The influence of local policy on contraceptive provision and use in three locales in the 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.

Résumé

Les Philippines possèdent un programme de planification familiale, mais la prévalence de la contraception moderne est modérée. Peu de femmes à faible revenu utilisent des méthodes modernes, ce qui aboutit chez elles à un taux de fécondité de 5,9. Ces limitations sont dues à un manque de soutien suivi des autorités nationales et locales aux méthodes modernes, en raison de l'opposition religieuse. Après le transfert de la responsabilité des services de santé aux autorités locales en 1991, trois dirigeants locaux, dans la province de Laguna et les villes de Manille et Puerto Princesa, ont adopté des politiques contre les méthodes contraceptives modernes. L'article analyse la situation et l'impact de ces politiques, en utilisant les informations tirées d'entretiens avec des fonctionnaires et des responsables de la planification familiale, de données publiées et d'études, ainsi que d'articles de journaux nationaux. Dans la province de Laguna et à Puerto Princesa, la mise en łuvre des politiques a été peu efficace ou de courte durée. À Manille, l'application stricte de la loi a profondément désorganisé les services municipaux de contraception gratuite pour les femmes à ressources modestes. La grande majorité des Philippins (89%) approuve les contraceptifs modernes. Il est urgent d'élargir l'accès des femmes à faible revenu aux contraceptifs modernes par la distribution ambulante et communautaire, particulièrement dans les quartiers pauvres de Manille, mais aussi dans le reste du pays. Des stratégies doivent aussi accroître l'offre de méthodes modernes et le soutien des autorités locales.

Resumen

Aunque en Filipinas existe un programa de planificación familiar, la prevalencia del uso de anticonceptivos modernos ha sido moderada. Menos mujeres de bajos ingresos usan métodos modernos, por lo cual la tasa de fertilidad entre ellas es de 5.9. Este uso limitado se debe a la falta de apoyo sistemático del gobierno nacional y local para métodos modernos debido a la oposición religiosa. Tras la devolución de la responsabilidad de los servicios de salud al gobierno local en 1991, tres líderes locales – en la Provincia de Laguna y las ciudades de Manila y Puerto Princesa – aprobaron políticas contra los anticonceptivos modernos. En este artículo se analiza el estado y el impacto de esas políticas, usando información de entrevistas con funcionarios del gobierno local y agentes de planificación familiar, datos y estudios publicados, e informes en periódicos nacionales. En la Provincia de Laguna y en Puerto Princesa, las políticas fueron aplicadas de manera inútil o de corta duración. Sin embargo, la ley de Manila, que se hace respetar estrictamente, ha interrumpido marcadamente el suministro de anticonceptivos gratuitos a mujeres de bajos ingresos. La gran mayoría de filipinos (el 89%) aprueba los anticonceptivos modernos. Existe una necesidad urgente de mejorar el acceso de las mujeres de bajos ingresos a los anticonceptivos modernos mediante la distribución ambulante y comunitaria, especialmente en los vecindarios pobres de Manila, pero también en el resto del país. También se necesitan estrategias para aumentar el apoyo del gobierno local para los métodos modernos y su suministro.

Key Words:

• contraception
• family planning services
• devolution
• unmet need
• health policy and programmes
• Philippines

The 1971 Philippines population policy¹ mandates the implementation of a family planning programme to promote contraceptive use among married women and reduce the country's total fertility rate. In nearly four decades, the extent of women's contraceptive use and modern method use, a programme impact measure,² has been moderate. While there were dramatic increases in the numbers of contraceptive and modern method users in the programme's first two decades (1973–1993), the same level of increase has not been sustained in later years. Table 1

short-legendTable 1

shows that since 1993, the percentage of married women using a contraceptive and a modern method has stabilised at not more than 50% and 36%, respectively. Lifetime births among Filipino women have fallen from 6.0 in 1973 to 3.4 in 2003,³ but this is still considered high.⁴ Among low-income women, who comprise a third of the 12.4 million married Filipino women of reproductive age, the impact has been much lower. Fewer low-income women were using contraceptives and adopting modern methods in 2005 (45.5% and 32.2%, respectively),⁵ resulting in a total fertility rate among them of 5.9 (national rate: 3.5).³

The lower level of contraceptive use among low-income women is not due to lack of knowledge or negative attitudes. Low-income women, like the rest of Filipinos, favour family planning⁶ and are highly knowledgeable about modern contraceptives.³ But about 25% of them have an unmet need for family planning.⁵ Data from 2003 indicated that 85.1% of the 28.8% who were not currently using a method but had a preference to use a method in the future would want a modern one. Among current modern contraceptive users, 98.3% would opt for the same method in future.³

Contraceptive supply

Lack of contraceptive supplies per se could not have constrained low-income women's modern contraceptive use. Since 1971, the family planning programme has received a steady level of supplies from the United States Agency for International Development (USAID), the United Nations Population Fund (UNFPA) and other international organisations. Before 1999, the Philippines had never had to purchase contraceptives, but only pay the import taxes on donated commodities.⁸ In 1999-2001, the main donor, USAID, supplied pills, male condoms, injectables and intrauterine devices worth US$40 million, covering 80% of the country's requirements.⁹ These contraceptives were distributed free through the public health sector at provincial, municipal, city and village levels, which at that time was funded and managed by the Department of Health.³

USAID decided to reduce its donations gradually, however, and announced that in 2008 it would stop its donations entirely, in order to foster contraceptive self-reliance in the Philippines. Having been informed well in advance that this was coming, the national government promulgated a 1999 Contraceptive Independence Initiative Policy “to ensure the availability of commodities for all segments through direct subsidy, 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 elsewhere 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 purchase, but the funds were returned because of “disbursement failure”.¹¹ No funds were approved from 2002 to 2006. Due to lack of funds, the country is currently not meeting low-income women's need for free contraception.¹²

Presidents Marcos and Ramos both recognised the adverse socio-economic implications of rapid population growth and made contraceptives available,¹³ but the four other Philippines presidents, during their terms, have not shown strong support for modern contraceptives. While all four of these presidents articulated the development implications of population growth, nowhere did they make explicit reference to family planning as a key strategy for solving the country's burgeoning population and poverty.¹³ Arroyo, the incumbent president, regards population as a social justice and economic development issue and addresses it through anti-corruption and resource management measures rather than through fertility control.¹⁴ The Arroyo administration's 2001 National Family Planning Policy at the Department of Health seeks “to help couples and individuals achieve their desired family size”, but fails to stipulate family planning as a strategy.¹³

Modern contraception is unmentioned because many presidents, including the incumbent, are highly identified with the Catholic church, with its anti-choice stance, including against modern contraception. While it promotes natural methods, the Church rejects artificial contraceptives,¹⁵ and seeks to scuttle any public procurement of contraceptives, including the 2007 Congress-approved local funds.¹¹ Currently, the Church is at loggerheads with many congressmen who are pursuing the passage of House Bill 5043, the Reproductive Health, Responsible Parenthood and Population Development Act of 2008, which aims to promote, among other things, modern and natural means of family planning, and contraceptive supply purchases by national and local government hospitals.¹⁶ If this bill is approved, the Church would likely try to derail its implementation through its own national network of allies at local level, whether or not the national leadership is pro-choice.

No one has calculated how many local leaders support the Church's actions against modern contraceptives, but they are a concern because they can sabotage programmes by telling people only about negative side effects and the “immoral” repercussions of using them.¹⁷¹⁸ They can also instruct their service providers not to inform women about or recommend these methods.⁶ Such actions have been part of the landscape in which the family planning programme struggles in the Philippines and are a continuing challenge.

In 1991, the Local Government Code mandated the devolution of health service delivery responsibilities and financial management, including for contraceptive delivery, from career civil servants in the Department of Health's regional, provincial and district offices, to elected officials in provincial, city and municipal governments. Within two years, some 95% of the Department's facilities, 60% of its personnel and 45% of its budget were transferred,¹² giving local leaders primary control of local health provision. However, the lack of institutional capacity to fulfil these devolved responsibilities has exacerbated rather than alleviated inequities in health service access, including as regards contraceptive delivery.¹² Although some local executives have made initial outlays for modern contraceptive delivery, in compliance with the terms of devolution,¹⁹ some anti-choice leaders have failed to do so, and some of these have further constrained low-income women's access to contraception through anti-choice policies. In 2001, the Laguna provincial governor and the mayors of Manila and Puerto Princesa issued such policies. Published information on these policies is scarce. This paper reports what is known about these policies and their consequences.

Methods and respondents

We obtained hard copies of the local policies from the governments of Laguna, Manila and Puerto Princesa. We also carried out brief phone, mail, e-mail or face-to-face interviews with the head of the provincial population office for Laguna, the city administrators for Puerto Princesa and Manila, and local government family planning programme field operations officers. We looked for prior studies and found only one qualitative study of the impact of the policy in Manila.²⁰ And we collected accounts in reputable national newspapers. General background information on the three locales was gathered from their official websites, and relevant family planning survey data were derived from the Philippines National Statistics Office website and publications. Manila City's field operations data on new contraceptive acceptors and contraceptive prevalence are for married women rather than low-income women. However, as 75% of public health sector contraceptive users are low-income women,⁵ these data will reflect their experiences.

Findings

Laguna

Located 30 km from Manila City (2000 population: 1.97 million), Laguna Province is a highly modernised agro-industrial economy with 28 municipalities, two cities and 674 villages. Laguna is led by a publicly-elected governor for a maximum of three three-year terms. In 1992, anti-choice Governor Lina was elected. In 1995, Lina, a nephew of the mayor of Manila who later instituted a similar law, issued a one-page memorandum in a local language through the provincial population officer addressed to all family planning clinic heads. Entitled “New Order of Provincial Head”, it reads (translated):

To adhere to the new order of the Provincial Head, I order you to stop providing all artificial contraceptives (oral pills, DMPA, IUD, ligation, vasectomy, and condom) except natural family planning methods. This order shall take effect starting today until it is changed or voided. Your prompt adherence and cooperation are expected.²¹

The memorandum was in effect for six years until Lina's term ended in 2001. Lina was immediately appointed Philippines Department of the Interior and Local Government Secretary. In 2003, he issued Memorandum Circular 204 (in English) calling for the integration of the standard-days method in all the country's local family planning programmes and enjoined provincial governors, city and municipal mayors, and the Department's regional directors to invest resources to promote this method, though the memorandum did not ban modern methods.²²

Although the Laguna law lasted for six years, its implementation was confined to the provincial capital of Sta. Cruz. In an interview, the current provincial population officer explained that Sta. Cruz was the sole area in Laguna in which contraceptive supplies were not available. Her office, being directly under the governor, had no recourse but to implement the order there, but Laguna's other cities and municipalities had no such prohibitions. Hence, contraceptive supplies and services at public health centres and several non-government organisations in those areas were uninterrupted. “Women who lived in Sta. Cruz who wanted to obtain modern methods only had to go to a neighbouring area to get them.” The local law was repealed by Governor Lazaro upon her election in 2001.²³ In 2006-2008, Lazaro allocated US$24,000-US$79,000 for contraceptive supplies (Personal communication, Ma. Corazon Colisara, Provincial Health Office, 16 March 2009).

Manila

The capital Manila has 897 villages (2000 population: 1.58 million). In 1998, a staunchly anti-choice Mayor Atienza was voted into office. In 2000, following in the footsteps of his nephew, Governor Lina, Atienza issued Executive Order No.003, entitled “Declaring Total Commitment and Support to the Responsible Parenthood Movement in the City of Manila and Enunciating Policy Declarations in Pursuit Thereof”.²⁴ Among other things, the Order expresses a “pro-life” stance on family and motherhood, responsible parenthood, the life of the “unborn”, and natural family planning “not just as a method but as a way of [developing] self-awareness in promoting the culture of life”. It condemns “criminal abortion, euthanasia, divorce and same-sex marriages as amoral and deplorable practices that weaken the basic unit of family and society”. It calls for “discouraging the use of artificial methods of contraception like condoms, pills, intra-uterine devices, surgical sterilization”.²⁴ And it mandates the city's health and social services to establish responsible parenthood and natural family planning programmes and activities.

For seven years, the law was effectively implemented by city officials, who were ordered not to recommend or provide modern contraceptives.²⁰ Atienza himself actively campaigned against modern contraceptives and regularly awarded cash prizes to women with large numbers of children during medical missions and at other venues, especially during election periods.²⁰ Overall, the city's family planning programme operations were severely disrupted. The study led by Likhaan reported the following disruptions in 2007:

• removal of contraceptive supplies and services from city health centres and hospitals,

• closure of non-government organisations that had been providing family planning information and services,

• harassment and labelling of health care workers in such institutions as “abortionists”,

• the cessation of occasional philanthropic medical services to offer modern methods of family planning.²⁰

Consequently, modern contraceptive supplies were officially effectively nil from 2000 on, and contraceptive use rates for new and current users decreased dramatically, as did the contraceptive prevalence rate (Table 2

short-legendTable 2

). However, interestingly, the birth rate did not increase.

Atienza completed his three terms in 2007. Currently, the city is led by Mayor Lim who, also anti-choice, has maintained the Executive Order (Personal communication, Criselda Coroza, City Health Office, 17 March 2009). In his 2008 speech at the Manila Cathedral School, referring to the pending Reproductive Health Bill 5043, Lim said:

“If the bill is passed and approved to become a law, the City of Manila will not follow its provision wherein local government units buy contraceptives using taxpayers' money.” ²⁶

Puerto Princesa

Puerto Princesa, capital of Palawan Province, has 66 villages, the majority of which are rural (2000 population: 0.162 million). ²⁵

Upon his 2001 election, anti-choice Mayor Socrates passed a six-page Executive Order (No.36, in English) entitled “Implementing Rules and Guidelines for the Implementation of Resolution No. 79-2001, Declaring the City of Puerto Princesa as a Pro-Life and Pro-Family City”.²⁷ Its first section highlighted the sanctity of human life; the inviolable right of every human to life and of every person to live with dignity, exercising freedom with responsibility in the fulfilment of his destiny; and the imperative to protect all human life. It defined the family as a man and a woman joined in lawful marriage, together with their children, and human sexuality as primarily for procreation within the family.²⁷

The second part described 11 “morally illicit” practices: induced abortion, divorce, same-sex marriages, euthanasia, artificial insemination, artificial birth control, cloning and other genetic manipulation, death penalty, prostitution, pornography and drug abuse. Of contraceptives, it stated that:

“The use of artificial birth control methods…not only prevent[s] the transmission of life but also reduce[s] the conjugal act into a selfish act and is therefore intrinsically morally unacceptable. The production, promotion and sale of such items also constitute a grave offence to God.” ²⁷

The other sections covered natural family planning and implementing agencies, and banned “artificial” contraceptives:

“Concerned personnel of the City Government are hereby ordered to refrain from further procurement and distribution of contraceptive drugs and other paraphernalia and to dispose of any such materials in their inventories for morally harmful.” ²⁷

The Order was ineffectually implemented because after less than a year in office, Mayor Socrates was subjected to a recall election in July 2002, and lost to returning pro-choice Mayor Hagedorn (Personal communication, Agustin Rocamora, City Administrator, 11 March 2009). Hagedorn immediately amended Executive Order No.36. His Executive Order No.9 (in English)²⁸ retained the previous title and still lists the “morally illicit” practices of induced abortion, euthanasia, cloning and other genetic manipulation, prostitution and drug abuse. However, it differed in one major respect; it clearly favoured family planning:

“While Puerto Princesa is a Pro-life and Pro-family City, it nonetheless recognizes the right of its constituents, particularly its women and men, parents, and families, to have several informed choices as far as responsible parenthood, family planning, and reproductive health are concerned… The City Government of Puerto Princesa thus recognises and supports the National Government's programmes on family planning, population control, reproductive health, responsible parenthood, and such other similar programmes. Consequently, in the interest of promoting public health and safety, and the general welfare of the City's populace, the City Health Office, Satellite Clinics, and all other concerned offices and units of the City Government are directed to coordinate and cooperate with concerned national government agencies in the implementation of such national programmes in the City of Puerto Princesa.” ²⁸

Mayor Hagedorn and his Executive Order are still in place today.

Discussion

President Arroyo does not support modern contraceptives due to church pressure. However, in the Philippines Congress, although opposition to such methods exists, many legislators support their provision to reduce poverty.²⁹ These pro-choice lawmakers, e.g. Senator Pia Cayetano and Congressman Edcel Lagman, work extremely hard to pass family planning-related bills, with support from women's groups such as Gabriela with its 200 institutional members (Personal communication, Emmy de Jesus, Secretary-General, 14 March 2009) and the academe.³⁰ In August 2009, after years of advocacy, the Magna Carta of Women, a law ensuring woman parity with men, which includes responsible, legal, safe and effective family planning methods for women, became law.³¹ Its approval shows that religious opposition can be surmounted through effective advocacy, which may help to pass Reproductive Health Bill 5043, now 12 votes away from approval.¹⁶

Figure 1 Rural family planning clinic, Mindanao, Philippines

Women's groups expanded their advocacy to local level due to the unprecedented action in Laguna, Manila and Puerto Princesa to prevent women from accessing modern contraceptives. Fortunately, two of the three policies were ineffectual, and the Puerto Princesa one short-lived due to the recall election. The Laguna memorandum was in effect for six years (1995-2001), but its enforcement was confined to the provincial capital.

The Laguna experience shows that there are many local leaders, health officers and service providers who are willing to defy an anti-contraception policy, and the Catholic church, in order to provide family planning services and help low-income women control their fertility. Protestant religious groups have expressed unequivocal support³² and the local governments of Quezon City,³³ Bohol and Aurora,³⁴ along with the current Puerto Princesa City government, have passed pro-contraceptive laws.

The Manila City policy remains a serious challenge. For more than seven years, and enforced by two succeeding mayors, its law (as far as our limited data can suggest) has severely disrupted the city's free contraceptive provision and method use among low-income women.³⁵ However, the city continues to record new and continuing users of modern methods and stable birth rates despite the apparent absence of modern contraceptive supplies. This may be because women are getting contraceptives from nearby cities, such as Quezon City, where no prohibition occurs, or are being served by ambulant providers, which have been introduced by some groups.²⁰ Or, more women could be having illegal abortions, which have been and remain common.³⁶

Women's groups have lodged a case against Manila's executive order, on the grounds that it constitutes an abuse of power on the part of the mayor. They argue that the city cannot violate the right of couples to regulate the size of their family, which is guaranteed in the country's Constitution,¹³ and that the city is obliged under national government policy to offer family planning services (Personal communication, Junice Melgar, Executive Director, Likhaan, 28 August 2009). But the Manila City administration contends that the policy is within the limits of the Mayor's executive powers.²⁰

While legal recourse and pressure on the part of women's and other pro-choice groups may succeed in the long term against such a policy, there is an urgent need to improve contraceptive access for Manila's low-income women. In tandem with medical missions and community service outreach programmes, more women's groups must station mobile clinics and ambulant service providers in cities nearest to Manila's low-income communities. Some groups, such as the Family Planning Organisation of the Philippines, have already initiated these moves (Personal communication, Roberto Ador, Executive Director, 25 August 2009). Other innovative solutions are needed to address access until local anti-choice executives conclude their term in office, such as in Puerto Princesa. Since there are increasing reports of low-income women in Manila with complications due to incorrect use of self-abortion methods (Personal communication, Junice Melgar, Executive Director, Likhaan, 28 August 2009), better post-abortion care is needed.

Advocacy and better family planning service delivery are likewise needed in locales that do not have anti-contraception policies, to improve contraceptive prevalence. In Quezon City, even with local government support, data from field operations show that contraceptive use overall was only 35–39% in 2004-2006,³⁷ while in poorer regions, where no such support exists, such as in Bicol, a family planning survey found that modern method use was 25% in 2006.⁷ Women's groups could invoke the Magna Carta of Women along with national population policies and Constitutional rights as legal platforms on which to advocate for better services. Moreover, they can publicise the approval of modern contraceptives by the overwhelming majority of Filipinos (89%)³⁸ as another compelling argument. Modern contraceptives are highly effective and their benefits greatly outweigh the risks of frequent pregnancies and unsafe abortion. Testimonies from satisfied users would be useful.⁶

To win local support further, women's groups should advocate for improving local institutional capacity,¹² developing an understanding of women's reproductive health and rights, and a commitment from local leaders to provide modern contraceptives. The Laguna government's 2006-2008 contraceptive budget allocation is laudable but it covers less than 10% of the estimated cost of contraceptives needed by local women.³⁹ Under devolved government, local funds are critical to serve low-income women's modern contraceptive needs. The phasing out of USAID's donations, Catholic church advocacy against contraception, and the absence of adequate national government funding has led to a greatly worsened situation for low-income women who seek contraception. A safety net guaranteeing access to contraceptives is needed.⁴⁰

Acknowledgments

We thank Irma Asuncion, Centre for Health Development-Metro Manila; Josefina Yanesa, Laguna Provincial Population Office; and Junice Melgar, Likhaan, for supplying data. For his professional advice, we thank Professor Hiko Tamashiro, Hokkaido University, Japan.