715367

research-article2017
APHXXX10.1177/1010539517715367Asia Pacific Journal of Public HealthBredenkamp and Buisman

Original Article
Asia Pacific Journal of Public Health
2017, Vol. 29(5) 367­–376
Twenty Years of Progress on © 2017 APJPH
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DOI: 10.1177/1010539517715367
https://doi.org/10.1177/1010539517715367
Philippines: An Equity Lens journals.sagepub.com/home/aph

Caryn Bredenkamp, PhD1, and Leander R. Buisman, PhD2

Abstract
This article assesses trends and inequalities in maternal and child health in the Philippines
between 1993 and 2013, using 6 national household surveys, and also compares the Philippines’
performance to 15 other Asia-Pacific countries. Thirteen indicators of child health outcomes
and maternal and child health interventions are examined. Two measures of inequality are used:
the absolute difference between the poorest and wealthiest quintile, and the concentration
index. Coverage of all indicators has improved, both on average and among the poorest quintile;
however, increases are very small for child health interventions (especially immunization
coverage). By the first measure of inequality, all indicators show narrowing inequalities. By
the second measure, inequality has fallen only for maternal health interventions. Compared
with other 15 other developing Asia-Pacific countries, the Philippines performs among the best
on the child health outcomes examined and above average on maternal health interventions
(except family planning), but only at or below average on child health interventions.

Keywords
health equity, maternal health, child health, Philippines, inequality, immunization, Asia, Demographic
and Health Survey

Introduction
A number of regional and global studies (eg, Suzuki et al,1 Victora et al,2 Wagstaff et al,3 Wagstaff
et al,4 Wagstaff et al,5 Alkenbrack et al,6 Victora et al7) have highlighted the importance of look-
ing beyond aggregate improvements in maternal and child health (MCH) to see whether they
may mask widening socioeconomic inequalities or a failure to reach the poor. These authors find
that, on aggregate and for most indicators, socioeconomic inequalities in the coverage of mater-
nal and child health indicators have been decreasing,8 while progress on inequalities in health
outcomes tends to be mixed. However, they also note that focusing only on these global trends
would lead one to miss important cross-country variation, thus underlining the important of
country-specific analysis. Indeed, Wagstaff et al3 find that, despite the overall trend of narrowing
of inequalities, inequalities in outcomes have widened in 42% of countries, while inequalities in
coverage have widened in 28% of countries.

1The World Bank, Washington DC, USA

2Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands

Corresponding Author:
Caryn Bredenkamp, Nutrition & Population Global Practice, The World Bank, 1818 H Street NW,
Washington DC 20433, USA.
Email: cbredenkamp@worldbank.org
368 Asia Pacific Journal of Public Health 29(5)

In the Philippines, there have been relatively few attempts to analyze whether improvements
in MCH outcomes and interventions have been associated with widening or narrowing socioeco-
nomic inequalities. Three recent studies9-11 look at trends in income-related inequalities for a
limited set of MCH indicators, but none use the latest available data. An additional study12 of
inequalities uses the latest data, but does not look at trends. With the Millennium Development
Goal (MDG) era having ended and the Philippines’ 2011-2016 Kalasugan Pangkalahatan health
strategy having drawn to a close, the timing is appropriate to ask whether the country achieved
its health system objective of ensuring “equitable” access to health care, beginning with those
Filipinos in “the lowest income quintiles?”
The objective of this article is to examine whether progress has been made on 13 indicators of
MCH outcomes and interventions over the 20-year period ending 2013 (which is the most recent
year for which comparable data are available) and whether these improvements were accompa-
nied by narrowing socioeconomic inequalities. It also asks how progress in the Philippines, on
levels and inequalities, compares with 15 other countries in the Asia-Pacific region.

Methods
Since 1990, the Philippines has produced 6 major nationally representative and publicly
available cross-sectional surveys that contain information on MCH-related outcomes and
interventions. These are the Demographic and Health Surveys (DHS) for 1993, 1998, 2003,
2008, and 2013, as well as a 2011 Family Health Survey (FHS) which is similar in design to
the DHS, but with a sample size more than 3 times as large. A FHS was also conducted in
2007, but the data are not publicly available. In this article, we use data from these 6 surveys
to examine trends in 13 indicators of maternal and child health. Of these indicators, 9 are
related to child health and 4 to maternal health; 5 are indicators of health status and 8 are
intervention indicators (see Table A1 in the appendix). These indicators were selected because
they are the ones that are used globally to monitor examine progress toward the MDGs related
to maternal and child health, and are available in the data. Child stunting and underweight,
while MDG indicators, are not examined because child anthropometry is not included in the
Philippines DHS.
We examine progress on each of this indicators on average, and among the poorest quintile.
We also examine whether progress is accompanied by narrowing or widening socioeconomic
inequalities (ie, whether the poorest have improved their position vis-à-vis the better-off).
Inequalities are measured in 2 ways: by the absolute difference between the poorest and the
wealthiest quintile, and by the concentration index (CI). A negative value of the CI indicates that
the indicator being analyzed takes higher values among the poor, while a positive value indicates
that the indicator takes higher values among the better-off. We use the wealth index as the living
standards measure with which to rank people from poorest to richest. The wealth index variable
is included in the public release of the DHS; for the FHS, we construct the wealth index ourselves
using the same approach as the DHS.13,14
In addition, we compare the performance of the Philippines with 15 other countries in the
Asia-Pacific region. These countries were selected based on the availability of a DHS or Multiple
Indicator Cluster Survey (MICS) from 2005 or later. The comparator countries and datasets are
the Afghanistan MICS 2010-2011, Bangladesh DHS 2011, Bhutan MICS 2010, Cambodia DHS
2010, India DHS 2005-2006, Indonesia DHS 2012, Lao PDR MICS 2011-2012, Maldives DHS
2009, Mongolia MICS 2010, Myanmar MICS 2009-2010, Nepal DHS 2011, Pakistan DHS
2012-2013, Thailand MICS 2005-06, Timor-Leste DHS 2009-2010, Vietnam DHS 2002, and
Vietnam MICS 2010-2011. We use 2 surveys for Vietnam because the 2010-2011 MICS does not
contain data on all indicators Although the DHS and MICS collect data on a number of common
indicators, variation across instruments used in different countries means that the number of
countries that can be used as comparators also varies by indicator. For the regional comparison,
Bredenkamp and Buisman 369

Table 1.  Summary of Findings.

Improved on Improved Among Narrowing Gap Between Narrowing Inequality
Indicator Average Poorest 20% Poorest and Richest 20% Overall (CI)

Child health status

  Infant mortality Yes Yes Yes No
  Under-5 mortality Yes Yes Yes No
 Diarrhea Yes (since 2003) Yes (since 2003) Yes No
 ARI Yes (since 1998) Yes (since 1998) Yes (since 1998) No
 Fever No No No No
Child health interventions
  Full immunization No Yes (since 2003) Yes (since 2003) No
  Measles immunization No Yes (since 1998) Yes (since 1998) No
  Treatment of diarrhea Yes Yes Yes No
  Treatment of ARI No Yes Yes Yes
Maternal health interventions
  4+ antenatal care visits Yes Yes Yes Yes
  Skilled birth attendance Yes Yes Yes Yes
 CPR Yes Yes Yes Yes
  Modern family planning Yes Yes Yes Yes

Abbreviations: ARI, acute respiratory infection; CI, concentration index; CPR, contraceptive prevalence rate.

we use the data from the most recent survey for each country. Because of the risk that the recency
of the Philippines data compared to other countries may influence the rankings, we report both
the 2013 and 2008 Philippines estimates.

Results
Overall
On average, indicators of child health status and maternal health interventions have improved,
while indicators of child health interventions have shown only small progress. Among the poor-
est 20%, though, almost all indicators (including child health interventions) have improved. The
gap between the poorest quintile and the wealthiest quintile has narrowed for almost every indi-
cator, while overall inequality (as measured by the concentration index) has narrowed only for
indicators of maternal health interventions. Table 1 summarizes these trends, by indicator, with
the specific estimates available in Tables A2-A4 in the appendix.

Health Status of Children

Infant and under-5 mortality rates have improved dramatically over the past 20 years for all
income groups, including for the poor. The absolute difference between the mortality rates of the
poorest and wealthiest quintiles has also fallen. This can be seen in the graphs which show that
the lines of the poorest and wealthiest quintiles lie closer to each other in 2013 compared with
1993 (see Figure 1). However, overall income-related inequality in mortality outcomes, as mea-
sured by the CI (see Table A2 in the appendix), appears to have widened slightly over time.
Among children, the incidence of fever and acute respiratory infections (ARIs) has been on a
downward trend since the late 1990s, while the incidence of diarrhea has been declining since the
early 2000s (see Figure 1). This is true not only for the total population but also for the poor.

Interventions to Promote Child Health

Over the past 2 decades, the increase in immunization coverage—whether measured by the full
immunization rate or by the measles immunization rate—has been very modest (see Figure 1).
370 Asia Pacific Journal of Public Health 29(5)

Infant mortality rate Under−five mortality rate Diarrhea incidence

120 120 100%

100 100 80%

80 80
60%
60 60
40%
40 40

20 20 20%

0 0 0%
1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015

Total Poorest 20% Richest 20% Total Poorest 20% Richest 20% Total Poorest 20% Richest 20%

ARI incidence Fever incidence Full immunization

100% 100% 100%

80% 80% 80%

60% 60% 60%

40% 40% 40%

20% 20% 20%

0% 0% 0%
1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015

Total Poorest 20% Richest 20% Total Poorest 20% Richest 20% Total Poorest 20% Richest 20%

Measles immunizatio
n Treatment of diarrhea Medical treatment of ARI
100% 100% 100%

80% 80% 80%

60% 60% 60%

40% 40% 40%

20% 20% 20%

0% 0% 0%
1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015

Total Poorest 20% Richest 20% Total Poorest 20% Richest 20% Total Poorest 20% Richest 20%

Antenatal care (at least 4 visits) Skilled birth attendance Contraceptive prevalence rate
100% 100% 100%

80% 80% 80%

60% 60% 60%

40% 40% 40%

20% 20% 20%

0% 0% 0%
1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015

Total Poorest 20% Richest 20% Total Poorest 20% Richest 20% Total Poorest 20% Richest 20%

Modern methods of family planning

100%

80%

60%

40%

20%

0%
1990 1995 2000 2005 2010 2015
Total Poorest 20% Richest 20%

Figure 1.  Trends and inequalities in child health status and interventions to improve child and maternal
health, Philippines, 1993-2013. y-axis for infant and under-5 mortality rates = number of deaths in
children per 1000 live births; y-axis for diarrhea, acute respiratory infection (ARI), and fever incidence =
percent of population.
Bredenkamp and Buisman 371

Full immunization, for example, increased by only 4 percentage points (from 72.2% to 76.6%)
between 1993 and 2013 and has actually declined from its 2008 peak of 79.7%. If the hepatitis B
vaccination series is included in the definition of full immunization (as it is in the 2013 DHS, but
not in previous DHS reports), performance on immunization coverage appears even worse, fall-
ing to well below 70% on average and to below 60% among the poorest quintile) (see Table A3
in the appendix). The poorest quintile lags well behind these averages: in 2013, there was a 17
percentage point gap between the (full) immunization coverage of the wealthiest quintile (84%)
and the poorest quintile (67%). That said, unlike the population average, the immunization cover-
age of the poorest quintile has consistently improved since the early 2000s.
The percentage of children getting appropriate treatment for diarrhea has improved greatly for
all income groups since 1993, from around 1 in 5 children to 1 in 2 children. Interestingly, this
intervention used to be concentrated among the poor, but over time, as overall population cover-
age improved in general, coverage among the wealthiest quintile increased by even more so that
this intervention is now concentrated among the better-off. That said, the gap in coverage between
the poorest 20% and the wealthiest 20% is small (see Figure 1). Again, as with immunization
coverage, the coverage of diarrhea interventions is now also worse than it was in 2008—for all
income groups.
There have been large increases between 1993 and 2013 in the percentage of children getting
medical treatment for ARI, from 53% to 60.4%, on average. The exception to this trend is the
2008 survey year when coverage was lower than in any other period in the past 20 years (see
Figure 1). The largest gains occurred among the poorest quintile, where treatment rates increased
from 38.8% to 57.4%, contributing to a narrowing in socioeconomic inequalities.

Interventions to Promote Maternal Health

There have been large improvements in the percentage of women receiving at least 4 antenatal
care visits over the past 20 years (see Figure 1). On average, coverage increased from 50.4% to
84.3%. Gains have been even greater in the poorer quintiles, with coverage rates more than dou-
bling in the poorest 2 quintiles. While income-related inequalities in access to antenatal care
persist (with coverage rates as high as 95.5% in the wealthiest quintile), over time inequalities
have narrowed considerably; the concentration index fell from 0.210 in 1993 to 0.061 in 2013
(see Table A4 in the appendix).
Access to skilled delivery has also seen large improvements, across all quintiles (see Table A4
in the appendix). Among the poorest quintile, there has been a near-doubling in coverage over the
past 2 decades and a 75% increase among the second poorest quintile. Coverage rates now reach
well above 90% in both the fourth and fifth quintiles. Inequalities in coverage have fallen sharply,
with the CI shrinking from 0.275 in 1993 to 0.161 in 2013. While coverage has improved consis-
tently over time, by far the largest jump in coverage occurred in the 5 years between the 2008 and
2013 surveys; during this period, quintile 1 made a 17 percentage point gain.
In addition to measuring the contraceptive prevalence rate, which includes both traditional
and modern methods of contraception and is typically measured only among married women, we
also examine changes in the percentage of all women of reproductive age (ie, 15-49 years) who
are using a modern method of contraception. This decision is motivated by the fact that 41% of
women aged 20-24 years have sex before the age of 20 years and more than one-fifth of women
in the Philippines give birth before reaching age 20 years, while the median age of marriage is
22.3 years14, suggesting a need for effective contraception among women who are not yet mar-
ried. As can be seen in Figure 1, use of modern methods of family planning has increased, but
while the trend is the same, coverage rates are much lower than for contraceptive prevalence (as
expected). Interestingly, in 2013, there is not much of a socioeconomic gradient in coverage in
the first 4 of the 5 income groups (see Table A4 in the appendix), suggesting that income (and
factors associated with it) is not the main barrier to increasing coverage.
372 Asia Pacific Journal of Public Health 29(5)

How Does the Philippines Compare With Its Neighbors?

The Philippines performs among the best of all developing Asia-Pacific countries when it comes
to child outcome indicators (ie, infant mortality and child mortality), eclipsing a number of her
main lower-middle income country comparators, like Indonesia, India, and Pakistan—both at the
level of population averages and among the poorest 20% (see Figure 2). On child health interven-
tions, namely immunization and care for diarrhea, performance is only at—or below—average
(median), and well behind many poorer countries like Afghanistan, Bangladesh, Myanmar, and
Timor-Leste (see Figure 2). The absolute gaps between rich and poor, on both outcomes and
interventions, is smaller than the median country in the group; this in line with the pattern that
countries with higher coverage rates tend to have smaller absolute gaps between rich and poor.
With regard to maternal health interventions, the Philippines performance is mixed (see Figure
2). On antenatal care coverage, the Philippines is well above average, trailing only the Maldives
and Mongolia, both with respect to population averages and the position of the poorest 20%. The
gap between the poor and rich appears is also smaller than most countries. On skilled birth atten-
dance, the Philippines ranks fifth out of 15 countries and, again, the gap between the poor and the
rich, while large, is typical for this level of coverage. However, use of modern methods of family
planning is around average, well below coverage rates in Indonesia, Bangladesh, India, and Nepal,
and quite similar to Cambodia; inequality in utilization is one of the smallest in the sample.

Discussion
Comparing our findings with those of other studies, there are some differences. Using data from
2003 and 2008, Molina et al9 found improvements in socioeconomic inequalities for antenatal care
use, but persistent inequalities in skilled birth attendance and institutional delivery. Using data
from 1990 to 2007, Kraft et al10 found substantial progress in child mortality, but substantial
inequalities between the poor and the better-off. Grundy et al11 found aggregate improvements in
coverage of immunization, skilled birth attendance, and child mortality, but large gaps between the
poor and better-off. Our contrasting finding of narrowing inequalities in maternal health interven-
tions appears to be due to the fact that we include the latest 2013 data; the coverage of the poor
improved markedly between 2008 and 2013. Our more pessimistic conclusion on the narrowing
of child health outcomes is because we use not only an absolute measure of rich-poor differentials
but also a measure of overall inequality (ie, the concentration index). In general, compared with
previous studies, we include more indicators, more data points, and more measures of inequality.
Among the most encouraging finding is the substantial improvement in the average coverage of
maternal health interventions in the Philippines over the past 20 years, together with falling inequal-
ities in coverage, especially in recent years. This suggests that the accelerated efforts of the
Department of Health (DOH) to improve maternal health are paying off. Indeed, the timing of the
rapid improvements in the coverage of maternal health interventions observed in the data coincides
with the implementation of the DOH’s Maternal, Newborn, Child Health and Nutrition Strategy.15,16
However, the analysis also draws attention to some acute shortcomings. In this regard, poor
immunization coverage stands out. Average coverage figures have improved by only 4 percent-
age points in 20 years and there is a 17 percentage point difference in the immunization coverage
rates of the poorest and wealthiest quintiles. With health service delivery largely decentralized to
local governments (cities and municipalities), remedying this will require intensified efforts by
both the DOH’s national programs (such the Expanded Program on Immunization, which pro-
vides vaccines) and the local governments to achieve results.
A limitation of this article is that it does not examine indicators of nutritional status and the
reason is that the Philippines does not have publicly available data on child anthropometry. The
 Infant mortality Under−five mortality Measles immunization
Maldives Philippines 2013 Maldives
Philippines 2013 Maldives Nepal
Philippines 2008 Philippines 2008 Bangladesh
Indonesia Indonesia Philippines 2008
Bangladesh Nepal Philippines 2013
Nepal Bangladesh Cambodia
Cambodia Cambodia Indonesia
Timor−Leste Timor−Leste Timor−Leste
India India Pakistan
Pakistan Pakistan India

0 20 40 60 80 100 120 0 20 40 60 80 100 120 0% 20% 40% 60% 80% 100%

Number of death children per 1,000 live births Number of death children per 1,000 live births Percent of population
Total Poorest 20% Richest 20% Total Poorest 20% Richest 20% Total Poorest 20% Richest 20%

Treatment of diarrhea Antenatal care (4+ visits) Skilled birth attendance Modern methods of family planning

Bangladesh Maldives Maldives Indonesia

Bhutan Mongolia Vietnam
Timor−Leste Philippines 2013 Mongolia Bangladesh
Thailand Bhutan Cambodia
Vietnam India
Philippines 2008 Philippines 2013
Myanmar Cambodia Myanmar Nepal
Afghanistan Lao PDR Philippines 2008
Maldives Vietnam Pakistan Philippines 2013
Philippines 2008 Myanmar Nepal
Philippines 2013 Cambodia
Timor−Leste India
Lao PDR Philippines 2008
Indonesia Nepal Indonesia
Nepal Indonesia Lao PDR Maldives
Mongolia Pakistan Bhutan
Pakistan India Timor−Leste Pakistan
Cambodia Afghanistan Bangladesh
Bangladesh Afghanistan Timor−Leste
India

0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100%
Percent of population Percent of population Percent of population Percent of population

Total Poorest 20% Richest 20% Total Poorest 20% Richest 20% Total Poorest 20% Richest 20% Total Poorest 20% Richest 20%

Figure 2.  Child health status and child and maternal health interventions, regional comparison.

373
374 Asia Pacific Journal of Public Health 29(5)

Philippines is 1 of only 5 countries (out of 69) that do not collect anthropometric data as part of
the DHS. Anthropometry is collected in the National Nutrition Survey (NNS), managed by the
Department of Science and Technology (DOST), but these data are not made available to the
public—or even to other government agencies and state-funded universities. The absence of
publicly available data on child nutritional status is an important gap that could be easily filled—
ideally through adding anthropometry to the DHS, but failing that through making NNS data
publicly available. This should be done soon, not least to lay the baseline for nutrition measure-
ment as part of the Sustainable Development Goals for health.
Another question is whether the choice of regional comparators makes the Philippines appear
to perform better, in relative terms, than it really does. Two factors could contribute to this. First,
while we use all the latest nationally-representative and comparable household surveys for the
Asia-Pacific region that were publicly available at the time of writing, we do not have data from
a number of important lower income comparator countries; most of the comparator countries are
low-income. Second, because the Philippines data are among the most recent in the comparator
set and, and health outcomes tend to improve over time, as new data are released for other coun-
tries, we may see the Philippines’ relative position in the rankings slip.
Finally, as with other studies that rely on these surveys, there is the risk of measurement error
due to respondent subjectivity and/or lack of knowledge, especially on the questions related to
fever, ARI and diarrhea incidence. Survey data on the incidence of these conditions reflect moth-
ers’ perception of health status, rather than actual health status. Consequently, one cannot com-
pletely disentangle whether lack of improvement (and widening inequalities) represents actual
lack of progress (and changes in the distribution of the illness) or is perhaps the result of an
increased ability among poor mothers to recognize these conditions.

Conclusion/Recommendations
We conclude that, on average, coverage of maternal health interventions is improving, but cover-
age of child health interventions is not. Among the poorest 20%, measures of child health status,
child health interventions, and maternal health interventions are all improving, and most dramati-
cally for maternal health interventions.
For conclusions on trends in inequality, the measure matters. The absolute gap between the
poorest and the richest is narrowing on all measures (child health, child health interventions, and
maternal health interventions). However, overall inequality as measured by the concentration
index (which also captures what is going on in the middle-income groups) shows narrowing
inequalities for maternal health interventions, but not for child health status or child health
interventions.
The regional comparison puts the performance of the Philippines in perspective. We find that,
compared with other countries in South and East Asia, the Philippines appears to be well ahead
on many indicators of maternal and child health, including infant mortality, child mortality, and
antenatal care utilization. Even in areas where we consider the Philippines performance in 2013
to be quite lackluster compared to the country’s performance in previous years, it seems that
coverage of health interventions is not necessarily lagging behind the rest of the region. That
said, the Philippines data are the most recent of all countries.
From a policy perspective, the best news is the marked improvements in maternal health inter-
ventions—both aggregate progress and narrowing inequalities. The most worrying news is the
tiny improvement in immunization coverage (only 4 percentage points in 20 years), coupled with
wide and persistent inequalities between rich and poor. The improvements in maternal health
interventions coincides with concerted effort by the DOH to improve that coverage; similar
efforts should now be made to tackle immunization coverage. The lack of publicly available data
Bredenkamp and Buisman 375

with which to analyze nutritional status is not only a challenge for research, but also an obstacle
to planning, and to achieving progress in reducing undernutrition, and requires action across
government departments to rectify.

Authors’ Note
The findings, interpretations, and conclusions expressed in this article are entirely those of the authors, and
do not necessarily represent the views of the World Bank Group, its Executive Directors, or the govern-
ments of the countries they represent.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or
publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publi-
cation of this article: The analysis on which this article draws was financed by the World Bank Group.

Supplementary Material
Supplementary material is available for this article online.

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