the whole program was the newly organized Commission on Population (Popcom). The organizations which had their own programs cooperated with the government agencies. Initially thought of as workable, the early strategy was soon found to be inadequate, and in July 1975, Popcom implemented an integrated development approach in population work. The strategy is complex, and as it undergoes refinement, the program may well profit from the experiences or lessions gained by a number of agencies in carrying out population/development activities. The approach used by the Office of Nonformal Education of the Philippines Rural Reconstruction Movement is seen as potentially helpful to the outreach project in developing 3 types of leadership in order to properly integrate or link private and public agencies, and ensure a continuing development program: political, educational, and technical. It is stressed that outsiders can help, but it is the community which must basically do the job themselves. So different government technicians are trained so that they can effectively train other people from the community, and do it in such a way that the program will be continuing and self-releasing.     

Focus on family planning measures

A blueprint for responsible parenthood titled "The Tokyo Initiative" was drawn up at a conference sponsored jointly by the Japan Science Society and the Population Crisis Committee in April 1977. Representatives of several U.N. agencies and nongovernmental organizations participated. The blueprint urges additional resources to make family planning services available in rural areas and unserved areas of cities. Expanded social and economic roles for women were also recommended since it was felt that unless women were allowed to participate in family and community decision-making, "programs for responsible parenthood will be doomed to failure." Adolescents should be educated about reproductive behavior, stressing the adverse effects of early pregnancy. Integrated family planning services which serve the cause of infant and child health and total responsibility for program design be placed as close as possible to people affected. The conference then issued a call for action to implement these family planning objectives.     

Publicity and education are fundamental to China's family planning programme

This article summarizes and discusses the documents concerning family planning promulgated by the Communist Party, National People's Congress and the Government of China since the start of China's family planning program. In 1955 a document was issued entitled the Directive Concerning Population Control pointing out that the public should be made aware of birth control. In 1965 the summary of the 2nd Conference on Urban Work discussed ways of explaining the significance of family planning, to make it a voluntary action of the people. In 1980 the necessity of 1 child per couple was pointed out and policies were formulated regarding ideological and political education. During the 80's several documents were issued which stressed the voluntariness and initiative of the people in practicing birth control, and that any type of coercion was prohibited. For 30 years the fundamental practice of strengthening publicity and education and opposing coercion has remained unchanged no matter how birth policies have been scored in population control since 1979.     

Family planning as preventive health measure

The link between health and family planning efforts in the Philippines goes back to the beginnings of the National Population Program. In this interview, Dr. Dumindin of the Ministry of Health (MOh) discusses the impact of family planning on health. The family planning program of the MOH, since its inception in 1970, has undergone expansion and taken new initiatives and directions to meet the changing needs of the target clientele. Family planning information, education, and motivation is provided and maintained during routine prenatal, natal, and postnatal clinic and field activities. As of January 1986, the MOH had a total of 2100 clinics--rural health units, medical centers, hospitals, mobile clinics, and special clinics--all over the country. It is estimated that the Ministry's family planning activities have averted around a million births. It is hoped to extend the coverage of the programs to areas that have not been reached before, through further community involvement, by enlisting the participation of more workers in the community, training them on integrated health and family planning services, setting up more service facilities and clinic extensions, and by improving contraceptive use-effectiveness. Hopefully, the Philippine people will become less program-dependent and more self-motivated, and they will recognize the need for birth spacing, birth limiting, and total health care--not as suggested from the outside, but coming from within themselves.     

Establishing legal system completely and controlling the excessive population growth]

China during the early years of Socialism concentrated on economic development. Population problems were given a low priority. But now, at this point in China's history, it is necessary to maintain the stability and uniformity of the birth policy through legislation, alter attitudes toward childbearing through legal education, and protect through laws the enthusiastic nature of family planning work of cadres. Without legislation, family planning work cannot endure. It is the proper time to promulgate "Family Planning Law", the body of laws written by the State Council after 5 years of research in family planning work. Critics of this view feel that conditions in rural areas are not ripe for such a law, or that because China is large and populous, laws are not the proper method for controlling population, or that legal restrictions would bring unforeseen consequences in the future. But China's population problem is immediate and dire, and conditions are indeed ripe for passing this law.     

Satisfied users clubs: family planning acceptors as model agents of the program

The National Population Program in the Philippines has encouraged family planning acceptors to shift from their passive role as recipients of family planning services into an active role as program participants. In the mid 1970s the Commission on Population (Popcom) began setting up satisfied users clubs in various regions of the country with the aid of the Ministry of Social Services and Development (MSSD). Other government institutions like the Ministry of Labor and Employment (MOLE) formed similar family planning groups. So did private agencies participating in the Program. There were indications at that time that community based family planning clubs could help the Program in informing couples about family planning and in motivating them to practice contraception. In 1977 a study conducted by the University of the Philippines Institute of Maternal Clinic found that family planning acceptors in Dumaguete City received social and psychological support from local barrio women's clubs. A 1978 Community Outreach Survey indicated that full time outreach workers (FTOWs) found statisfied users clubs helpful in increasing the number of new acceptors in their areas and in bringing down the number of family planning dropouts. Once a decision to create a club is made, club organizers meet with the barangay captain and his council to get their approval and seek their cooperation in inviting people to join the proposed club. Once the approval is given known family planning users in the community or mothers of reproductive age are invited to attend a community assembly. Of 59 clubs surveyed, only 10 had a formal constitution and bylaws. All clubs elected their officers and conducted monthly meetings which lasted from 2-4 hours. The main selling proposition of the clubs is the involvement of members in nonfamily planning activities like income generating schemes, skills training, nutrition seminars, and immunization of children. 81% of the officers of all 59 clubs were family planning acceptors. The majority of officers had undergone voluntary sterilization. Only 8 of the 59 clubs considered themselves single purpose clubs committed to the promotion of family planning. The other 51 were multipurpose organizations, with both family planning and nonfamily planning activities. In the area of family planning, the club's objectives were to increase family planning acceptors, disseminate family planning information, and maintain current users.     

Speech at the UN International Conference on Population,Mexico City,August, 1984

In seeking a solution to its population problem, China, as a developing socialist country, has been making unremitting efforts to develop economy while controlling the rapid growth. The objective is to control rapid population growth so that population growth may be in keeping with socioeconomic development and commensurate with utilization of natural resources and environmental protection. In the past decade, and particularly since 1979, China has made much progress in developing economy and gained remarkable successes in controlling population growth. The natural population growth rate dropped to 1.15% in 1983, from 2.089% in 1973. Living standards have improved with a gradual annual increase of per capita income. All this proves that the policy of promoting family planning to control population growth along with planned economic development is correct. In China family planning is a basic state policy. The government has advocated the practice of "1 couple, 1 child" since 1979. This does not mean that 1 couple could have 1 child only in every case. The government provides guidance for the implementation of family planning programs in the light of specific conditions such as economic developments, cultural background, population structure, and the wishes of the people in different localities. The requirements are more flexible in rural than in urban areas and more so among the people of national minorities than among the people of the Han Nationality. In rural areas, couples who have actual difficulties and want to have 2 children may have a 2nd birth with planned spacing. In carrying out its family planning program, China has consistently adhered to the principle of integrating state guidance with the masses' voluntariness. The government has always emphasized the importance of encouraging the people's own initiatives, through publicity and education, which is the key link in implementing the family planning program.     

Integrating family planning with nutrition and parasite control

At the Inter-Governmental Coordinating Committee Workshop on an Integrated Approach towards Family Planning and Health Programs held at Kuala Lumpur from March 23 to 25, 1977, the feasibility of integrating family planning with nutrition and parasite control through the proper planning of motivational considerations, resource allocation and coordination was studied in detail. Discussion focused on the experience of participating countries in generating community participation in total health programs. Malaysia reported that in the expansion of the national program into the rural areas functional integration has been the approach. In Indonesia nutrition has been an important objective of maternal and child health services. A total integrated development approach has been the objective in the Philippines where family planning information-education-communication has been integrated with nutrition programs and a pilot project on integration of family planning and parasite control has been conducted. Thailand reported on the introduction of an integrated family planning and parasite control program, while Sri Lanka reported on an integrated approach that included family planning with maternity and child health services. A recommendation of the meeting was that experimental pilot projects be established which include nutrition and parasite control elements within the framework of family planning services.     

The participation of non-governmental organizations in the Philippine population program

In 1957 the National Council of Churches in the Philippines (NCCP) established the Family Welfare Center, offering an educational program in family planning; it was subsequently expanded and reorganized into the Planned Parenthood Movement of the Philippines. Since its creation in 1970 the Philippine Population Program has brought together government, private, and religious activities. Under the 1987-92 development plan nongovernmental organizations (NGOs) will be taking a more active role in the implementation of the population program by contributing to the maternal and child health/family planning and the information, education, and communication (IEC) components. There are more than 50 private organizations engaged in such population activities. These include national women's organizations and development NGOs with a mass base. The Family Planning Organization of the Philippines is carrying out a 3-year comparative study of the effectiveness of community volunteers in the acceptance of natural family planning. The Reproductive Health Philippines has completed a follow-up of Depo Provera defaulters in a previous clinical study of Depo Provera acceptors conducted in 1985-87. IEC support from various medical and social organizations also helped advance family planning and population awareness of the program. The Mary Johnston Hospital and Iglesia ni Kristo have been front-runners in sterilization through their mobile teams and regular clinics. On the negative side, funding constraints are threatening the very existence of some NGOs. Even those that do not face such constraints face problems related to cost effectiveness, priority setting, capability building, and staff development. A survey of the Population Center Foundation identified some urgent concerns: sharing experience in self-reliance, enhancement of the managerial skills of staff, and funding problems. NGOs complement the family planning services of the government as well as focus on the smooth flow of IEC activities.     

PPAT works with private clinics and industrial enterprises

Doctors from private clinics have responded to an effort by the Planned Parenthood Federation of Thailand (PPAT) to enlist their voluntary services in support of family planning goals. The private doctors will provide contraceptive services at a nominal cost to the public or free to those who cannot pay. Representatives of PPAT, the Labor Department, the Health Department, and 31 industrial factories in Parthum Thani province met last year to work to find ways of including family planning services as part of workers' welfare in every factory. The participants recommended that family planning services should be officially included as part of workers' welfare. The National Population Clearinghouse/Documentation Center has established its home office at Bangkok. Documentary collection activity is focusing on 5 subject areas: family planning, population/demogrpahy, maternal/child health, nutrition, and primary health care. The Center has already begun to translate selected materials from English into Thai.     

NFP promotion in the Philippines: all program components covered

At least 50 of the 105 agencies in the Philippines listed in the "Directory of Agencies with Population Activities" are actively participating in the promotion of natural family planning (NFP). Of these, 40 offer instruction on its use, 22 provide training to clinic personnel or field workers, 19 conduct information/education/communication (IEC) activities, and 6 undertake research. The Population Center Foundation's (PCF's) Information Support to Population Projects (ISP) has prepared a preliminary inventory of programs and projects on NFP, covering some of those that were done in recent years, are being implemented, or have been proposed. Some projects described in the inventory are reviewed. Recent research or research proposals are showhow related, all leading to how the method can be effectively promoted and how couples can be taught its proper use. Instruction on NFP appears in all training activities of Popcom's regional offices, particularly in their refresher courses. Program managers are being trained in managing and monitoring activities to promote the method. In 1980 outreach workers, doctors, nurses, and midwives were trained by Popcom to motivate couples to practice the method and to teach them how to use it correctly. That same year, Popcom's office in the Ilocos region introduced the rhythm dial calendar, a simplified version of the rhythm slide rule. The Ministry of Health National Family Planning Office incorporates natural family planning instruction in its training seminars for the Ministry's health personnel in the regions. As in training, all regional offices of Popcom promote NFP along with other methods that they make available to prospective acceptors. This is in keeping with the program's "cafeteria approach" to family planning. In 1982 Popcom began intensifying the provision of services in NFP, allocating around 4 million pesos to preparations for its effective promotion. In support of service delivery efforts are IEC activities such as the development, production, and distribution of brochures and other reading material on NFP, schoolroom instruction, and lectures. The intensification of IEC efforts in the private sector to promote the modern and scientific techniques of NFP is most clearly evident in a fairly recent seminar sponsored by the Communication Foundation for Asia. Program agencies with activities in natural family planning are listed.