1. Philippine Population Management Program (PPMP) Monitoring and Evaluation Alejandro N. Herrin and Aniceto C. Orbeta, Jr. August 28, 2003

2. 2 Outline Monitoring and evaluation framework Some findings Information gaps Future directions

3. 3 Objective Strategy Outputs (services, capacity- building, advocacy, organizational support) Basic inputs Utilization (intermediate outcomes Outcomes (achievement of policy objectives) Other factors Framework for PPMP Monitoring and Evaluation

4. 4 Objective/ Strategy OutputsUtilization/ Intermediate Outcomes Outcomes Objective 1: To help couples/parents to achieve their desired family size within the context of responsible parenthood. Strategy 1: Responsible Parenthood and Family Planning (RP/FP)  Family planning services availability  Advocacy/ communication program  Training programs  Organizational support  Contraceptive prevalence rate: total and by method mix  Unmet need for contraception  Total fertility rate: wanted and unwanted Responsible Parenthood and Family Planning (RP/FP)

5. 5 Use of Expenditures 19982000 Amount (in million pesos) Percent Amount (in million pesos) Percent 1. Reproductive health/family planning (RH/FP) 12,423.689.8 14,166.0 83.8 FP services and counseling 1,162.58.4 1,401.2 8.3 RH services and counseling (excluding FP) 9,203.166.5 11,157.6 66.0 2. Adolescent health and youth development (AHYD) 23.30.2 17.3 0.1 3. Population and development integration (POPDEV) 45.40.3 40.2 0.2 4. Policy making, data collection, etc. 1,247.09.0 2,351.2 13.9 5. Mixed PPMP services and activities 90.10.7 338.4 2.0 TOTAL EXPENDITURES 13,829.3100.0 16,913.2 100.0 PPMP Expenditures by Use, 1998 and 2000 Source: Racelis and Herrin (2003) Outputs

6. 6 Uses of Expenditures Sources of Expenditures, 2000 NGFAPsLGU Phil- Health Donors and CAsNGOsHHsTotal 1. RH/FP 17.4 7.2 15.4 7.8 2.1 1.8 32.1 83.8 1.1 FP 0.7 - 1.8 0.0 1.5 0.5 3.7 8.3 1.2 RH (excluding FP) 16.1 0.0 13.6 7.8 0.1 28.4 66.0 2. AHYD 0.0 - - - - 0.1 - 3. POPDEV 0.0 0.2 - - 0.0 - 0.2 4. Policy & data collection 6.9 - 5.7 1.0 0.3 0.0 - 13.9 5. Mixed 0.8 - - - 0.2 1.1 - 2.0 Total Expenditures 25.1 7.4 21.1 8.9 2.6 2.9 32.1 100.0 Percent Distribution of Total PPMP Expenditures by Strategy/Activity and by Source of Expenditures, 2000 Outputs

7. 7 Sources of supply of modern methods Source of Supply NDS 1993 NDHS 1998 FPS 199520002002 Total percent100.0 Public Sector71.572.078.473.770.1 Government hospital 32.622.726.525.423.6 RHU/UHC 12.422.716.126.521.6 BHS 25.023.933.819.622.1 BSPO/BHW 1.51.92.02.22.6 Private26.526.317.924.728.5 Private hospital/clinic 16.415.49.810.610.5 Private doctor 2.61.91.5 1.3 Private nurse/midwife 0.3 0.40.3 Pharmacy/store 7.58.56.611.616.0 NGO 0.1 0.50.3 Industry-based clinic 0.2 0.1 Other private1.71.41.91.1 Outputs

8. 8 Sources: NDS 1968 to 1993 and NDHS 1998 Utilization

9. 9 Fertility and CPR, Selected Countries 2002 TFRCPR All Methods CPR Modern Methods Thailand1.872%70% Indonesia2.357%55% Vietnam2.375%56% Philippines3.246%28% Source: UNESCAP (2003) Utilization

10. 10 PoorestSecondThirdFourthRichestMean TFR6.54.73.62.92.13.7 ASFR (15-19)1309032291246.0 Use of modern contraception (%)19.626.132.7 29.228.0 Fertility and contraceptive use: 1998 NDHS Source: Gwatkin, et al. (2000) Utilization TFR=total fertility rate ASFR (15-19)= age-specific fertility rate among women 15-19 years old.

11. 11 Percent of Currently Married Women by Method, Poor and Non-Poor, 2000 and 2002 Type of Method 2000 FPS2002 FPS PoorNon-PoorPoorNon-Poor Any method40.150.242.951.5 Any modern method26.335.029.537.6 Pill 13.313.814.515.6 IUD 3.03.43.83.6 Injection 3.02.33.72.8 Condom 0.81.61.31.8 Female sterilization 5.113.25.813.3 Male sterilization 0.10.2 0.1 Mucus/billings/ovulation 0.1 LAM 0.90.40.30.2 Any traditional method13.915.113.413.9 Utilization

12. 12 Percentage of currently married women with unmet need for family planning 1993 NDS2002 FPS Total For Spacing For LimitingTotal For Spacing For Limiting Total26.212.413.820.510.69.9 Residence Urban23.511.412.119.59.89.7 Rural29.113.615.621.511.410.2 Education No educ.33.618.415.2 Elem.29.811.618.1 H. S.25.613.512.1 College20.311.58.8 Utilization

13. 13 Sources: NDS 1968 to 1993 and NDHS 1998 Outcomes

14. 14 PoorestSecondThirdFourthRichestMean TFR 6.54.73.62.92.13.7 ASFR (15-19) 1309032291246.0 Use of modern contraception (%) 19.626.132.7 29.228.0 Fertility and contraceptive use: 1998 NDHS Source: Gwatkin, et al. (2000) Outcomes

15. 15 Total and Wanted Fertility Rates, 1993 and 1998 Background Characteristics 1993 NDS1998 NDHS Total Wanted Fertility Rate Total Fertility Rate Total Wanted Fertility Rate Total Fertility Rate Total2.94.12.73.7 Residence Urban2.63.52.33.0 Rural3.34.83.34.7 Education No education4.04.93.95.0 Elementary3.75.53.35.0 High school2.93.92.73.6 College or higher2.42.82.52.9 Outcomes

16. 16 1993 NDS1998 NDHS Urban62.860.0 Rural63.563.7 No education47.642.7 Elementary70.672.1 High school60.660.4 College54.553.3 Total62.861.9 Percent of Married Women Who Want No More Children Outcomes

17. 17 Summary: Family planning Outcomes: Slow fertility decline, high unwanted fertility among the poor Utilization: Low contraceptive use of modern methods. More likely due to lack of access to high quality and preferred methods than lack of demand, especially among the poor. Outputs: Lack of consistency in policy to reduce fertility and promote FP, especially with the promotion of modern and effective “artificial” methods, which affect total effort as reflected in government allocation of resources to contraceptive supplies. Households finance close to half of total expenditures for direct FP services.

18. 18 Objective/ Strategy OutputsUtilization/ Intermediate Outcomes Outcomes Objective 2: To reduce maternal mortality, infant mortality and child mortality through improved reproductive health. Strategy 2: Reproductive Health/Family Planning Program (RH/FP)  Reproductive health services availability  Advocacy/ communication program  Training programs  Organizational support indicators Utilization (coverage) rates of RH services  Maternal mortality  Infant mortality  Child mortality Reproductive Health /Family Planning (RH/FP)

19. 19 10 elements of reproductive health (DOH AO 1-A, January 15, 1998) 1.Family planning 2.Maternal and child health and nutrition 3.Prevention and management of abortion complications 4.Prevention and treatment of reproductive tract infections including STDs and HIV/AIDS 5.Breast and reproductive tract cancers and other gynecological conditions 6.Adolescent reproductive health 7.Education and counseling on sexuality and sexual health 8.Men’s reproductive health 9.Violence against women and children 10.Prevention and treatment of infertility and sexual disorders Outputs

20. 20 Use of Expenditures 19982000 Amount (in million pesos) Percent Amount (in million pesos) Percent 1. Reproductive health/family planning (RH/FP) 12,423.689.8 14,166.0 83.8 FP services and counseling 1,162.58.4 1,401.2 8.3 RH services and counseling (excluding FP) 9,203.166.5 11,157.6 66.0 2. Adolescent health and youth development (AHYD) 23.30.2 17.3 0.1 3. Population and development integration (POPDEV) 45.40.3 40.2 0.2 4. Policy making, data collection, etc. 1,247.09.0 2,351.2 13.9 5. Mixed PPMP services and activities 90.10.7 338.4 2.0 TOTAL EXPENDITURES 13,829.3100.0 16,913.2 100.0 PPMP Expenditures by Use, 1998 and 2000 Source: Racelis and Herrin (2003) Outputs

21. 21 Uses of Expenditures Sources of Expenditures, 2000 NGFAPsLGU Phil- Health Donors and CAsNGOsHHsTotal 1. RH/FP 17.4 7.2 15.4 7.8 2.1 1.8 32.1 83.8 1.1 FP 0.7 - 1.8 0.0 1.5 0.5 3.7 8.3 1.2 RH (excluding FP) 16.1 0.0 13.6 7.8 0.1 28.4 66.0 2. AHYD 0.0 - - - - 0.1 - 3. POPDEV 0.0 0.2 - - 0.0 - 0.2 4. Policy & data collection 6.9 - 5.7 1.0 0.3 0.0 - 13.9 5. Mixed 0.8 - - - 0.2 1.1 - 2.0 Total Expenditures 25.1 7.4 21.1 8.9 2.6 2.9 32.1 100.0 Percent Distribution of Total PPMP Expenditures by Strategy/Activity and by Source of Expenditures, 2000 Outputs

22. 22 MCHS 1999200020012002 Percent who received prenatal care94.293.994.694.1 Percentage who received from: Doctor44.745.541.345.4 Nurse/midwife49.449.954.050.3 Traditional birth attendant/hilot5.84.5 4.2 Others0.1*0.20.1 Percent who received Iron tablet/capsule78.678.581.182.2 Percent who received Iodine capsule58.964.564.4 Percent who received tetanus toxoid vaccine69.970.471.470.4 Note: * less than 0.1 percent Prenatal care, 1999-2002 Utilization

23. 23 PoorestSecondThirdFourthRichestMean To doctor10.123.745.464.782.338.5 To midwife/nurse61.359.747.930.215.248.2 Medically trained provider71.583.493.394.997.585.7 2+ visits75.983.991.792.995.486.1 Pre-natal care visits (%): 1998 NDHS Source: Gwatkin, et al. (2000) Utilization

24. 24 2002 FPS Poor Total No. of children (000)3780 Doctor13.0 Midwife/nurse22.1 Hilot63.0 Non-poor Total No. of children (000)5840 Doctor46.2 Midwife/nurse30.6 Hilot22.7 Percent of children 0-59 months by type of delivery attendant Percentage for “Others” not shown. Utilization

25. 25 PoorestSecondThirdFourthRichestMean By a doctor 7.116.535.750.275.830.9 By midwife/nurse 14.129.337.133.816.025.5 By medically trained provider 21.245.972.883.991.956.4 In a public facility 7.116.028.729.326.319.5 In a private facility 1.64.111.825.552.514.8 At home 91.079.459.444.821.265.5 Delivery attendance (%): 1998 NDHS Source: Gwatkin, et al. (2000) Utilization

26. 26 MCHS 1999200020012002 All Women ('000) 5062578647816870 Percent who received postnatal care 63.160.064.571.0 Percentage who received from: Doctor 47.551.747.1 Nurse/midwife 37.537.139.9 Traditional birth attendant/hilot 14.910.812.8 Type of service Abdominal exam 55.355.458.456.9 Breast exam 36.236.437.136.3 Internal exam 30.234.630.235.9 Family planning advice 40.840.342.240.6 Breastfeeding advice 58.256.156.355.2 Baby care advice 67.164.267.562.6 Check-up of baby77.877.979.578.2 Postnatal care, 1999-2002 Utilization

27. 27 High risk fertility behavior, 1993 and 1998 Risk defined in terms of early ( 34) childbearing, short birth intervals ( 3) Outcomes

28. 28 Sources: Flieger 1982; Flieger and Cabigon 1984; NSCB 1992; UNESCAP 2002 Outcomes

29. 29 Sources: Flieger 1982; Flieger and Cabigon 1984; NSCB 1992; UNESCAP 2002 Philippines Thailand South Korea Outcomes

30. 30 PoorestSecondThirdFourthRichestMean IMR48.839.233.724.920.936.0 Under 5 MR79.860.549.733.429.254.9 Infant and child mortality by income class: 1998 NDHS Source: Gwatkin, et al. (2000) Outcomes

31. 31 Maternal mortality ratio estimates Estimates for other countries for 1990-98: –South Korea: 20 –Malaysia: 39 –China: 65 –Thailand: 44 –Singapore: 6 –Indonesia: 450 –Philippines: 170 Source: World Bank (2001) Outcomes

32. 32 Summary: Reproductive health Outcomes: slow decline in infant and child mortality; high infant and child mortality among the poor; high maternal mortality; high risk births; little information on other aspects of RH. Utilization: Low utilization of MCH services provided by trained medical providers among the poor. Subsidized public sector services captured by the better off. Outputs: Traditional services in place but public delivery now the main responsibility of LGUs probably not highly efficient nor of high quality. Households finance close to half of direct RH expenditures.

33. 33 Objective/ Strategy OutputsUtilization/ Intermediate Outcomes Outcomes Objective 3: To reduce the incidence of teenage pregnancy, incidence of early marriage, and the incidence of other reproductive health problems. Strategy 3: To ensure that adolescents are provided with appropriate information, knowledge, education and services on population and reproductive health. (AHYP)  Education and counseling services availability  Advocacy/ communication program  Training programs  Organizational support  Attendance in education and counseling programs  Coverage of advocacy and communication program  Age at marriage  Fertility rate among teenagers and youth  Indicators of reproductive health behavior and problems among the adolescent and youth (e.g.,STD, HIV/AIDS?) Adolescent Health and Youth Development (AHYD)

34. 34 Use of Expenditures 19982000 Amount (in million pesos) Percent Amount (in million pesos) Percent 1. Reproductive health/family planning (RH/FP) 12,423.689.8 14,166.0 83.8 FP services and counseling 1,162.58.4 1,401.2 8.3 RH services and counseling (excluding FP) 9,203.166.5 11,157.6 66.0 2. Adolescent health and youth development (AHYD) 23.30.2 17.3 0.1 3. Population and development integration (POPDEV) 45.40.3 40.2 0.2 4. Policy making, data collection, etc. 1,247.09.0 2,351.2 13.9 5. Mixed PPMP services and activities 90.10.7 338.4 2.0 TOTAL EXPENDITURES 13,829.3100.0 16,913.2 100.0 PPMP Expenditures by Use, 1998 and 2000 Source: Racelis and Herrin (2003) Outputs

35. 35 Uses of Expenditures Sources of Expenditures, 2000 NGFAPsLGU Phil- Health Donors and CAsNGOsHHsTotal 1. RH/FP 17.4 7.2 15.4 7.8 2.1 1.8 32.1 83.8 1.1 FP 0.7 - 1.8 0.0 1.5 0.5 3.7 8.3 1.2 RH (excluding FP) 16.1 0.0 13.6 7.8 0.1 28.4 66.0 2. AHYD 0.0 - - - - 0.1 - 3. POPDEV 0.0 0.2 - - 0.0 - 0.2 4. Policy & data collection 6.9 - 5.7 1.0 0.3 0.0 - 13.9 5. Mixed 0.8 - - - 0.2 1.1 - 2.0 Total Expenditures 25.1 7.4 21.1 8.9 2.6 2.9 32.1 100.0 Percent Distribution of Total PPMP Expenditures by Strategy/Activity and by Source of Expenditures, 2000 Outputs

36. 36 Age-specific birth rates (per 1,000 women) Age group 1973 NDS 1978 RPFS 1983 NDS 1986 CPS 1993 NDS 1998 NDHS 15-19565055485046 20-24228212220192190177 25-29302251258229217210 30-34268240221198181155 35-39212179165140120111 40-441008978625140 45-492827201587 Outcomes

37. 37 Outcomes

38. 38 PoorestSecondThirdFourthRichestMean Total fertility rate 6.54.73.62.92.13.7 Age-specific fertility rate (15-19) 1309032291246.0 Use of modern contraception (%) 19.626.132.7 29.228.0 Fertility and contraceptive use: 1998 NDHS Source: Gwatkin, et al. (2000) Outcomes

39. 39 Background characteristics 1993 NDS1998 NDHS Age 150.5 161.31.6 173.65.0 1810.310.5 1919.021.3 Residence Urban4.84.7 Rural8.910.8 Education No education15.217.3 Elementary13.515.9 High school5.55.7 College or higher1.84.5 Total6.57.2 Teenagers who have begun childbearing, 1993 and 1998 Outcomes

40. 40 Summary: Adolescent health and youth development Outcomes: Early childbearing and high fertility, especially among the poor. Utilization: Lack of information on services and their utilization. Outputs: Very little expenditures on AHYD. Current expenditures mainly coming from NGOs, suggesting that there is little public sector programs for AHYD.

41. 41 Objective/ Strategy OutputsUtilization/ Intermediate Outcomes Outcomes Objective 4: To contribute to policies that will assist government to achieve a favorable balance between population distribution, economic activities, and the environment. Strategy 4: Integrate population variables, with emphasis on migration and urbanization, into development policies, plans and programs at all levels. (POPDEV)  Advocacy/IEC program on POPDEV integration  Training program on POPDEV integration  Program of research and conferences  Technical assistance program in place  Trained planners in selected provinces and cities.  Number of researches and conferences held  Number of LGUs receiving technical assistance  Integration of POPDEV in local development plans Population and Development Integration (POPDEV)

42. 42 Use of Expenditures 19982000 Amount (in million pesos) Percent Amount (in million pesos) Percent 1. Reproductive health/family planning (RH/FP) 12,423.689.8 14,166.0 83.8 FP services and counseling 1,162.58.4 1,401.2 8.3 RH services and counseling (excluding FP) 9,203.166.5 11,157.6 66.0 2. Adolescent health and youth development (AHYD) 23.30.2 17.3 0.1 3. Population and development integration (POPDEV) 45.40.3 40.2 0.2 4. Policy making, data collection, etc. 1,247.09.0 2,351.2 13.9 5. Mixed PPMP services and activities 90.10.7 338.4 2.0 TOTAL EXPENDITURES 13,829.3100.0 16,913.2 100.0 PPMP Expenditures by Use, 1998 and 2000 Source: Racelis and Herrin (2003) Outputs

43. 43 Uses of Expenditures Sources of Expenditures, 2000 NGFAPsLGU Phil- Health Donors and CAsNGOsHHsTotal 1. RH/FP 17.4 7.2 15.4 7.8 2.1 1.8 32.1 83.8 1.1 FP 0.7 - 1.8 0.0 1.5 0.5 3.7 8.3 1.2 RH (excluding FP) 16.1 0.0 13.6 7.8 0.1 28.4 66.0 2. AHYD 0.0 - - - - 0.1 - 3. POPDEV 0.0 0.2 - - 0.0 - 0.2 4. Policy & data collection 6.9 - 5.7 1.0 0.3 0.0 - 13.9 5. Mixed 0.8 - - - 0.2 1.1 - 2.0 Total Expenditures 25.1 7.4 21.1 8.9 2.6 2.9 32.1 100.0 Percent Distribution of Total PPMP Expenditures by Strategy/Activity and by Source of Expenditures, 2000 Outputs

44. 44 Summary: POPDEV Outcomes: Not much expected if little activities are in place. Utilization: Not much expected if little activities are in place. Outputs: Not much activities during the period covered – 1998 to 2000 as reflected in the small expenditures for the POPDEV program.

45. 45 Information gaps Reasonably updated data on FP use, source of supplies of modern methods, and fertility, but not so with infant, child and maternal mortality, and outcomes data on youth. Very limited utilization (intermediate outcomes) and outcomes data on the other components of RH. Limited disaggregation of utilization and outcomes indicators by major social groups, e.g., poor vs. non-poor. Limited disaggregation of expenditure data by major public/private and modern/traditional providers of RH/FP services. Limited indicators of utilization and outcomes for AHYD and POPDEV.

46. 46 Future directions Greater effort at systematic development and application of POPDEV “tools” (data and analysis of interrelationships) to inform policy at both national and LGU levels. Monitoring of population welfare through a rights- based, gender and life cycle approach to ensure that gains in one stage of the life cycle are not lost in the next, or that disadvantages in one stage are adequately compensated in the subsequent stages.